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Coronary artery perforation is one of the most common and feared complications of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We evaluated the utility of the recently presented OPEN-CLEAN (Coronary artery bypass graft, Length of occlusion, Ejection fraction, Age, calcificatioN) perforation score in an independent multicenter CTO PCI dataset. Of the 2,270 patients who underwent CTO PCI at 7 centers, 150 (6.6%) suffered coronary artery perforation. Patients with perforations were older (69 ± 10 vs 65 ± 10, p <0.001), more likely to be women (89% vs 82%, p = 0.010), more likely to have history of previous coronary artery bypass graft (38% vs 20%, p <0.001), and unfavorable angiographic characteristics such as blunt stump (64% vs 42%, p <0.001), proximal cap ambiguity (51% vs 33%, p <0.001), and moderate-severe calcification (57% vs 43%, p = 0.001). Technical success was lower in patients with perforations (69% vs 85%, p <0.001). The area under the receiver operating characteristic curve of the OPEN-CLEAN perforation risk model was 0.74 (95% confidence interval 0.68 to 0.79), with good calibration (Hosmer-Lemeshow p = 0.72). We found that the CTO PCI perforation risk increased with higher OPEN-CLEAN scores: 3.5% (score 0 to 1), 3.1% (score 2), 5.3% (score 3), 7.1% (score 4), 11.5% (score 5), 19.8% (score 6 to 7). In conclusion, given its good performance and ease of preprocedural calculation, the OPEN-CLEAN perforation score appears to be useful for quantifying the perforation risk for patients who underwent CTO PCI., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and often leads to serious adverse clinical events., Aims: We sought to develop a risk score to predict clinical coronary artery perforation in patients undergoing CTO PCI., Methods: We analysed clinical and angiographic parameters from 9,618 CTO PCIs in the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO). Logistic regression prediction modelling was used to identify variables independently associated with clinical perforation, and the model was internally validated with bootstrapping. Clinical coronary artery perforation was defined as any perforation requiring treatment., Results: The incidence of clinical coronary perforation was 3.8% (n=367). Five factors were independently associated with perforation and were included in the score: patient age ≥65 years +1 point (odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.37-2.33), moderate/severe calcification +1 point (OR 1.85, 95% CI: 1.41-2.42), blunt/no stump +1 point (OR 1.45, 95% CI: 1.10-1.92), use of antegrade dissection and re-entry +1 point (OR 2.43, 95% CI: 1.61-3.69), and use of the retrograde approach +2 points (OR 4.02, 95% CI: 2.95-5.46). The resulting score showed acceptable performance on receiver operating characteristic (ROC) curve (area under the curve [AUC]: 0.741, 95% CI: 0.712-0.773). The Hosmer-Lemeshow test indicated a good fit (p=0.991), and internal validation with bootstrapping demonstrated good agreement with the model with observed AUC: 0.736 (95% bias-corrected CI: 0.706-0.767)., Conclusions: The PROGRESS-CTO perforation score may be a useful tool for predicting clinical coronary perforation during CTO PCI.

Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Our objective was to describe the incidence, mechanisms, treatment, and outcomes of coronary artery perforation during CTO PCI. We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022. The incidence of coronary perforation was 4.9% (n = 503). Patients who experienced coronary perforation were older and were more likely to have had previous coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher Japanese CTO and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) scores. Technical (66% vs 87%, p &lt;0.001) and procedural (55% vs 87%, p &lt;0.001) success rates were lower in perforation cases. The CTO target vessel was the most common perforation site (66%). The retrograde approach was responsible for the perforation in 47% of cases, and guidewire exit was the most common perforation mechanism. The proportion of Ellis class 1, 2, 3, and 3 -"cavity spilling" coronary perforations was 20%, 41%, 28%, and 11%, respectively. In 52% of perforations, 1 or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%), and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events was higher in perforation cases (18% vs 1.3%, p &lt;0.001). In conclusion, coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital major adverse cardiovascular events., Competing Interests: Disclosures Dr. Alaswad: Consultant and speaker for Boston Scientific, Abbott Cardiovascular, Teleflex, and Cardiovascular Systems, Inc. Dr. Karmpaliotis: Honoraria - Boston Scientific and Abbot Vascular; Equity: Saranas, Soundbite, Traverse Vascular. Dr. Jaffer: Sponsored research: Canon, Siemens, Shockwave, Teleflex, Mercator, and Boston Scientific; Consultant: Boston Scientific, Siemens, Magenta Medical, International Medical Device Solutions, Asahi Intecc, Biotronik, Philips, Intravascular Imaging Inc. Equity interest: Intravascular Imaging Inc, DurVena. Massachusetts General Hospital - licensing arrangements: Terumo, Canon, and Spectrawave, for which Dr. Jaffer has the right to receive royalties. Dr. Khatri: Personal Honoria for proctoring and speaking: Abbott Vascular, Asahi Intecc Co., Ltd., Terumo, and Boston Scientific. Dr. Poommipanit: Asahi Intecc Co., Ltd., Abbott, Vascular-Consultant. Dr. Jaber: Medtronic and proctoring fees from Abbott. Dr. Rinfret: Abbott Vascular, Abiomed, Boston Scientific Corporation, SoundBite Medical, Teleflex consultant. Dr. Nicholson: Is a proctor and on the speakers' bureau and the advisory board for Abbott Vascular, Boston Scientific, and Asahi Intecc Co., Ltd.; he reports intellectual property with Vascular Solutions. Dr. Patel: Consulting Honoraria from Abbott, Medtronic, Terumo, and Cardiovascular Systems, Inc. Dr. Mahmud: Consultant for Abiomed, Medtronic, and Boston Scientific, and chairs multiple Data, Safety, and Monitoring Boards. Dr. Davies: Honoraria from Asahi Intecc Co., Ltd., Boston Scientific, Medtronic, and Siemens Healthineers, in addition to being a member of an advisory board for Shockwave Medical. Dr. Kerrigan: Consultant to Abiomed, Asahi Intecc Co., Ltd., Biotronik, Cordis, Boston Scientific, Ischemaview Inc., Osprey Medical, Penumbra, Philips, and Teleflex. Dr. Abi-Rafeh: Proctor and speaker honoraria for Boston Scientific and Abbott Vascular. Dr. ElGuindy: Consulting honoraria: Medtronic, Boston Scientific, Asahi Intecc Co., Ltd., Abbott; Proctorship fees: Medtronic, Boston Scientific, Asahi Intecc Co., Ltd., and Terumo; Educational grants: Medtronic. Dr. Brilakis: Consulting/speaker honoraria from Abbott Vascular, American Heart Association (Associate Editor: Circulation), Amgen, Asahi Intecc Co., Ltd., Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Elsevier, GE Healthcare, IMDS, InfraRedx, Medicure, Medtronic, Opsens, Siemens, and Teleflex; Research support: Boston Scientific, GE Healthcare; owner at Hippocrates LLC; shareholder at Minneapolis Heart Institute Ventures, Cleerly Health, and Stallion Medical. The remaining authors have no conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To examine the incidence, treatment and outcomes of perforation during percutaneous coronary intervention (PCI)., Background: Coronary perforation is a potentially life-threatening PCI complication., Methods: We examined the clinical, angiographic, and procedural characteristics, management, and outcomes of coronary perforation at a tertiary care institution., Results: Between 2014 and 2019, perforation occurred in 70 of 10,278 PCIs (0.7%). Patient age was 71 ± 12 years, 66% were men, and 30% had prior coronary artery bypass graft surgery. Among perforation cases, the prevalence of chronic total occlusions was 33%, moderate/severe calcification was 66% and moderate/severe tortuosity was 41%. The frequency of Ellis class 1, 2, and 3 perforations was 14%, 50%, and 36%, respectively. Most (n = 51; 73%) were large vessel perforations, 16 (23%) were distal vessel perforations and 3 (4%) were collateral vessel perforations (1 septal and 2 epicardial). Hypotension occurred in 26%, pericardial effusion in 36% and tamponade in 13%; 47% of perforations did not have clinical consequences. Perforations were most often treated with prolonged balloon inflation (63%), reversal of anticoagulation (39%), and covered stent implantation (33%). Technical and procedural success were 73% and 60%, respectively, and major periprocedural adverse cardiac events occurred in 21% of the patients. Three patients (4%) required emergent CABG surgery and four (6%) died., Conclusions: Coronary perforation is an infrequent complication of PCI. Most perforations are large vessel perforations and often require further intervention. The incidence of death or emergent cardiac surgery is low.