Ann Thorac Surg 2008;86:1002-1004. doi:10.1016/j.athoracsur.2008.02.097
© 2008 The Society of Thoracic Surgeons
Case Reports
Emergency Surgery After Saphenous Vein Graft Perforation Complicated by Catheter Balloon Entrapment and Hemorrhagic Shock
Roberto Lorusso, MD, PhDa,*,
Giuseppe De Cicco, MDa,
Federica Ettori, MDb,
Salvatore Curello, MDb,
Sandro Gelsomino, MDa,
Carlo Fucci, MDa
a Cardiac Surgery, Civic Hospital, Brescia, and Experimental Cardiac Surgery Unit, Careggi Hospital, Florence, Italy
b Cardiology Catheterization Units, Civic Hospital, Brescia, and Experimental Cardiac Surgery Unit, Careggi Hospital, Florence, Italy
Accepted for publication February 29, 2008.
* Address correspondence to Dr Lorusso, Cardiac Surgery Unit–Civic Hospital, Piazzale Spedali Civili, Brescia, 1 – 2512, Italy (Email: roberto_lorusso{at}iol.it).
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Abstract
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Emergency surgery for acute vein graft perforation and balloon entrapment during percutaneous angioplasty is reported here. Prompt extracorporeal circulation through peripheral cannulation enabled the control of systemic perfusion despite cardiac arrest. Vein graft repair was achieved by an autologous pericardial patch. Appropriate and tailored mechanical circulatory support allowed successful extracorporeal circulation withdrawal, limited intraoperative cardiac damage, and postoperative controlled recovery of ventricular function with ultimate favorable outcome.
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Introduction
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Vein graft perforation (VGP) during percutaneous coronary intervention is a rare event. Polytetrafluoroethylene-covered stent placement and percutaneous pericardiocentesis have been the treatments applied to counteract life-threatening complications [1–3]. However, uncontrollable bleeding, cardiac tamponade, refractory cardiogenic shock, and cardiac arrest may occur [2] making the surgical revision mandatory with obvious technical and clinical challenges related to sternal reopening with additional patent grafts and the ongoing hemodynamic compromise. We report the case of a patient who underwent surgical procedure for percutaneous vein graft angioplasty with stent deployment complicated by VGP, hemopericardium, cardiac arrest, and entrapment of the balloon-related catheter in the stent net migrated outside the vein graft through the graft laceration.
A 65-year-old man was admitted to the cardiology unit because of unstable angina. He had undergone coronary artery bypass grafting surgery 14 years before (ie, left internal mammary artery on the left anterior descending coronary artery, vein grafts on the obtuse marginal, and posterior descending coronary arteries).
At coronary angiography, significant vein graft stenosis was shown at the mid-portion of vein conduit nourishing the posterior descending artery (Fig 1), whereas the anastomosis of the left internal mammary artery and the second vein graft were perfectly patent. During percutaneous stent placement an acute VGP occurred (Fig 1) with initial signs of hemorrhagic shock, which was initially controlled with an intrastent balloon inflation. At the end of the balloon inflation procedure further hemodynamic compromise suddenly developed, shortly followed by cardiac arrest. While resuscitation maneuvers were applied, coronary angiography showed a massive hemorrhage through the graft perforation likely due to an extended wall laceration. Furthermore, the intra-graft stent was shown to be partially migrated outside the vein graft causing a balloon entrapment. This situation impeded a covered graft deployment and prompted the surgical intervention because of persistence of intra-pericardic bleeding (Fig 1).
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Fig 1. (A) Coronary angiography showing the graft anastomosed to the right coronary artery (RCA), narrowing, and (B) the dye flowing outside the vein graft into the pericardial cavity (*).
