Off-pump treatment of coronary artery perforation after percutaneous intervention with a pericardial patch
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a Department of Cardiac Surgery, C.U.B. Erasme Hospital, 808 Route de Lennik, 1070 Brussels, Belgium
b Department of Cardiology, Erasme Hospital, Brussels, Belgium
Abstract
Coronary artery perforation is a rare complication of percutaneous coronary interventions, usually requiring surgical intervention. A case of perforation of the diagonal branch after stent deployment is reported. Off-pump surgery was performed with the use of a pericardial patch and surgical glue to close the perforation. Epidemiology and treatment are discussed.
Key Words: Coronary perforation; Stent; Pericardial patch
1. Introduction
Coronary artery perforation is a rare, but life-threatening complication of percutaneous coronary interventions and surgical treatment is necessary in 63% of cases [1]. We describe a case presenting with tamponade and treated by drainage, removal of the stent and use of an autologous pericardial patch and surgical glue for the closure of the coronary perforation.
2. Case report
A 47-year-old woman was admitted with a new onset of exertional angina. Her past medical history revealed diabetes mellitus, asthma and osteoporosis. She was treated with aspirin and insulin. Her electrocardiogram was normal. The stress test was positive. Her myocardial scintigraphy showed an alteration of the left ventricular function in the anterior territory. Coronary angiography showed a 90% lesion in the diagonal branch and a 50% lesion in the first portion of the left anterior descending coronary artery (LAD). A percutaneous coronary intervention was performed.
A floppy wire and a 2.5x20 mm balloon were inserted from the right femoral artery. The balloon was inflated to 18 atm in the LAD and flow was increased in the two branches. Two 3x23 mm Cypher drug-eluting stents (Cordis Cardiology, Miami Lakes, FL) were deployed, first in the LAD and subsequently in the diagonal branch.
The balloon was inflated to 16 atm within the diagonal branch. After balloon deflation, coronary angiography revealed extravasation of contrast into the pericardial cavity. Because the patient was gradually becoming hypotensive, the balloon was inflated at the perforation site inside the stent. During these procedures, no ST-T segment changes were observed. However, a repeat angiogram with the balloon deflated showed persistent leakage of contrast into the pericardial cavity. The patient was urgently taken to the operating room with the balloon inflated.
She underwent standard anesthetic procedure and surgery was performed through a median sternotomy. When the pericardium was opened, 400 ml of fresh blood was evacuated. The stent extremity was observed protruding from the diagonal branch (Fig. 1), the inflated balloon preventing blood extravasation. A fresh autologous pericardial patch was fixed around the perforation with 6-0 polypropylene sutures on the beating heart. Before the end of the suture, the coronary balloon was deflated and removed from the right femoral sheath and the stent was easily removed by the surgeon. Surgical glue, Tissucol (Baxter AG, Vienna, Austria), was applied under and around the pericardial patch. The postoperative course was uneventful, there was no evidence of myocardial infarction, with only a modest increase of cardiac enzymes, and unchanged postoperative cardiac function. The patient was discharged on day seven after surgery.
3. Discussion
Coronary artery perforation is a rare but dreaded complication of percutaneous coronary intervention. It has been reported to occur in 0.2–0.8% [1–3] of the procedures. Higher incidence was observed with the use of atheroablative devices that cut, vaporize, or drill the vessel wall [1,4]. The coronary artery perforation is more frequent in female patients [3]. Hemodynamically significant pericardial effusion occurs in 0.38% of cases necessitating drainage by pericardiocentesis or surgical intervention [2]. The therapeutic alternatives for coronary artery perforation include prolonged balloon inflation, bare stents, polytetrafluo- roethylene-covered stents, autologous vein graft-covered stents, micro coils, preclotted autologous blood clot embolization [5–8] and surgery.
Ellis and associates [1] proposed a classification system for coronary perforation of types 1–3 based on severity. Our patient met the criteria for type 3: extravasation of contrast material through a frank perforation requiring surgical intervention.
