Coronary artery perforation (CAP) is an uncommon but potentially catastrophic complication of percutaneous coronary intervention (PCI). Despite advances in device technology and operator expertise, CAP remains associated with significant morbidity and mortality. Contemporary treatment strategies have evolved considerably, incorporating covered stents, embolization techniques, and rapid pericardial intervention.

Objective

To evaluate the incidence, predictors, management approaches, and clinical outcomes of coronary artery perforation during contemporary PCI procedures.

Methods

A prospective observational study was conducted involving 8,520 consecutive PCI procedures performed between January 2022 and December 2024 at three tertiary cardiac centers. Patients who developed coronary artery perforation were identified and analyzed. Clinical, angiographic, procedural, and outcome data were collected.

Results

Coronary perforation occurred in 52 patients (0.61%). The majority were Ellis Type II (42.3%) and Type III (34.6%) perforations. Independent predictors included severe calcification, chronic total occlusion (CTO), rotational atherectomy, and hydrophilic guidewire use. Covered stents were utilized in 36.5% of cases, coil embolization in 13.5%, and prolonged balloon inflation in 65.4%. Cardiac tamponade developed in 25.0% of patients. Overall in-hospital mortality was 7.7%.

Conclusion

Coronary artery perforation remains a rare but life-threatening complication of PCI. Early recognition, immediate hemostatic measures, and availability of contemporary bailout devices significantly improve patient outcomes.