Case report
Coronary artery perforations: Four different cases and a review
Perfurações de artérias coronárias: quatro casos diferentes e uma revisão
Ismail Dogu Kilica,
, Yusuf Izzettin Alihanoglua, Serhat B. Yildizb, Ozgur Taskoyluc, Mustafa Zungurd, Ihsan S. Uyare, Harun Evrengula
Autor para correspondência
idogukilic@yahoo.com
Corresponding author: Pamukkale University Hospital, Department of Cardiology, Denizli/TURKEY.
Corresponding author: Pamukkale University Hospital, Department of Cardiology, Denizli/TURKEY.
a Pamukkale University, Medical Faculty, Department of Cardiology, 20070 Denizli/Turkey
b Denizli State Hospital, Department of Cardiology, 20115 Denizli/Turkey
c Servergazi State Hospital, Department of Cardiology, 20185 Denizli/Turkey
d Sifa University, Medical Faculty, Department of Cardiology, 35040 Izmir/Turkey
e Sifa University, Medical Faculty, Department of Cardiovascular Surgery, 35040, Izmir/Turkey
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"apellidos" => "Uyar" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 6 => array:3 [ "nombre" => "Harun" "apellidos" => "Evrengul" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Pamukkale University, Medical Faculty, Department of Cardiology, 20070 Denizli/Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Denizli State Hospital, Department of Cardiology, 20115 Denizli/Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servergazi State Hospital, Department of Cardiology, 20185 Denizli/Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Sifa University, Medical Faculty, Department of Cardiology, 35040 Izmir/Turkey" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Sifa University, Medical Faculty, Department of Cardiovascular Surgery, 35040, Izmir/Turkey" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author: Pamukkale University Hospital, Department of Cardiology, Denizli/TURKEY." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Perfurações de artérias coronárias: quatro casos diferentes e uma revisão" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1500 "Ancho" => 4815 "Tamanyo" => 389016 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Long, thin, angulated and eccentric critical sequential lesions with thrombus in the mid to distal portion of the left anterior descending coronary artery (A); type IV coronary rupture showing prominent contrast flow into the left ventricle (B); control angiogram showing no extravasation around the target area after covered stent implantation (C).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). Its incidence depends on the material and methods for visualizing or opening the coronary arteries. With the advent of new devices and technologies, interventionalists attempt more complex lesions, including more calcified or tortuous vessels.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The first patient was a 70-year-old man complaining of chest pain despite medical treatment. Coronary angiography (CAG) was performed electively with a diagnosis of stable angina pectoris. CAG revealed a long, angulated, eccentric critical lesion in the mid right coronary artery (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A). Direct stenting of the target lesion was performed, and then a type I coronary perforation (limited to the vessel wall without extravasation) was detected on the angiogram (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B). Prolonged balloon inflation only was applied to the ruptured area and the control angiogram showed no extravasation (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C). There was no pericardial effusion on transthoracic echocardigraphy after the procedure.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The second patient was a 58-year-old woman who went to the cardiology outpatient clinic with new-onset, progressive, oppressive chest pain, diagnosed as unstable angina. A long, calcified, eccentric critical lesion was detected in the mid to distal left anterior descending (LAD) coronary artery during CAG (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A). Stenting of the target lesion was performed after balloon predilatation. A type II perforation (showing limited extravasation with some myocardial blushing) was seen on CAG (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>B). A covered stent was immediately implanted to cover the rupture and anticoagulation was reversed. No myocardial blushing was seen on the control CAG (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>C). A mild pericardial effusion, not causing tamponade, was detected by echocardigraphy.