Ann Thorac Surg 2001;71:2024-2026
© 2001 The Society of Thoracic Surgeons
Case report
Emergent operation for percutaneous coronary rupture after abciximab administration
Charles S. Roberts, MDa,
N. Ruben Bocanegra, PAa
a Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
Accepted for publication April 18, 2000.
Address reprint requests to Dr Roberts, Division of Cardiothoracic Surgery, The University of North Carolina, 108 Burnett-Womack Bldg. CB#7065, Chapel Hill, NC 27599-7065
e-mail: charless{at}med.unc.edu
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Abstract
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A 72-year-old woman had rupture of a coronary artery during angioplasty in the setting of abciximab therapy. Prolonged reinflation of the balloon failed to produce closure of the perforated site. Emergency coronary ligation and bypass after abciximab administration was associated with excessive postoperative bleeding.
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Introduction
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Intrapericardial extravasation of blood from a coronary artery ruptured during balloon angioplasty is rare [1]. Iatrogenic rupture of a coronary artery in the setting of abciximab therapy is described.
A 72-year-old woman was admitted for elective placement of a stent in her left anterior descending coronary artery (LAD). For more than 5 years, she had angina pectoris, which was increasing in frequency and duration. She was taking isosorbide dinitrate and aspirin, as well as sublingual nitrates as needed. An exercise stress thallium test was positive, and a cardiac catheterization with coronary angiography was done. The left ventricular ejection fraction was 0.59, and the apex was akinetic. The LAD had a long severe narrowing (99% diameter reduction) in its midportion with sluggish distal filling, and the second diagonal branch had a proximal 90% diameter reduction. The left circumflex coronary artery had a 50% diameter reduction distally, with the posterior descending branch arising from it. The right coronary artery was diminutive and unobstructed.
Eight days after the angiography, she returned for elective placement of a stent in the LAD. At the start of the procedure, abciximab was administered intravenously as a bolus of 12.5 mg. The LAD narrowing was crossed with a guide wire and predilated with a balloon. After balloon deflation, an injection of contrast medium showed extravasation from the LAD into the pericardial space (Fig 1). The balloon was immediately reinflated at low pressure for 10 minutes, allowing distal flow through the perfusion balloon. After balloon deflation, a repeat injection of contrast medium still showed extravasation. Therefore, the balloon was reinflated at low pressure, and preparations were made for emergent operation.
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Fig 1. Right anterior oblique view of the left inferior descending coronary artery, which has a perforation through which contrast medium has entered the pericardial space.
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Because she had stable hemodynamics, the left internal mammary artery was taken down. Pericardiotomy revealed hemopericardium but no active coronary bleeding because the balloon was still inflated. At the midportion of the LAD, the epicardial fat was hemorrhagic (Fig 2). Heparin was given and cardiopulmonary bypass established. Two segments of greater saphenous vein were removed from the left thigh, and three coronary anastomoses were made. A vein graft was sewn to the posterior descending branch of the left circumflex coronary artery, another vein graft to the second diagonal branch, and the left internal mammary artery to the LAD just beyond the hemorrhagic epicardial fat.
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Fig 2. Operative view of the quiescent heart during cardiopulmonary bypass, showing extensive subepicardial hemorrhage surrounding the site of rupture of the left anterior descending coronary artery.
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The aortic cross-clamp was removed, and the two aortosaphenous vein graft anastomoses were made. The balloon was deflated and withdrawn, and the site of rupture of the LAD began to bleed profusely as the heart began to beat. Therefore, the LAD was ligated using deep sutures, proximal to the anastomosis of the left internal mammary artery to the LAD. The patient then was weaned easily from cardiopulmonary bypass.
During the next 12 hours, approximately 3.5 L of blood drained through the mediastinal tubes. Aprotinin was given postoperatively in a bolus of 1 million units, followed by 500,000 units per hour for 3 hours. In addition, seven units of packed red blood cells, six units of platelets, and six units of fresh frozen plasma were administered during the first 12 hours. Immediately after the operation hemoglobin was 7.7 mg/dL and at 12 hours was 9.7 mg/dL. The prothrombin time and partial thromboplastin time remained mildly elevated during those 12 hours. No reoperation was undertaken.
On the ninth postoperative day, she had an episode of sustained monomorphic ventricular tachycardia that produced hemodynamic instability and required external cardioversion. Six days later, an internal defibrillator with a right ventricular lead system was implanted. An echocardiogram on the 11th postoperative day showed normal left ventricular systolic function and apical akinesis, as noted preoperatively. She was discharged on the 19th day after her cardiac operation; and at 8 months postoperatively in clinic, she was asymptomatic.
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Comment
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Abciximab has been reported to decrease the ischemic complication rate [2] but to increase the bleeding complication rate [3] of coronary angioplasty and atherectomy. This report draws attention to two clinical problems in one patient in the setting of abciximab therapy, ineffectiveness of prolonged balloon reinflation to close an iatrogenic coronary perforation and excessive bleeding after emergent operation. In the absence of abciximab, prolonged reinflation of the balloon in the LAD coronary artery might have produced permanent closure of the perforated site. This was not the case in our patient who had received abciximab, which blocks the platelet glycoprotein IIb/IIIa receptor, thus preventing platelet adhesion and aggregation.
In patients who require emergent coronary artery bypass grafting, abciximab has been associated with excessive bleeding in some reports [4–6], but not in others [7, 8]. Emergency coronary bypass, in general, has been associated with a higher early mortality rate compared with elective operation, particularly in patients over 70 years of age [9]. Excessive postoperative bleeding in our 72-year-old patient aggravated an already high-risk situation thereby delaying her convalescence.
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References
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Abstract
Introduction