In our case, coronary artery bypass grafting was not performed because the diagonal vessel was small without dissection, and the stent was easily removed. The presence of a stent in the LAD further influenced the decision, as a more extensive surgery would increase the risk of early thrombosis. Surgical strategies are not standardized but mainly depend on the surgical anatomy, simple ligation of the vessel is not recommended as it may cause myocardial infarction. We believe such extensive methods are not usually necessary for perforation repair. Our approach is a feasible and reasonable option for the treatment of coronary perforation caused by stent insertion.
References
Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation 1994;90:2725–2730.
Gunning MG, Williams IL, Jewitt DE, Shah AM, Wainwright RJ, Thomas MR. Heart 2002;88:495–498.
Gruberg L, Pinnow E, Flood R, Bonnet Y, Tebeica M, Walksman R, Satler LF, Pichard AD, Kent KM, Leon MB, Lindsay J. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2000;86:680–682.
Van Suylen RJ, Serruys PW, Simpson JB, De Feyter PJ, Strauss BH, Zondervan PE. Delayed rupture of right coronary after directional atherectomy for bail out. Am Heart J 1991;121:914–916.
Thomas MR, Wainwright RJ. Use of intracoronary stent to control intrapericardial bleeding during coronary artery rupture complicating coronary angioplasty. Cathet Cardiovasc Diagn 1993;30:169–172.
Ramsdale DR, Mushahwae SS, Morris JL. Repair of coronary artery perforation after rotastenting by implantation of the Jostent covered stent. Cathet Cardiovasc Diagn 1998;45:310–313.
Dorros G, Jain A, Kumar K. Management of coronary artery rupture: covered stent or microcoil embolization. Cathet Cardiovasc Diagn 1995;36:148–154.
Hadjimiltiades S, Paraskevaides S, Kazinakis G, Louridas G. Coronary perforation during balloon angioplasty: a case report. Cathet Cardiovasc Diagn 1998;45:417–420.(Bachar El Oumeiri, Alex L)
b Department of Cardiology, Erasme Hospital, Brussels, Belgium
Abstract
Coronary artery perforation is a rare complication of percutaneous coronary interventions, usually requiring surgical intervention. A case of perforation of the diagonal branch after stent deployment is reported. Off-pump surgery was performed with the use of a pericardial patch and surgical glue to close the perforation. Epidemiology and treatment are discussed.
Key Words: Coronary perforation; Stent; Pericardial patch
1. Introduction
Coronary artery perforation is a rare, but life-threatening complication of percutaneous coronary interventions and surgical treatment is necessary in 63% of cases [1]. We describe a case presenting with tamponade and treated by drainage, removal of the stent and use of an autologous pericardial patch and surgical glue for the closure of the coronary perforation.
2. Case report
A 47-year-old woman was admitted with a new onset of exertional angina. Her past medical history revealed diabetes mellitus, asthma and osteoporosis. She was treated with aspirin and insulin. Her electrocardiogram was normal. The stress test was positive. Her myocardial scintigraphy showed an alteration of the left ventricular function in the anterior territory. Coronary angiography showed a 90% lesion in the diagonal branch and a 50% lesion in the first portion of the left anterior descending coronary artery (LAD). A percutaneous coronary intervention was performed.
A floppy wire and a 2.5x20 mm balloon were inserted from the right femoral artery. The balloon was inflated to 18 atm in the LAD and flow was increased in the two branches. Two 3x23 mm Cypher drug-eluting stents (Cordis Cardiology, Miami Lakes, FL) were deployed, first in the LAD and subsequently in the diagonal branch.
The balloon was inflated to 16 atm within the diagonal branch. After balloon deflation, coronary angiography revealed extravasation of contrast into the pericardial cavity. Because the patient was gradually becoming hypotensive, the balloon was inflated at the perforation site inside the stent. During these procedures, no ST-T segment changes were observed. However, a repeat angiogram with the balloon deflated showed persistent leakage of contrast into the pericardial cavity. The patient was urgently taken to the operating room with the balloon inflated.