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The third patient was a 47-year-old man, who was referred to the cardiology clinic with chest pain on exercise. Since exercise stress testing showed 3-mm horizontal ST-segment depression at the target heart rate, CAG was scheduled. A long, thin, eccentric and calcified critical lesion was seen in the mid circumflex coronary artery during CAG (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A). Stenting after balloon predilatation was planned, but a type III coronary rupture (demonstrating significant contrast streaming into the pericardium) was observed while the guidewire was being advanced (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B). Because a covered stent of suitable size for such a thin lesion was not available in the catheterization laboratory, the patient underwent urgent surgical repair with prolonged balloon inflation proximal to the ruptured area to prevent cardiac tamponade. In addition, reversal of anticoagulation therapy was achieved by protamine.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The fourth patient was a 74-year-old woman who went to the emergency department with new-onset severe chest pain and was diagnosed with acute anterior myocardial infarction. She was transferred to the catheterization laboratory for primary PCI. Long, thin, angulated and eccentric critical sequential lesions with thrombus were detected in the mid to distal portion of the LAD (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>A). After stenting followed by balloon predilatations, prominent contrast flow into the left ventricle was detected on CAG, indicating type IV coronary rupture (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>B). A covered stent was immediately implanted in the ruptured area and anticoagulation was reversed. Control CAG showed no extravasation around the target area (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>C). The echocardiogram revealed mild pericardial effusion with no evidence of cardiac tamponade.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The hemodynamic parameters of all of these patients were within normal limits during follow-up and they were discharged fully recovered from the hospital.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Review</span><p id="par0035" class="elsevierStylePara elsevierViewall">CAP is a rare but feared complication of PCI. Its incidence varies according to patient, lesion and procedure characteristics; studies have reported incidences ranging from 0.29 to 3.0%.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Risk increases with the complexity of the lesions, including chronic total occlusions, angulated calcified type B2 and type C lesions, long (>10 mm), eccentric lesions, and small vessel size.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Older age and previous coronary artery bypass graft surgery also increase the risk.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,5</span></a> Risk factors include conditions associated with increased calcification such as diabetes, hypertension and chronic renal failure.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> Although females are thought to be more prone to perforation due to their smaller vasculature, the data are inconsistent.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Ellis et al. classified coronary perforations based on their angiographic appearance.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Type I perforations are limited to the vessel wall and produce an intramural crater without extravasation on the angiogram. In contrast to type I, types II and III are not limited to the vessel wall. Type II perforations show limited extravasation with pericardial or myocardial blushing on angiography, whereas in type III prominent contrast streaming from a ≥1-mm tear is seen. In the cavity spilling subtype (type IV for some authors) contrast flow can be seen from the perforation site into a cardiac chamber or cavity, such as the left ventricle or coronary sinus, rather than into the pericardium or myocardium. Muller et al. proposed adding a type V to the classification, describing distal perforation associated with the use of hydrophilic and/or stiff guides.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Although other classifications are used, Ellis’ is the most widely accepted.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,10,11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">CAP may occur with the use of guiding catheters, guidewires, oversized balloon/stents, cutting balloons, intravascular ultrasound (IVUS) catheters, or debulking techniques, or following balloon rupture.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,12,13</span></a> A significant proportion of perforations occur with guidewires crossing the lesion, with distal wire perforation or wire fracture.