TCT-766 Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: an analysis of 1,013 perforation cases from the British Cardiovascular Intervention Society database

Kinnaird, Tim; Calvert, Patrick; Anderson, Richard; Sirker, Alexander; de Belder, Mark; Ludman, Peter; Johnson, Thomas; Mamas, Mamas

Abstract

Background
The evidence base for coronary perforation (CP) occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited with the specific role of acute pharmacology in its clinical presentation unclear.

Methods
Using the BCIS national PCI database, the incidence, predictors and outcomes of CP during ACS-PCIwere defined.Data was analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regressions were used to identify predictors of CP and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors, and between use or not of glycoprotein inhibitors (GPI).

Results
During the study period, 1,013 CPs were recorded during 270,329 ACS-PCI procedures (0.37% incidence) with no significant temporal change in its frequency during the study period. The only patient-related factors associated with an increased risk of perforation were age per year (odds ratio (OR) 95% confidence intervals 1.03 [1.03-1.04], p<0.001), and female gender(OR 1.28 [1.08-1.51], p=0.004). Several procedural factors were associated with an increased risk of perforation including CTO intervention (OR 3.08 [2.44-3.89], p<0.001), dual arterial access (OR 1.85, [1.39-2.47], p<0.001), left main PCI (OR 1.46, [1.00-2.12], p<0.001), vein graft PCI (OR 2.54, [1.53-4.22], p=0.002), number of stents used per stent (OR 1.35, [1.25-1.45], p<0.001), longest stent used per mm (OR 1.01, [1.01-1.02], p<0.001), micro-catheter use (OR 1.97, [1.04-3.73], p=0.37), and rotational atherectomy use (OR 1.88[1.29-2.74], p=0.001). Diabetes mellitus (OR 0.75 [0.60-0.92], p=0.006), and a trainee first operator (OR 0.75, [0.61-0.89], p=0.002) were associated with a lower risk of coronary perforation. Using propensity score matching to evaluate the association between differing P2Y12 inhibitos, prasugrel was associated with a lower risk of perforation compared to clopidogrel (p=0.007) and compared to ticagrelor (p=0.022,). Glycoprotein inhibitor use was not associated with an excess of coronary perforation when propensity score matching was used (p=0.088). Clinical tamponade occurred in 29.6% of patients although emergency reparative cardiac surgery was undertaken rarely (2.5%). There was a significant reduction in both tamponade and need for surgery over the study period (p<0.001 for both trends). Amongst the independent predictors of tamponade, use of any glycoprotein inhibitor was independently associated with its occurrence (OR 1.50, [1.08-2.06], p=0.014) although this difference was driven only by abciximab (OR 1.73 [1.20-2.48], p=0.003).The adjusted odds ratios for adverse clinical outcomes indicated a significant impact of a CP with emergency cardiac surgery (OR 27.5, [14.09-53.72], p<0.001), transfusion (OR 14.3, [6.67-30.52], p<0.001), in-hospital major bleeding (OR 6.6, [4.88-8.85], p<0.001), in-hospital death (OR 8.2, [6.29-10.51], p<0.001), and in-hospital MACE (OR 8.1, [6.42-10.09], p<0.001) all associated with coronary perforation. Using multi-variate analysis, the independent associates of 30-day mortality in those patients who experienced a coronary perforation included age, shock or ventilation on presentation, and renal disease. Use of any glycoprotein inhibitor was not independently associated with death at 30 days (OR 1.58, [0.86-2.92], p=0.143). However, when each glycoprotein inhibitor was included in the multivariate model separately, there was a significant association between abciximab and 30-day mortality (OR 2.28 [1.11-4.65], p=0.024) which was not observed with eptifibatide or tirofiban. Finally, coronary perforation was associated with an excess of 12-month mortality (OR 2.7 [1.69-4.23], p<0.001). Kaplan Meier plots for mortality by perforation status to 12-months confirmed the significant impact of a perforation on patient survival to 12-months (p<0.001).

Conclusion
Coronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes.Abciximab use increased the risk of tamponade and 30-day mortality.

Citation

Kinnaird, T., Calvert, P., Anderson, R., Sirker, A., de Belder, M., Ludman, P., Johnson, T., & Mamas, M. TCT-766 Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: an analysis of 1,013 perforation cases from the British Cardiovascular Intervention Society database

• Presentation Conference Type: Conference Paper (published)
• Online Publication Date: Sep 17, 2018
• Publication Date: 2018-09
• Deposit Date: Jun 21, 2023
• Journal: Journal of the American College of Cardiology
• Print ISSN: 0735-1097
• Electronic ISSN: 1558-3597
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 72
• Issue: 13
• Article Number: B306
• DOI: https://doi.org/10.1016/j.jacc.2018.08.1994
• Keywords: Cardiology and Cardiovascular Medicine
• Public URL: https://keele-repository.worktribe.com/output/491318
• Additional Information: This article is maintained by: Elsevier; Article Title: TCT-766 Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: an analysis of 1,013 perforation cases from the British Cardiovascular Intervention Society database; Journal Title: Journal of the American College of Cardiology; CrossRef DOI link to publisher maintained version: https://doi.org/10.1016/j.jacc.2018.08.1994; Content Type: simple-article; Copyright: Copyright © 2018 Published by Elsevier Inc.