She underwent standard anesthetic procedure and surgery was performed through a median sternotomy. When the pericardium was opened, 400 ml of fresh blood was evacuated. The stent extremity was observed protruding from the diagonal branch (Fig. 1), the inflated balloon preventing blood extravasation. A fresh autologous pericardial patch was fixed around the perforation with 6-0 polypropylene sutures on the beating heart. Before the end of the suture, the coronary balloon was deflated and removed from the right femoral sheath and the stent was easily removed by the surgeon. Surgical glue, Tissucol (Baxter AG, Vienna, Austria), was applied under and around the pericardial patch. The postoperative course was uneventful, there was no evidence of myocardial infarction, with only a modest increase of cardiac enzymes, and unchanged postoperative cardiac function. The patient was discharged on day seven after surgery.
3. Discussion
Coronary artery perforation is a rare but dreaded complication of percutaneous coronary intervention. It has been reported to occur in 0.2–0.8% [1–3] of the procedures. Higher incidence was observed with the use of atheroablative devices that cut, vaporize, or drill the vessel wall [1,4]. The coronary artery perforation is more frequent in female patients [3]. Hemodynamically significant pericardial effusion occurs in 0.38% of cases necessitating drainage by pericardiocentesis or surgical intervention [2]. The therapeutic alternatives for coronary artery perforation include prolonged balloon inflation, bare stents, polytetrafluo- roethylene-covered stents, autologous vein graft-covered stents, micro coils, preclotted autologous blood clot embolization [5–8] and surgery.
Ellis and associates [1] proposed a classification system for coronary perforation of types 1–3 based on severity. Our patient met the criteria for type 3: extravasation of contrast material through a frank perforation requiring surgical intervention.
In our case, coronary artery bypass grafting was not performed because the diagonal vessel was small without dissection, and the stent was easily removed. The presence of a stent in the LAD further influenced the decision, as a more extensive surgery would increase the risk of early thrombosis. Surgical strategies are not standardized but mainly depend on the surgical anatomy, simple ligation of the vessel is not recommended as it may cause myocardial infarction. We believe such extensive methods are not usually necessary for perforation repair. Our approach is a feasible and reasonable option for the treatment of coronary perforation caused by stent insertion.
References
Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, Cowley MJ, Raymond RE, Safian RD, Whitlow PL. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation 1994;90:2725–2730.
Gunning MG, Williams IL, Jewitt DE, Shah AM, Wainwright RJ, Thomas MR. Heart 2002;88:495–498.
Gruberg L, Pinnow E, Flood R, Bonnet Y, Tebeica M, Walksman R, Satler LF, Pichard AD, Kent KM, Leon MB, Lindsay J. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2000;86:680–682.
Van Suylen RJ, Serruys PW, Simpson JB, De Feyter PJ, Strauss BH, Zondervan PE. Delayed rupture of right coronary after directional atherectomy for bail out. Am Heart J 1991;121:914–916.
Thomas MR, Wainwright RJ. Use of intracoronary stent to control intrapericardial bleeding during coronary artery rupture complicating coronary angioplasty. Cathet Cardiovasc Diagn 1993;30:169–172.
Ramsdale DR, Mushahwae SS, Morris JL. Repair of coronary artery perforation after rotastenting by implantation of the Jostent covered stent. Cathet Cardiovasc Diagn 1998;45:310–313.
Dorros G, Jain A, Kumar K. Management of coronary artery rupture: covered stent or microcoil embolization. Cathet Cardiovasc Diagn 1995;36:148–154.
Hadjimiltiades S, Paraskevaides S, Kazinakis G, Louridas G. Coronary perforation during balloon angioplasty: a case report. Cathet Cardiovasc Diagn 1998;45:417–420.(Bachar El Oumeiri, Alex L)