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Percutaneous cardiopulmonary assistance was quickly instituted by peripheral cannulation of the groin vessels (20-French arterial cannula and a 24-French long venous cannula). Sternal re-entry was performed, having care not to dissect the adhesions between the left ventricle and the sternum because of the left internal mammary densely attached to the sternum. After careful dissection, a large VGP (3 x 1 cm) was observed at the middle segment of the vein graft anastomosed to the posterior descending coronary artery. Through the vein laceration, the stent was protruding and clearly visible, causing a balloon entrapment because of stent distortion. Through the vein graft laceration, the stent and the balloon catheter were completely exteriorized, the balloon catheter cut, and finally removed (Fig 1). The graft perforation was finally repaired with an autologous glutaraldehyde-treated pericardial patch with a 6-0 prolene running suture.
A period of controlled cardiocirculatory assistance (ie, 1 hour) was performed until an optimal cardiac contractility was resumed and metabolic acidosis was fully counteracted. Eventually, the extracorporal circulation (ECC) was gradually discontinued with optimal hemodynamic and cardiac functional conditions with the assistance of an intra-aortic balloon counterpulsation. The perioperative course was uneventful. Postoperative echocardiography carried out on postoperative day 5, which showed preserved left ventricular contractility and no pericardial fluid. The patient was discharged on postoperative day 7. At 6 months, the patient is doing well with no residual angina.
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Comment
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Vein conduit perforation during percutaneous stent or balloon inflation-related procedures is rare, although potentially has dreadful complications [1–4]. Oversizing of the balloon, ulcerated plaque, severely diseased, and old conduits have been described as predisposing factors for VGP [2, 4]. Vein graft laceration during percutaneous coronary intervention has been reported in the literature, but we believe that no surgical approach because of uncontrollable vein graft bleeding and angioplasty balloon entrapment has ever been previously described. Vein graft perforation is usually controlled by balloon inflation and occlusion of the iatrogenic laceration, subsequently sealed by covered stents. Cardiac tamponade, cardiogenic shock, and cardiac arrest are potential complications, but immediate percutaneous pericardiocentesis has been shown to be successful in some circumstances. However, surgical treatment might be mandatory in peculiar instances, although with inherent limitations due to the time-consuming sternal re-entry and the possibility of additional graft damage during cardiovascular dissection. The cardiovascular conditions may make this approach mandatory, as shown in our case, due to the rapid deterioration of the cardiocirculatory conditions, because of refractory hemorrhagic shock and cardiac arrest. The availability of a cardiocirculatory support system with peripheral approach, as shown in our experience, allows a safer control of the ongoing hemodynamic deterioration, enhances a better cardiovascular dissection due to chamber downloading, and makes any kind of metabolic or blood-related abnormality easily counteracted (namely acidosis and rapid anemia) while guaranteeing optimal oxygenation without lung ventilation, which may further obstacle cardiac and vein conduit harvesting.
Therefore, we advocate, in case of percutaneous procedures for the treatment of vein graft stenosis and the presence of established predisposing factors to VGP, the presence or immediate availability of a cardiocirculatory assist device, which by a peripheral approach may allow a safe control of the catastrophic complications and enhance surgical repair.
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References
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- Tassanawiwat W, Biondi-Zoccai GG, Sangiorgi G, et al. Percutaneous saphenectomy: a potentially dreadful complication of cutting balloon angioplasty in saphenous vein grafts Int J Cardiol 2006;106:418-419.[Medline]
- Namay DL, Roubin GS, Tommaso CL, Warren SG, Douglas JS, King 3rd SB. Saphenous vein graft rupture during percutaneous transluminal angioplasty Cathet Cardiovasc Diagn 1988;14:258-262.[Medline]
- Stankovic G, Colombo A, Presbitero P, et al. Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts: the RECOVERS Trial Circulation 2003;108:37-42.[Abstract/Free Full Text]
- Myles JL, Ratliff NB, Hollman J, Zaidi A, Tan TB. Mechanisms of vessel injury during percutaneous transluminal angioplasty of saphenous vein bypass grafts and coronary arteries Am J Pathol 1988;2:133-136.
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Abstract
Introduction
