Conservative Management of Coronary Perforation: Lessons from the Oleander Bloom

Coronary artery disease is a leading cause of morbidity and mortality worldwide, and percutaneous coronary intervention (PCI) is a standard therapeutic procedure for patients with symptomatic coronary artery disease, particularly those presenting with acute coronary syndromes, such as non-ST-elevation MI (NSTEMI).¹ PCI has benefitted from substantial procedural and technological advancements over recent decades, leading to increased success rates and reduced complications.² However, despite these advances, PCI remains associated with certain risks, particularly in cases involving complex and heavily calcified coronary lesions.³ One of the most serious and challenging complications of PCI is coronary perforation, an event with the potential for severe haemodynamic consequences, including cardiac tamponade and shock, which may necessitate emergent intervention.⁴

The risk of coronary perforation is amplified in cases where extensive coronary calcification is present, as the rigidity of calcified plaques can interfere with balloon or stent advancement and expansion, leading to micro-disruptions or direct vessel tears.³ For this reason, intravascular imaging modalities, such as intravascular ultrasound (IVUS), are frequently used in PCI to assess the lesion’s characteristics and determine optimal strategies to minimise procedural risk and maximise patient benefit.⁵ Yet, even with careful planning, heavily calcified lesions often pose a procedural challenge and carry an increased risk of adverse outcomes.

Management of coronary perforation depends on multiple factors, including the size and location of the perforation, haemodynamic stability and the presence of any accompanying pericardial effusion. Traditional management approaches range from conservative observation in haemodynamically stable patients to balloon tamponade, covered stent placement, and, in severe cases, pericardiocentesis and/or emergency surgical repair. The decision to adopt a conservative versus an interventional approach must balance the risks and benefits of further invasive procedures against the potential for natural containment of the perforation. In patients with localised, self-contained perforations without significant extravasation or haemodynamic instability, conservative management may be considered as a viable option.⁶

This report presents a case of coronary perforation during an IVUS-guided PCI in a 62-year-old male patient with NSTEMI and significant coronary calcification. Despite the development of a visually striking perforation, conservative management was successfully used due to the patient’s stable haemodynamic status and the contained nature of the perforation. This case highlights the potential for non-invasive management strategies in select patients and contributes to the growing body of evidence supporting individualised approaches in the treatment of PCI-related complications.

Case Presentation

A 62-year-old man presented to the cardiac assessment unit reporting chest pain of 1 week’s duration, accompanied by left arm discomfort. He had a history of hypertension, hypercholesterolaemia and elevated BMI. The patient was on a regimen of lercanidipine 10 mg once daily for blood pressure control and reported not taking a statin, despite his elevated cholesterol levels. Initial evaluation included a transthoracic echocardiogram, which demonstrated preserved left ventricular (LV) function with mild LV hypertrophy.

The subsequent episode of chest pain was triggered by light farm work. The patient described a sudden onset of palpitation, accompanied by sharp epigastric pain rated 9/10, dyspnoea and general weakness. Left arm pain had persisted over the previous week, which he attributed to the recent use of a 24-hour blood pressure cuff. The patient had recently resumed lercanidipine 10 mg daily, but continued to deny statin usage. Repeat echocardiography confirmed good LV function with mild LV hypertrophy, and his syntax score was calculated at 20.

Coronary angiography revealed diffuse atheromatous disease, most notable for a distal left main (LM) stem lesion with a severe stenosis before the bifurcation (Figure 1 and Supplementary Video 1 ). Additional findings included diffuse, moderate stenosis in the proximal left anterior descending artery (LAD), a moderate lesion in the mid left circumflex artery (LCx) and diffuse, moderate stenosis in the dominant right coronary artery. The impression was significant left main stem disease with acute coronary syndrome. This prompted referral for a heart team evaluation to discuss management options, including PCI versus coronary artery bypass grafting.

The patient was discussed by the heart team with a consensus for PCI due to his low-tertile syntax score and lack of significant ostial Cx disease. The patient underwent IVUS-guided PCI to the LCx and LM-LAD. Angiography was performed via the right radial artery using a 7 Fr sheath and Judkins left 3.5 guide catheter. The LAD and Cx were wired with workhorse wires (balanced middle wire and SION blue). The LCx was successfully treated with a 3.5 × 30mm Resolute Onyx drug-eluting stent post-dilated with a 4.0-mm non-compliant (NC) balloon. The IVUS result was satisfactory.