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Physical features of the wire affect the likelihood of CAP. In general, stiffer guides increase the risk of perforation. Likewise, hydrophilic-coated wires have been found to be associated with CAP in some series.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> However; this may reflect either use of these low-friction hydrophilic coated wires to facilitate passage through more complex lesions or their ease of distal migration.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Perforations occur more frequently with debulking techniques than with non-debulking techniques. Considering the mechanism of vessel injury, atheroablative devices often cause type III perforations.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Perforation is more likely when IVUS is used, probably because IVUS is frequently used for complex lesions or when PCI is complicated.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Whether concomitant administration of GP IIb/IIIa inhibitors increases the likelihood of CAP is controversial, since some studies show increased perforation while others do not.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,19–21</span></a> This may be a selection bias, since these agents are generally used in more complicated conditions, but another possible explanation is that they may unmask a minimal vessel tear and convert it to overt perforation.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therapeutic strategies include prolonged balloon inflation, covered stents, reversal of anticoagulation, embolization of the distal vessel and surgery, the choice depending on the site and severity of the perforation, the patient's hemodynamic status and the equipment available in the catheterization laboratory.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Echocardiography should be performed as soon as a perforation is identified. If pericardial hemorrhage or hemodynamic collapse occur pericardiocentesis should be performed immediately with multiple side holes for continuous aspiration, after which the drain should be kept in place for 6–24 hours and reaccumulation should be monitored with echocardiography.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Administration of fluids is recommended. A balloon should immediately be placed with inflations lasting up to 5-10 minutes to block extravasation. If the perforation cannot be sealed, repeated inflations should be made. Distal ischemia being a concern, perfusion balloons can be used without blocking distal blood flow. Reversal of anticoagulation can be achieved with protamine. As previously shown, the use of protamine is safe and does not predispose to stent thrombosis.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,22</span></a> However, diabetic patients on protamine containing insulin and patients with fish allergy are at increased risk for protamine reactions. GP IIb/IIIa inhibitors should also be discontinued and platelet transfusions should be used if needed.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Deployment of a covered stent is another therapeutic approach, especially with a large tear involving a proximal or mid coronary artery. Autologous vein-covered stents have been used successfully in the past,<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a> but this technique is time-consuming and requires expertise. Polytetrafluoroethylene (PTFE) is an inert and biocompatible polymer composed of carbon chains saturated with fluorine and in contrast to vein-covered stents, PTFE-covered stents are easy and rapid to deploy. However, due to the high profile and poor flexibility of these stents, it is often difficult to deliver them to the target site, especially when the vessel is heavily calcified and tortuous.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The use of IVUS to ensure correct stent implantation and final high-pressure balloon inflation may improve the outcome.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Pericardium-covered stents with greater flexibility are an alternative treatment, although experience is limited.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> Stent thrombosis and in-stent restenosis are major concerns with covered stents, as is side branch occlusion.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,25</span></a> Although data are scarce, prasugrel, due to its lack of intrinsic resistance, can be considered the thienopyridine of choice for stent thrombosis.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Another major drawback, the time elapsed between deflation of the sealing balloon and the final delivery of the covered stent to the lesion site, can be overcome by a dual catheter technique.