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Nonoperative management of aortocoronary saphenous vein graft rupture during percutaneous transluminal coronary angioplasty
August
Nonoperative Management Aortocoronary Saphenous Vein Rupture During Percutaneous Transluminal Coronary Angioplasty PAUL S. TEIRSTEIN, MD GEOFFREY 0. HARTZLER, MD
V
essel rupture is an extremely rare complication of percutaneous transluminal coronary angioplasty (PTCA1.l We report a case of saphenous vein graft rupture resulting in cardiac tamponade with successful nonoperative management.
A 7%year-old man, 13 years after coronary artery bypass grafting, underwent coronary angiography for intractable angina. A vein graft was inserted into the distal right coronary artery, which consisted solely of a small posterolateral branch. This coronary graft contained a lengthy, tubular, 95% diameter stenosis in its midportion in addition to a subtotal occlusion just proximal to the graft insertion site [Fig. 1). Initial attempts to dilate the midgraft lesion with a 3.5-mm and then a 4.0-mm Simpson-Robert balloon failed to achieve full balloon expansion and resulted in balloon rupture at 8 atm of pressure. The lesion was then reFrom the Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri 64111. Manuscript received December 18, 1986; revised manuscript received April 9,1987, accepted April 10. 1987.
I, 1987
WE
AMERICAN
JOLRNAL
OF CARDIOLOGY
Volume
BO
397
crossed with a &&mm Gruentzig S-style balloon and a very prolonged (8-minute) dilatation commenced with 8 atm, slowly increasing to 12 atm of pressure. A ringlike, 75% diameter constriction of the balloon persisted until a pressure of 12 atm was reached and the balloon opened partially, followed by balloon rupture and immediate extravasation of contrast material into the pericardium, visualized fluoroscopically. The balloon and wire were withdrawn and graft reinjected, showing a rapidly growing collection of contrast surrounding the vein graft [Fig. 2 and 3] in addition to a more faintly opacified mixture of blood and contrast surrounding the diaphragmatic and apical cardiac borders. Saline solution was administered, a dopamine infusion was prepared and the heparin was reversed with protamine. An l&gauge, thin-walled needle was quickly inserted into the pericardial space, followed by a guidewire and pigtail catheter. Over a 2minute period, 300 ml of pericardial blood was withdrawn with prompt recovery of systolic blood pressure to 140 mm Hg. Reinjection into the graft after pericardiocentesis showed jet-like spurting of contrast into the pericardial space (Fig. 4). Over the subsequent 24 hours, there was minimal drainage from the pericardial catheter. One day after the procedure, the creatinine kinase level increased to 1,318 mIU/mm (9% MB] without electrocardiographic appearance of Q waves. On day 5, after the procedure, a 2-dimensional echocardiogram showed no residual pericardial effusion. Eight days after the procedure, repeat angiography showed total occlusion of the vein graft. Left ventricular angiography revealed a limited posterobasal region of hypokinesia with otherwise normal left ventricular contractility. Successful PTCA is usually accomplished by disruption and splitting of the atheromatous plaque, with stretching of the media and adventitia.2 Prolonged balloon inflation at high pressures may cause extension of
FIGURE 1. Left anterior oblique projection. A high-grade tubular zone of narrowing is evident within the body of the vein graft to the distal right coronary artery. There is an additional subtotal occlusion just proximal to the graft insertion site with contrast filling only a posterolateral branch.
FIGURE 2. Left anterior oblique loon rupture, contrast injection rapidly expanding accumulation pericardiai space.
projection. Immediately after into the vein graft demonstrates of blood and contrast within
bata the
378
BRIEF
REPORTS
FIGURE 3. Left anterior oblique projection. This frame from the tine film was taken approximately 10 seconds after the frame in Figure 2. It shows larger accumulation of blood and contrast within the pericardium.