During subsequent PCI to the LM-LAD, catheter advancement was challenging due to the tortuous, corkscrew morphology of the proximal LAD. Although initial ballooning with a (1:1 sized) 3.0 × 20mm semi-compliant balloon was achieved, subsequent attempts to deliver a 3.0 mm NC balloon were unsuccessful (despite the advancement of a 6 Fr guide extension catheter into the ostial LAD; Figures 2A and 2B). Subsequent angiography revealed extravasation of contrast medium near the distal LM and proximal LAD (Figure 3 and Supplementary Video 2). The exact perforation site was difficult to determine due to extensive calcification, suggesting that the perforation likely resulted from the disruption of a calcific spicule or shard following pre-dilatation or guide extension catheter advancement.

In cases involving heavily calcified lesions, the use of a guide extension catheter can facilitate device delivery, but may also contribute to vascular injury as a result of the force required for advancement. In this case, the possibility of guide extension catheter-induced perforation cannot be excluded, as the lesion’s calcific morphology and procedural challenges likely predisposed the vessel to structural compromise. As a result, the operators were unable to deliver balloons to the area of perforation, which was initially concerning. Reassuringly, antegrade flow in both the LAD and LCx was maintained, and only transient inferolateral ECG changes were observed, which quickly resolved. The patient had no chest pain. Blood pressure remained stable throughout, and a focused echocardiogram confirmed the absence of pericardial effusion.

Given the stable clinical status and lack of ongoing extravasation, the perforation was likely self-contained, promoting localised tamponade with pericardial thrombus formation. Protamine reversal was not administered due to the patient’s stable haemodynamics and the concern that reversing anticoagulation could promote LAD wire thrombosis, increasing the risk of procedural complications. The decision was made to defer further attempts at stent delivery, with plans to consider repeat PCI using rotational atherectomy (rotablation) via femoral access if necessary. The patient was managed conservatively for 2 weeks with inpatient monitoring in the cardiac care unit with dual antiplatelet therapy. During this period, serial echocardiograms were performed at regular intervals, confirming the absence of pericardial effusion or new haemodynamic instability (Box 1 ). The decision to proceed with a second intervention was based on stable clinical parameters and lesion reassessment.

Two weeks later, the patient returned for a repeat PCI to the LM-LAD. Femoral access with a 7 Fr extra back-up 4 guide catheter was chosen to maximise catheter stability, and support and facilitate equipment delivery into the LAD. IVUS imaging confirmed eccentric nodular calcification from the mid-LM to proximal LAD. A second IVUS image (Figure 4 ) further highlights the presence of a prominent calcific nodule, demonstrating the extent of the lesion, and providing insights into the mechanism contributing to the initial balloon failure and perforation. Following straightforward pre-dilatation, a 4.0 × 30 mm Resolute Onyx drug-eluting stent was deployed from the proximal LAD into the LM. The stent was post-dilatated with a 4.5 mm NC balloon, and further optimised with a 5.0 mm NC balloon in the left main stem using the proximal optimisation technique, yielding excellent IVUS and angiographic results (Figure 5 ). Haemostasis was achieved with an 8 Fr Angio-Seal device. The patient was discharged on dual antiplatelet therapy after an uneventful 6-hour observation.

Discussion

Coronary perforation is a rare, but potentially life-threatening, complication during PCI, occurring in approximately 0.1–0.6% of cases.⁴ The risk is particularly high in patients with complex and heavily calcified lesions, as these characteristics can compromise the flexibility of the vessel wall and increase resistance to dilatation or stent expansion. Calcified plaques pose a unique challenge during PCI, as modification may lead to vessel trauma, either through balloon-based therapies or atherectomy.⁷ In this case, a localised coronary perforation likely resulted from the dislodgment of a calcific shard rather than a direct tear, creating a self-contained perforation that did not compromise haemodynamic stability or lead to pericardial effusion and cardiac tamponade.

Management of coronary perforation must be tailored to each patient, considering various factors, such as perforation size, location, haemodynamic status and the presence of pericardial effusion.⁸ Conservative management is often preferred in cases where the perforation is contained, without extensive extravasation or haemodynamic instability and where the patient’s condition remains stable.^9,10 This strategy typically includes antiplatelet pharmacotherapy to reduce the risk of thrombosis, close monitoring for any signs of haemodynamic compromise and serial imaging to ensure stability of the perforation.⁴

In cases involving severe calcified nodules, intravascular lithotripsy (IVL) has emerged as a valuable adjunct to modify lesion compliance. The acoustic pressure waves delivered by IVL fracture superficial and deep calcium, potentially reducing the risk of spicule disruption and vessel trauma during PCI.¹¹ While not used in this case, IVL could have been considered to optimise lesion preparation and mitigate the risk of perforation.