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Alternative therapies used in selected cases include coil embolization, thrombogenic particles including polyvinyl alcohol, gelfoam, thrombin, embolic agents like N-butyl cyanoacrylate glue, and autologous blood clot.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31</span></a> Although potentially useful in emergency situations, these agents carry a risk of loss of the vessel lumen and subsequent infarction. Vessel occlusion techniques should therefore be used as a last resort for the treatment of distal perforations, in which the potential for myocardial injury is limited.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">If a large perforation causes severe ischemia or hemodynamic deterioration or cannot be sealed with the available techniques, emergency surgery is indicated. Surgical intervention may be life-saving, but, since these patients have more severe perforations, it is associated with higher morbidity and mortality and worse outcome. Earlier surgical referral should be considered in this context when dealing with high-grade perforations.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="par0075" class="elsevierStylePara elsevierViewall">CAP is a rare but feared complication in the catheterization laboratory. PCI in calcified or tortuous vessels or in chronic total occlusions or complex lesions increases the risk of CAP. Choosing appropriate therapy may be life-saving.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres290299" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec273997" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres290298" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec273996" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Review" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusions" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-02-19" "fechaAceptado" => "2013-02-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec273997" "palabras" => array:3 [ 0 => "Coronary artery perforation" 1 => "Complication" 2 => "Percutaneous coronary intervention" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec273996" "palabras" => array:3 [ 0 => "Perfurações de artérias coronárias" 1 => "Complicação" 2 => "Intervenção coronária percutânea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coronary artery perforation (CAP) is a rare but feared complication of percutaneous coronary intervention. With the advent of new devices and technologies, interventionalists attempt more complex lesions, including more calcified or tortuous vessels and chronic total occlusions, which increases the incidence of CAP. A short literature review, in addition to four cases of CAP, is presented in this report.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">As perfurações das artérias coronárias são raras, mas complicações temidas nas intervenções coronarianas percutâneas. Com o advento de novos dispositivos e tecnologias, a tentativa de intervenção em lesões mais complexas, incluindo os vasos mais calcificados ou tortuosos ou oclusões crónicas, leva a maior incidência de perfurações de artérias coronárias. Uma breve revisão da literatura, além de quatro casos de perfurações de artérias coronárias foi apresentada no presente trabalho.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1479 "Ancho" => 4484 "Tamanyo" => 442755 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A long, angulated, and eccentric critical lesion in the mid right coronary artery (A); type I coronary perforation limited to the vessel wall without extravasation (B); control angiogram showing no extravasation (C) after prolonged balloon inflation at the ruptured area.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1496 "Ancho" => 4628 "Tamanyo" => 465999 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A long, calcified, and eccentric critical lesion in the mid to distal left anterior descending coronary artery (A); type II perforation showing limited extravasation with some myocardial blushing (B); no myocardial blushing is seen on the control angiogram after covered stenting (C).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1500 "Ancho" => 3779 "Tamanyo" => 343962 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A thin, long, eccentric and calcified critical lesion in the mid circumflex coronary artery (A); guidewire-induced type III coronary rupture demonstrating significant contrast streaming into the pericardium (B).</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1500 "Ancho" => 4815 "Tamanyo" => 389016 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Long, thin, angulated and eccentric critical sequential lesions with thrombus in the mid to distal portion of the left anterior descending coronary artery (A); type IV coronary rupture showing prominent contrast flow into the left ventricle (B); control angiogram showing no extravasation around the target area after covered stent implantation (C).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Increased coronary perforation in the new device era. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 10 | 9 | 19 |
