title: Outcomes of patients with coronary artery perforation complicating percutaneous coronary intervention and correlations with the type of adjunctive antithrombotic therapy: pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials.
abstract: BACKGROUND
  The lack of a specific counteragent to bivalirudin may complicate the management of patients with coronary artery (CA) perforation during percutaneous coronary intervention (PCI).
  
  
  OBJECTIVE
  Assess outcomes of patients with CA perforation from three PCI trials comparing intravenous bivalirudin with provisional glycoprotein (GP) IIb/IIIa inhibition versus unfractionated heparin (UFH) plus GP IIb/IIIa.
  
  
  METHODS
  A pooled analysis of patients treated with PCI in three randomized trials including REPLACE-2, ACUITY, and HORIZONS-AMI.
  
  
  RESULTS
  Among a total of 12,921 patients, CA perforation occurred in 35 patients (0.27%). By multivariable analysis, baseline creatinine clearance was the only independent predictor of CA perforation (per 10 mL/min decrease, odds ratio [95% confidence interval]= 1.28 [1.11, 1.47], P = 0.0007). At 30 days, patients with versus without CA perforation had significantly (all P values < or =0.001) higher rates of 30-day mortality (11.4% vs. 1.0%), myocardial infarction (MI) [Q wave: 22.9% vs. 5.7%; non-Q wave: 17.1% vs. 4.9%], target vessel revascularization (TVR) [20.1% vs. 1.8%], and composite end-point of death/MI/TVR (31.4% vs. 7.8%). Patients assigned to bivalirudin versus UFH plus a GP IIb/IIIa inhibitor had nonsignificantly lower rates of death (0% vs. 18.8%, P = 0.08), similar rates of MI (26.7% vs. 25.0%, P = 0.92), significantly lower rates of TVR (6.7% vs. 37.5%, P = 0.04), and similar rates of the composite end-point of death/MI/TVR (35.5% vs. 26.7%, P = 0.54).
  
  
  CONCLUSIONS
  In three PCI trials, treatment of patients experiencing CA perforation with adjunctive antithrombotic therapy of bivalirudin monotherapy was not associated with worse outcomes compared to treatment with UFH plus GP IIb/IIIa inhibitors.
authors.affiliation: Columbia University Medical Center and the Cardiovascular Research Foundation, New York, USA.
authors.forename: Jacob A
authors.initials: JA
authors.lastname: Doll
authors.forename: Eugenia
authors.initials: E
authors.lastname: Nikolsky
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: A Michael
authors.initials: AM
authors.lastname: Lincoff
authors.forename: Adriano
authors.initials: A
authors.lastname: Caixeta
authors.forename: Brent
authors.initials: B
authors.lastname: McLaurin
authors.forename: Ecaterina
authors.initials: E
authors.lastname: Cristea
authors.forename: Martin
authors.initials: M
authors.lastname: Fahy
authors.forename: Vijaya
authors.initials: V
authors.lastname: Kesanakurthy
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage; D017024:Chemotherapy, Adjuvant; D003331:Coronary Vessels / Q000293:injuries*; D004359:Drug Therapy, Combination; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006493:Heparin / Q000008:administration & dosage; D006629:Hirudins / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000401:mortality / Q000601:surgery*; D009204:Myocardial Revascularization / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D010446:Peptide Fragments / Q000008:administration & dosage*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D011994:Recombinant Proteins / Q000008:administration & dosage; D015996:Survival Rate; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000209:etiology* / Q000628:therapy*
chemical_list: D000925:Anticoagulants; D005343:Fibrinolytic Agents; D006629:Hirudins; D010446:Peptide Fragments; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D006493:Heparin; C074619:bivalirudin