Distal Coronary Artery Perforations During Percutaneous Coronary Intervention: A Review with Case-Based Clinical Experience
DOI:
https://doi.org/10.66288/actamedi.2026.56Keywords:
coronary artery perforation, ddistal coronary perforation, percutaneous coronary intervention, guidewire-related complications, autologous fat embolization, bailout therapyAbstract
Objective:
Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), associated with significant morbidity and mortality. The management of distal CAPs poses particular clinical challenges due to limited therapeutic options. This review evaluates the mechanisms, contemporary management strategies, and specifically the role of autologous fat tissue embolization in the treatment of distal CAPs occurring during PCI, based on the current literature and supported by our single-center clinical experience.
Methods:
The contemporary literature regarding the definition, classification, and treatment approaches for distal CAPs was reviewed. In addition, findings reported in the literature were assessed in conjunction with our single-center clinical experience in managing distal CAPs occurring during PCI using autologous fat tissue embolization.
Results:
Published data indicate that distal CAPs are most frequently associated with guidewire manipulation, with small vessel diameter representing a major risk factor. In the presented cases, perforations were classified as Ellis type II or type III, and complete angiographic success was achieved in all patients following autologous fat tissue embolization. Contrast extravasation was fully resolved, and no perforation-related major complications or mortality were observed during in-hospital stay or short-term clinical follow-up.
Conclusion:
Distal CAPs are rare but potentially life-threatening complications of PCI. Guidewire manipulation appears to be a key determinant of perforation risk, particularly in distal coronary segments with a vessel diameter of less than 1 mm. In distal perforations refractory to prolonged balloon inflation, autologous fat tissue embolization may be considered a feasible bailout therapeutic option, supported by both the available literature and clinical experience.
References
1. Kinnaird, T., Kwok, C. S., Kontopantelis, E., Ossei-Gerning, N., Ludman, P., deBelder, et al. British Cardiovascular Intervention Society and the National Institute for Cardiovascular Outcomes Research (2016). Incidence, Determinants, and Outcomes of Coronary Perforation During Percutaneous Coronary Intervention in the United Kingdom Between 2006 and 2013: An Analysis of 527 121 Cases From the British Cardiovascular Intervention Society Database. Circulation. Cardiovascular interventions, 9(8), e003449. https://doi.org/10.1161/CIRCINTERVENTIONS.115.003449 DOI: https://doi.org/10.1161/CIRCINTERVENTIONS.115.003449
2. Zou, Y. L., Li, J. Q., Wang, D. Y., Gong, Y. T., Sheng, L., Li, Y. (2024). Conquer coronary artery perforation with magic hands. Journal of geriatric cardiology : JGC, 21(4), 379–386. https://doi.org/10.26599/1671-5411.2024.04.002 DOI: https://doi.org/10.26599/1671-5411.2024.04.002
3. Ellis, S. G., Ajluni, S., Arnold, A. Z., Popma, J. J., Bittl, J. A., Eigler, N. L., et al. Whitlow, P. L. (1994). Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation, 90(6), 2725–2730. https://doi.org/10.1161/01.cir.90.6.2725 DOI: https://doi.org/10.1161/01.CIR.90.6.2725
4. Shaukat, A., Tajti, P., Sandoval, Y., Stanberry, L., Garberich, R., Nicholas Burke, M. et al. E. S. (2019). Incidence, predictors, management and outcomes of coronary perforations. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 93(1), 48–56. https://doi.org/10.1002/ccd.27706 DOI: https://doi.org/10.1002/ccd.27706
5. Teis, A., Fernández-Nofrerías, E., Rodríguez-Leor, O., Tizón, H., Salvatella, N., Valle, V. Et al. (2010). Coronary artery perforation by intracoronary guide wires: risk factors and clinical outcomes. Revista espanola de cardiologia, 63(6), 730–734. https://doi.org/10.1016/s1885-5857(10)70148-1 DOI: https://doi.org/10.1016/S1885-5857(10)70148-1
6. Wang, X., & Ge, J. (2014). Balloon Occlusion Types in the Treatment of Coronary Perforation during Percutaneous Coronary Intervention. Cardiology research and practice, 2014, 784018. https://doi.org/10.1155/2014/784018 DOI: https://doi.org/10.1155/2014/784018
7. Xenogiannis, I., & Brilakis, E. S. (2019). Advances in the treatment of coronary perforations. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions, 93(5), 921–922. https://doi.org/10.1002/ccd.28205 DOI: https://doi.org/10.1002/ccd.28205
8. Giannini, F., Candilio, L., Mitomo, S., Ruparelia, N., Chieffo, A., Baldetti, L. et al. (2018). A Practical Approach to the Management of Complications During Percutaneous Coronary Intervention. JACC. Cardiovascular interventions, 11(18), 1797–1810. https://doi.org/10.1016/j.jcin.2018.05.052 DOI: https://doi.org/10.1016/j.jcin.2018.05.052
9. He, L. Y., Han, J. L., Guo, L. J., Zhang, F. C., Cui, M., & Gao, W. (2015). Effect of transcatheter embolization by autologous fat particles in the treatment of coronary artery perforation during percutaneous coronary intervention. Chinese medical journal, 128(6), 745–749. https://doi.org/10.4103/0366-6999.152482 DOI: https://doi.org/10.4103/0366-6999.152482
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Rauf Avcı, Ahmet Genç
This work is licensed under a Creative Commons Attribution 4.0 International License.
