What did the authors do?

We tried to improve the coronary perforation algorithm so that it becomes more comprehensive and covers preventive measures, prediction, prompt recognition, understanding of the injury mechanism and the source of bleeding, implementation of therapy to restabilize the hemodynamic status, and sealing of the perforation according to the cause for a successful outcome (Figure 1). Furthermore, we classified coronary vessel perforation into five categories and provided a simplified universal and type-specific approach to manage coronary artery perforation.

What this perforation algorithm adds:

• Is straightforward, more comprehensive and starts with preventive measures;
• Highlights predicting the complication before it happens and preparing the operator to deal with it, as some complications are not preventable;
• Stresses early recognition of perforations to identify the source of bleeding and for understanding the mechanism of bleeding, as these steps will better influence the management strategy and outcome;
• Highlights the crucial role of imaging in prevention, prediction, device selection, understanding the site and mechanism of injury, and accompanying the management strategy;
• Summarizes how to stabilize the hemodynamic status by focusing on pericardiocentesis indication, the reversal of anticoagulation, and hemodynamic support as a case-by-case decision according to the situation, if necessary;
• Classifies the cause of bleeding into five categories, each of which has a different causal mechanism and subsequently differs in management;
• Highlights the challenges and difficulties in diagnosing and managing the cardiac wall hematoma, taking into consideration a hematoma that deteriorates the hemodynamic status without effusion “dry tamponade” and how it can mask the situation with false impressions that there is no source of bleeding or obvious pathology;
• Stresses the importance of early recognition and immediate sealing before the initiation of the self-propagating process (avulsed capillary vessels providing active bleeding that fuels its expansion), regardless of the stable image of staining, as well as the role of close monitoring and a second control image to demonstrate the dynamicity of the injury (diffuse bleeding could persist after successful but delayed percutaneous sealing);
• Highlights coronary steal phenomena and their consequences;
• Stresses CABG perforation as a separate category, as this type of perforation is challenging and differs in management depending on the site of injury (cardiac or extracardiac).

How this algorithm might affect practice:

We reformatted a new coronary perforation algorithm. It starts with prevention and prediction, goes through understanding the source and mechanism of bleeding, and finally classifies the cause of bleeding into proximal, distal, coronary artery bypass graft and collateral vessel, pericardial, myocardial extravasation, and vessel-chamber perforation, as each causality necessitates a different management strategy to improve outcomes.

Conclusions

Coronary perforation is a potentially life-threatening complication in all patients undergoing percutaneous coronary intervention. Thus, it is crucial for interventional cardiologists to take precautions to avoid this complication.

In this context, the cardiac vessel perforation algorithm could be more comprehensive and cover the preventive measures and predictors, take into consideration prompt recognition, implement actions to restabilize the hemodynamic status, highlight understanding the source and mechanism of bleeding, and classify the cause of bleeding into type-specific approaches to manage it adequately, as each causality would necessitate a different management strategy for a successful outcome.

Invasive coronary imaging may guide a safe percutaneous coronary intervention strategy in terms of the device-section.