CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/coronary-perforationIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • ImageContrast outside the vessel: a crater (Ellis I), a myocardial or pericardial blush (Ellis II), a jet through an exit hole of 1 mm or more (Ellis III), or spill into a chamber or the coronary sinus (III cavity spilling) 12.
  • ImageA wire tip that moves freely beyond the vessel outline, or a wire tip that will not move, after stiff or polymer jacketed wiring 2.
  • MonitorFalling pressure and a rising heart rate after a high pressure inflation, an oversized balloon, atherectomy or a balloon rupture; beta blocked patients may not speed up 23.
  • PatientNew chest pain, restlessness, nausea or a vasovagal look minutes after the inflation.
  • EchoA new or growing pericardial effusion; right sided collapse when it becomes tamponade 3.
  • PatientDistal wire perforations can bleed slowly and declare hours after the case 2.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Inflate a balloon sized to the vessel at or just proximal to the hole, semicompliant and no more than 8 to 10 atm, and keep it up for at least 10 to 15 minutes 2.
  2. Call for help: a second operator, echo to the room, and tell the team this is a perforation.
  3. Stop glycoprotein IIb/IIIa inhibitors or cangrelor; stop bivalirudin, which takes up to 2 hours to wear off; do not give protamine yet 24.
  4. Support the pressure: fluids, vasopressors, and atropine for a vasovagal slowing 2.
  5. Echo now; drain the pericardium at once if the patient is unstable, by echo or fluoroscopic guidance, and consider returning the blood through a venous sheath 23.
  6. Notify cardiac surgery early, before the percutaneous options are exhausted 2.
  7. Get a second arterial access if the guide is not 8 Fr, for a second guide 2.
  8. Large vessel: deliver a covered stent across the hole through one large guide (block and deliver) or a second guide (ping pong), then post dilate it at high pressure 2.
  9. Sources differ: the Graftmaster needs a 6 Fr guide (7 Fr for 4.5 and 4.8 mm) in Brilakis's table and a 7 Fr guide per the package insert quoted by Kern; check the current IFU 24.
  10. Distal branch: wire the branch, take a microcatheter to the hole and embolize with fat or coils; a covered stent over the branch origin if the branch cannot be wired 2.
  11. Test injection: no more contrast leaving the vessel. In prior CABG patients treat even small perforations at once, as loculated effusions can be lethal 2.
  12. Reverse heparin with protamine only after all equipment is out of the coronary and the pericardium is drained 24.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Protamine (after equipment is out)1 mg per 100 units of heparin, maximum 50 mg, no faster than 5 mg per minute; anaphylaxis risk after NPH insulin or with fish allergy 2.Weight based dose in the Cath Med App
  • Sources differ: Brilakis gives 1 mg per 100 units in chapter 26 and 1 to 1.5 mg per 100 units in chapter 3; the Cath Med App calculator uses 0.25 mg per 100 units. Follow your lab protocol 256.
  • Atropine0.5 mg IV, repeat to a total of 3 mg, for vasovagal bradycardia 5.
  • Norepinephrine0.1 to 0.5 mcg/kg/min IV infusion 5.
  • Phenylephrine50 to 100 mcg IV bolus, then 0.5 to 1.4 mcg/kg/min 5.
  • Eptifibatide, tirofiban, cangrelorStop the infusion; there is no reversal agent and platelet function returns gradually 5.Weight based dose in the Cath Med App

Who to call

The escalation ladder, first call first.

  1. Second operator: now, to run the balloon while you set up the covered stent or the coils.
  2. Echo: to the room for the effusion and to guide the drain.
  3. Cardiac surgery: early, while the balloon is up; surgery for bleeding that percutaneous sealing does not stop 2.
  4. Anesthesia: if the airway or sedation becomes a problem, or for the operating room.
  5. Shock team: if the pressure does not recover after drainage.
  6. Interventional radiology: for coils if the lab rarely coils 2.

The bailout step by step

Covered stent through a second guide (ping pong) 24

  1. Keep the sealing balloon inflated over the first wire.
  2. Pull the first guide back slightly in the aorta; engage the ostium with a second guide (6 Fr or larger for PK Papyrus, 8 Fr ideal for Graftmaster) from the second access 2.
  3. Advance a second wire to the tip of the inflated balloon.
  4. Deflate the balloon briefly, pass the second wire beyond the hole, reinflate.
  5. Bring the covered stent on the second wire up to the proximal edge of the inflated balloon.
  6. Deflate and pull back the balloon, cross the hole with the covered stent, deploy; if it will not cross, reinflate the balloon and add support.
  7. Remove the first wire and balloon; post dilate the covered stent at high pressure with a noncompliant balloon 2.
  8. Test injection; stent any edge dissection that could let bleeding reenter 2.
  9. With one 8 Fr guide the same steps run through a single guide (block and deliver), the balloon and the stent side by side 2.

Prevent

  • Size balloons and stents to the vessel, with intravascular imaging when in doubt; avoid very high pressure inflations 2.
  • Confirm the wire is in the vessel architecture before advancing anything over it 2.
  • Swap stiff and polymer jacketed wires for a workhorse wire once across; trap the wire during exchanges 2.
  • Keep the distal wire tip in view when collimating 7.

After care and documentation

  • Echo before leaving the lab and again with any drop in pressure; distal perforations can declare hours later 2.
  • Leave a pericardial drain overnight when one was placed 4.
  • No glycoprotein IIb/IIIa inhibitor or cangrelor after a distal perforation, as tamponade can follow hours later 2.
  • Document the Ellis class, the hole site, the devices used, the volume drained and the time to seal.
  • Report a covered stent or device problem through your device reporting process; debrief the team.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0002: Chest pain and a restless patient after post-dilation of a calcified LAD
  • EMG-0006: A restless patient after a high pressure inflation
  • EMG-0029: Slow pressure fall during a wire escalation

References

  1. Ellis SG, Ajluni S, Arnold AZ, et al. Increased coronary perforation in the new device era: incidence, classification, management, and outcome. Circulation 1994;90:2725-2730.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 26, Perforation.
  3. Sorajja P. Pericardiocentesis. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 18.
  4. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  6. CathLabHub Cath Med App: weight based heparin, protamine, bivalirudin, eptifibatide, adenosine, aminophylline and dobutamine doses (cathlabhub.com/meds). Check the doses against your lab protocol.
  7. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 28, Other complications: hypotension, radiation skin injury, contrast induced acute kidney injury.
  8. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/coronary-perforation. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.