Recent literature increasingly supports conservative management as a viable option for select cases of coronary perforation, especially in patients with calcified plaques that may naturally tamponade small perforations.^10,12 A study by Gunning et al. demonstrated that patients with localised, self-contained perforations without haemodynamic instability could often be managed conservatively with positive outcomes.¹³ The duration of conservative management varies depending on the size of the perforation and patient stability. Literature suggests that observation for at least 24–48 hours is critical, with extended inpatient monitoring up to 2 weeks in select cases to confirm resolution. Patients undergo serial echocardiographic assessment to rule out late pericardial effusion or tamponade.¹⁴ This approach helps to avoid the risks associated with more invasive interventions, which include additional vascular injury, prolonged hospitalisation and the potential for further complications.⁶ Similarly, Lemmert et al. reviewed outcomes in patients with contained coronary perforations, and found that conservative management was associated with lower rates of morbidity and quicker recovery times compared with interventions involving balloon tamponade or covered stent placement.¹⁵

In contrast, interventions, such as balloon tamponade, covered stent placement and surgical repair, are typically reserved for cases with extensive extravasation or significant haemodynamic instability. Balloon tamponade involves inflating a balloon at the site of perforation (or proximal to) to control bleeding, but it requires careful assessment of the perforation size and location to ensure effectiveness.¹⁶ Covered stents offer an alternative by providing a physical barrier over the perforation, but their use is generally restricted to patients with severe perforations where conservative measures may be inadequate. Covered stents carry additional risks, including increased thrombogenicity, which necessitates intensified antiplatelet therapy and may expose the patient to bleeding complications.¹⁷ In the most severe cases, where perforation cannot be managed by endovascular techniques, open surgical repair becomes necessary, although it is associated with higher morbidity and a prolonged recovery process.¹⁸

In the present case, the decision to pursue conservative management was supported by the patient’s stable haemodynamic profile, the contained nature of the perforation and the absence of pericardial effusion on serial imaging. Dual antiplatelet therapy was administered to maintain stent patency while minimising bleeding risks, and regular echocardiography was used to ensure the perforation remained stable. Importantly, conservative management aligns with an individualised approach, considering patient-specific factors, such as lesion characteristics and overall health status.

This case highlights the need for a flexible, case-by-case approach to managing PCI complications, particularly in older patients with calcified lesions, where the risk of coronary perforation is higher. As the frequency of PCI for complex lesions continues to rise, understanding the scenarios in which conservative management can be safely pursued is crucial. This report adds to the body of evidence suggesting that, under controlled conditions, and despite alarming initial appearances, conservative management may be a safe and effective option for coronary perforations in stable patients.

Ultimately, conservative management relies on comprehensive monitoring and imaging to mitigate the risks of further complications. As clinical experience with complex coronary lesions grows, so too does the importance of research and updated guidelines in determining the optimal management approach for PCI-related complications. Further studies comparing outcomes between conservative and interventional management in different patient populations are warranted to guide clinicians on best practices, particularly as this field evolves with advancements in both PCI techniques and imaging modalities.

Conclusion

This case demonstrates the successful conservative management of a striking, but localised, coronary perforation during PCI in a patient with marked coronary calcification within a tortuous vessel course. The patient’s haemodynamic stability, absence of pericardial effusion and the self-contained nature of the perforation allowed for a non-invasive pharmacotherapy-led approach that promoted vascular healing. This report supports the growing body of evidence indicating that conservative management in select, stable patients may suffice without the need for invasive interventions. Highlighting the role of individualised assessment and imaging, this case reinforces the potential of conservative strategies to optimise patient outcomes in PCI-related complications.

The coronary perforation in this case can be likened to the blooming of a slender, yet lethal, flower, reminiscent of the oleander. Just as the oleander’s delicate petals conceal its toxic nature, a perforation, although minute and contained, embodies a silent threat that demands our utmost vigilance. This comparison serves as a reminder to approach such situations with both awe for the intricate beauty of coronary interventions and caution for the underlying risks they entail. In every bloom, there lies both the potential for growth and the need for mindfulness of its dangers.

This case contributes to interventional cardiology practice by highlighting a rarely discussed, but clinically relevant, alternative – strategic deferment of intervention in select cases of coronary perforation. The role of imaging, risk stratification and patient monitoring in guiding this decision makes the case particularly instructive. With evolving PCI techniques and lesion modification strategies, future research should explore when conservative management is not just an option, but a preferred strategy.