Ann Thorac Surg 2004;77:708-711
© 2004 The Society of Thoracic Surgeons
Case report
Coronary endarterectomy and stent removal after iatrogenic perforation
Toshihiro Fukui, MD*a,
Shuichiro Takanashi, MDa,
Wahei Mihara, MDa,
Kazunori Ishikawa, MDa,
Yasuyuki Hosoda, MDa
a Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan
Accepted for publication April 18, 2003.
* Address reprint requests to Dr Fukui, Department of Cardiovascular Surgery, Shin-Tokyo Hospital, 473-1 Nemoto, Matsudo City, Chiba 271-0077, Japan
e-mail: tm-fukui{at}gem.hi-ho.ne.jp
 |
Abstract
|
|---|
Coronary perforation is a rare complication of percutaneous coronary intervention. We report a case of type 3 coronary artery perforation after stenting of the left anterior descending coronary artery. Pericardiocentesis was required to treat cardiac tamponade and prolonged balloon inflation did not stop the bleeding. Urgent surgical intervention with coronary endarterectomy, removal of the stent, and bypass grafting using the left internal mammary artery to the left anterior descending artery was successful. Complete removal of stent with endarterectomy is a feasible option for perforation as a complication of coronary stenting.
|
Introduction
|
|---|
Coronary artery perforation is a rare, but life-threatening, complication of percutaneous coronary intervention and surgical treatment is necessary up to 63% of the time [1]. We will describe a successful surgical intervention involving removal of the stent with coronary endarterectomy and coronary bypass grafting after coronary perforation.
A 67-year-old male was admitted to our institution with new onset of exertional angina. His electrocardiogram was normal and cardiac enzymes were not elevated. Based on a diagnosis of unstable angina, he was treated with intravenous heparin and nicorandil. Coronary angiography showed a long segmental lesion with up to 90% stenosis in the middle portion of the left anterior descending coronary artery (LAD) (Figure 1a).
Four days later, a percutaneous coronary intervention (PCI) was performed.
View larger version (67K):
[in this window]
[in a new window]
|
Fig 1. Preoperative coronary artery angiogram. (A) A segmental lesion with up to 90% stenosis in the middle portion of the left anterior descending artery can be seen. (B) There is extravasation of contrast into the perivascular tissue with a jet into the pericardial cavity.
|
|
A floppy wire and a 2.5 x 20 mm balloon was inserted from right radial artery and across the culprit lesion. The balloon was inflated to 18 atm for 30 s and thrombolysis in myocardial infarction (TIMI) grade 3 flow was obtained within the LAD. A 3 x 33 mm Multi-Link Tristar stent (Guidant Corporation, Santa Clara, CA) was deployed at 16 atm for 20 s. Soon after balloon deflation, chest pain developed in the patient. Coronary angiography revealed extravasation of contrast into the perivascular tissue and a jet into the pericardial cavity (Figure 1b). Because the patient was gradually becoming hypotensive, pericardiocentesis was performed under echocardiographic guidance. The balloon was inflated at the perforation site at 2 atm for 41 min. During these procedures, no ST-T segment changes were observed and no further blood was present in the pericardiostomy tube drainage. Hemodynamics were stabilized with the administration of dopamine (5 µg · kg-1 · min-1). 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.
Via a median sternotomy the left internal mammary artery (LIMA) was harvested. When the pericardium was opened, freshly clotted blood was seen around the LAD. Cardiopulmonary bypass (CPB) was established using ascending aortic cannulation and right atrial venous cannulation. Bleeding from the LAD was observed when the inflated coronary balloon was deflated and removed from the right radial sheath. After aortic clamping and initiation of both antegrade and retrograde cardioplegia infusion, cardiac arrest was obtained. Coronary arteriotomy was started from just distal to the stent implanted site and extended proximally for 45 mm. The failed stent was removed (Figure 2b)
and the intima was badly torn. There were small flaps from placement of the stent. Because the intima could not be reconstructed an endarterectomy was performed at the stent implantation site. The distal intimal end of the endarterectomy was fixed with 8-0 polypropylene sutures. The hole of perforation site could be observed directly and it was closed using 7-0 polypropylene sutures (Figure 2c). The LIMA was incised longitudinally to match the length of the LAD arteriotomy and an anastomosis was performed using a running 8-0 polypropylene suture. Weaning from CPB was uneventful. The postoperative angiogram showed an excellent angioplasty (Figure 3). There was no evidence of myocardial infarction and postoperative cardiac function was the same as preoperative cardiac function.