| 2024 Outubro | 35 | 36 | 71 |
| 2024 Setembro | 52 | 23 | 75 |
| 2024 Agosto | 55 | 30 | 85 |
| 2024 Julho | 42 | 36 | 78 |
| 2024 Junho | 40 | 23 | 63 |
| 2024 Maio | 91 | 13 | 104 |
| 2024 Abril | 58 | 24 | 82 |
| 2024 Maro | 44 | 27 | 71 |
| 2024 Fevereiro | 53 | 25 | 78 |
| 2024 Janeiro | 41 | 24 | 65 |
| 2023 Dezembro | 41 | 22 | 63 |
| 2023 Novembro | 69 | 22 | 91 |
| 2023 Outubro | 61 | 26 | 87 |
| 2023 Setembro | 53 | 19 | 72 |
| 2023 Agosto | 36 | 22 | 58 |
| 2023 Julho | 47 | 9 | 56 |
| 2023 Junho | 49 | 14 | 63 |
| 2023 Maio | 62 | 27 | 89 |
| 2023 Abril | 49 | 6 | 55 |
| 2023 Maro | 55 | 27 | 82 |
| 2023 Fevereiro | 41 | 15 | 56 |
| 2023 Janeiro | 43 | 13 | 56 |
| 2022 Dezembro | 46 | 18 | 64 |
| 2022 Novembro | 52 | 25 | 77 |
| 2022 Outubro | 34 | 18 | 52 |
| 2022 Setembro | 37 | 22 | 59 |
| 2022 Agosto | 33 | 32 | 65 |
| 2022 Julho | 43 | 34 | 77 |
| 2022 Junho | 26 | 18 | 44 |
| 2022 Maio | 30 | 32 | 62 |
| 2022 Abril | 39 | 26 | 65 |
| 2022 Maro | 29 | 40 | 69 |
| 2022 Fevereiro | 24 | 23 | 47 |
| 2022 Janeiro | 37 | 28 | 65 |
| 2021 Dezembro | 23 | 33 | 56 |
| 2021 Novembro | 35 | 49 | 84 |
| 2021 Outubro | 36 | 41 | 77 |
| 2021 Setembro | 37 | 30 | 67 |
| 2021 Agosto | 25 | 28 | 53 |
| 2021 Julho | 22 | 24 | 46 |
| 2021 Junho | 23 | 11 | 34 |
| 2021 Maio | 20 | 27 | 47 |
| 2021 Abril | 50 | 36 | 86 |
| 2021 Maro | 89 | 17 | 106 |
| 2021 Fevereiro | 39 | 13 | 52 |
| 2021 Janeiro | 33 | 11 | 44 |
| 2020 Dezembro | 34 | 10 | 44 |
| 2020 Novembro | 29 | 6 | 35 |
| 2020 Outubro | 20 | 4 | 24 |
| 2020 Setembro | 28 | 9 | 37 |
| 2020 Agosto | 36 | 7 | 43 |
| 2020 Julho | 41 | 8 | 49 |
| 2020 Junho | 31 | 4 | 35 |
| 2020 Maio | 32 | 5 | 37 |
| 2020 Abril | 31 | 8 | 39 |
| 2020 Maro | 31 | 4 | 35 |
| 2020 Fevereiro | 58 | 21 | 79 |
| 2020 Janeiro | 36 | 7 | 43 |
| 2019 Dezembro | 38 | 6 | 44 |
| 2019 Novembro | 30 | 6 | 36 |
| 2019 Outubro | 28 | 6 | 34 |
| 2019 Setembro | 25 | 13 | 38 |
| 2019 Agosto | 27 | 6 | 33 |
| 2019 Julho | 30 | 15 | 45 |
| 2019 Junho | 24 | 8 | 32 |
| 2019 Maio | 33 | 12 | 45 |
| 2019 Abril | 52 | 26 | 78 |
| 2019 Maro | 33 | 18 | 51 |
| 2019 Fevereiro | 39 | 11 | 50 |
| 2019 Janeiro | 23 | 3 | 26 |
| 2018 Dezembro | 35 | 7 | 42 |
| 2018 Novembro | 160 | 10 | 170 |
| 2018 Outubro | 574 | 14 | 588 |
| 2018 Setembro | 198 | 12 | 210 |
| 2018 Agosto | 97 | 13 | 110 |
| 2018 Julho | 83 | 8 | 91 |
| 2018 Junho | 94 | 14 | 108 |
| 2018 Maio | 97 | 10 | 107 |
| 2018 Abril | 90 | 18 | 108 |
| 2018 Maro | 124 | 12 | 136 |
| 2018 Fevereiro | 76 | 11 | 87 |
| 2018 Janeiro | 107 | 8 | 115 |
| 2017 Dezembro | 200 | 17 | 217 |
| 2017 Novembro | 98 | 13 | 111 |
| 2017 Outubro | 91 | 26 | 117 |
| 2017 Setembro | 88 | 11 | 99 |
| 2017 Agosto | 197 | 13 | 210 |
| 2017 Julho | 94 | 8 | 102 |
| 2017 Junho | 49 | 13 | 62 |
| 2017 Maio | 90 | 14 | 104 |
| 2017 Abril | 22 | 13 | 35 |
| 2017 Maro | 20 | 36 | 56 |
| 2017 Fevereiro | 142 | 7 | 149 |
| 2017 Janeiro | 27 | 6 | 33 |
| 2016 Dezembro | 57 | 11 | 68 |
| 2016 Novembro | 128 | 4 | 132 |
| 2016 Outubro | 202 | 4 | 206 |
| 2016 Setembro | 289 | 35 | 324 |
| 2016 Agosto | 168 | 15 | 183 |
| 2016 Julho | 33 | 6 | 39 |
| 2016 Junho | 10 | 23 | 33 |
| 2016 Maio | 1 | 0 | 1 |
| 2016 Abril | 163 | 5 | 168 |
| 2016 Maro | 274 | 31 | 305 |
| 2016 Fevereiro | 243 | 37 | 280 |
| 2016 Janeiro | 237 | 36 | 273 |
| 2015 Dezembro | 196 | 18 | 214 |
| 2015 Novembro | 186 | 26 | 212 |
| 2015 Outubro | 230 | 33 | 263 |
| 2015 Setembro | 180 | 16 | 196 |
| 2015 Agosto | 255 | 25 | 280 |
| 2015 Julho | 289 | 25 | 314 |
| 2015 Junho | 189 | 17 | 206 |
| 2015 Maio | 167 | 20 | 187 |
| 2015 Abril | 202 | 33 | 235 |
| 2015 Maro | 200 | 8 | 208 |
| 2015 Fevereiro | 180 | 7 | 187 |
| 2015 Janeiro | 178 | 11 | 189 |
| 2014 Dezembro | 162 | 14 | 176 |
| 2014 Novembro | 173 | 16 | 189 |
| 2014 Outubro | 183 | 11 | 194 |
| 2014 Setembro | 126 | 18 | 144 |
| 2014 Agosto | 112 | 7 | 119 |
| 2014 Julho | 93 | 13 | 106 |
| 2014 Junho | 96 | 14 | 110 |
| 2014 Maio | 106 | 14 | 120 |
| 2014 Abril | 113 | 17 | 130 |
| 2014 Maro | 116 | 22 | 138 |
| 2014 Fevereiro | 114 | 18 | 132 |
| 2014 Janeiro | 108 | 26 | 134 |
| 2013 Dezembro | 100 | 24 | 124 |
| 2013 Novembro | 72 | 21 | 93 |
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