View larger version (39K):
[in this window]
[in a new window]
|
Fig 2. (A) Drawing of the procedure. (B) Intraoperative photograph: After coronary arteriotomy the failed stent was removed. Arrowheads indicate the extent of the arteriotomy. (C) Intraoperative photograph: An endarterectomy was performed and the perforation was closed. Arrowheads indicate the extent of the arteriotomy. The arrow indicates the perforation site.
|
|
View larger version (142K):
[in this window]
[in a new window]
|
Fig 3. Postoperative angiogram illustrating an excellent angioplasty using the left internal mammary artery.
|
|
|
Comment
|
|---|
The incidence of coronary artery perforation during PCI is reported to be between 0.2% and 0.8% [1–4]. Hemodynamically significant pericardial effusion occurs in 0.38% of cases necessitating drainage by pericardiocentesis or surgical intervention [4]. 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. The nonsurgical treatments of coronary perforation that have been reported in the literature include prolonged balloon inflation, autologous vein cover stent [5], and implantation of a polytetrafluoroethylene covered stent [6]. However type 3 perforations, with brisk pericardial extravasation, require surgical intervention with coronary artery bypass surgery in 63% of cases [1]. Operative repair of coronary perforation is either by coronary bypass grafting or ligation of the bleeding vessel without bypass graft [7]. We opted to perform more aggressive and complete repair of the coronary artery with stent removal, endarterectomy, closure of perforation, and bypass grafting. We performed an endarterectomy because the intima had been badly torn by the stent and it could not be reconstructed. We believe such extensive methods are not usually necessary for perforation repair. However simple ligation of the vessel is not recommended when bleeding continues as septal and diagonal branches between ligatures will be sacrificed possibly causing myocardial infarction. Our approach is a feasible and reasonable option for the treatment of coronary perforation caused by stent insertion when the lesion is long or tortuous.
|
References
|
|---|
- Ellis S.G., Ajluni S., Arnold A.Z., et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation 1994;90:2725-2730.[Abstract/Free Full Text]
- Gruberg L., Pinnow E., Flood R., et al. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2000;86:680-682.[Medline]
- Von Sohsten R., Kopistansky C., Cohen M., Kussmaul W.G., III Cardiac tamponade in the "new device" era: evaluation of 6999 consecutive percutaneous coronary interventions. Am Heart J 2000;140:279-283.[Medline]
- Gunning M.G., Williams I.L., Jewitt D.E., Shah A.M., Wainwright R.J., Thomas M.R. Coronary artery perforation during percutaneous intervention: incidence and outcome. Heart 2002;88:495-498.[Abstract/Free Full Text]
- Colombo A., Itoh A., Di Mario C., et al. Successful closure of a coronary vessel rupture with a vein graft stent: case report. Cathet Cardiovasc Diagn 1996;38:172-174.[Medline]
- Casella G., Werner F., Klauss V.V., Mudra H. Successful treatment of coronary artery perforation during angioplasty using a new membrane-coated stent. J Invasive Cardiol 1999;11:622-626.[Medline]
- Gonzalez-Santos J.M., Vallejo J.L., Pineda T., Zuazo J.A. Emergency surgery after coronary disruption complicating PTCA. Report of four cases. Thorac Cardiovasc Surg 1985;33:244-247.[Medline]
Top
Abstract
Introduction