this split into the media and adventitia, resulting in vessel rupture. Using a relatively oversized balloon may also contribute to vessel rupture. One previously reported case of arterial rupture during PTCA was attributed to the use of a balloon larger than the coronary artery itself.3 However, in this case, as in our present case, vessel rupture was also coincident with balloon rupture. In our patient, balloon rupture observed by fluoroscopy was immediately associated with a line of dye spurting into the pericardial space. Although balloon oversize could have contributed to the vein graft rupture, we suspect that an extremely high pressure jet of dye resulting from balloon rupture caused localized vessel perforation. Successful management of cardiac tamponade due to graft rupture during PTCA with pericardiocentesis alone has not been previously reported. The single previous case report of coronary arterial rupture resulted in fatal cardiac tamponade despite pericardial drainage.3 Four previously reported patients with vessel perforation (by guidewire) before balloon inflation survived. Three had small, hemodynamically insignificant pericardial effusions.4,5 One had cardiac tamponade that responded to pericardiocentesis followed by urgent thoracotomy.6 Indications for urgent surgery after vessel rupture include hemodynamic compromise due to cardiac tamponade unresponsive to peri-
FIGURE 4. Right anterior oblique projection. After drainage of the pericardial space with a pigtail catheter, the vein graft was reinjected. Arrow points to a jet of dye spurting from the ruptured mldgraft into the pericardial space.
cardiocentesis and the need for revascularization of the myocardiumperfused by the ruptured vessel. In this patient, the quantity of myocardium supplied by the small distal right coronary artery was considered too small to justify urgent surgery. Reversal of heparin and pericardiocentesis restored hemodynamic function and thoracotomy was not needed. This case demonstrates that PTCA-induced vessel rupture can be managed nonoperatively if percutaneous pericardial drainage restores hemodynamic stability and surgical revascularization is not indicated. Furthermore, this case implicates balloon rupture, once considered a relatively benign event, in the genesis of a serious PTCA complication. 1. Cowley M, Dorros G, Kelsey S, Van Raden M, Detre K. Acute coronary events associated with percutaneous transluminal coronary angioplasty. Am J Cardiol 1984;53:12C-l6C. 2. Block P. Mechanism of transluminal angioplasty. Am J Cardiol 1984;53: 69C-71C. 3. Saffitz J, Rose T, Oaks J, Roberts W. Coronary arterial rupture during coronary angioplasty. Am J Cardiol 1983;51:902-904. 4. Meier B. Benign coronary perforation during percutaneous transluminal coronary angioplasty. Br Heart J 1985;54:33-35. 5. Grollier G, Bories H, Commeau P, Foucault J, Potier J. Coronary artery perforation during coronary angioplasty. Clin Cardiol 1986;9:28-29. 6. Kimbiris D, Iskandrian A, Goel I, Bemis C, Gehl L, Owens J, Segal B. Transluminal coronary angioplasty complicated by coronary artery perforation. Cathet Cardiovasc Diagn 1982;8:481-487.
Nonoperative Management Aortocoronary Saphenous Vein Rupture During Percutaneous Transluminal Coronary Angioplasty PAUL S. TEIRSTEIN, MD GEOFFREY 0. HARTZLER, MD
V
essel rupture is an extremely rare complication of percutaneous transluminal coronary angioplasty (PTCA1.l We report a case of saphenous vein graft rupture resulting in cardiac tamponade with successful nonoperative management.
A 7%year-old man, 13 years after coronary artery bypass grafting, underwent coronary angiography for intractable angina. A vein graft was inserted into the distal right coronary artery, which consisted solely of a small posterolateral branch. This coronary graft contained a lengthy, tubular, 95% diameter stenosis in its midportion in addition to a subtotal occlusion just proximal to the graft insertion site [Fig. 1). Initial attempts to dilate the midgraft lesion with a 3.5-mm and then a 4.0-mm Simpson-Robert balloon failed to achieve full balloon expansion and resulted in balloon rupture at 8 atm of pressure. The lesion was then reFrom the Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri 64111. Manuscript received December 18, 1986; revised manuscript received April 9,1987, accepted April 10. 1987.
I, 1987
WE
AMERICAN
JOLRNAL
OF CARDIOLOGY
Volume
BO
397
crossed with a &&mm Gruentzig S-style balloon and a very prolonged (8-minute) dilatation commenced with 8 atm, slowly increasing to 12 atm of pressure. A ringlike, 75% diameter constriction of the balloon persisted until a pressure of 12 atm was reached and the balloon opened partially, followed by balloon rupture and immediate extravasation of contrast material into the pericardium, visualized fluoroscopically. The balloon and wire were withdrawn and graft reinjected, showing a rapidly growing collection of contrast surrounding the vein graft [Fig. 2 and 3] in addition to a more faintly opacified mixture of blood and contrast surrounding the diaphragmatic and apical cardiac borders. Saline solution was administered, a dopamine infusion was prepared and the heparin was reversed with protamine. An l&gauge, thin-walled needle was quickly inserted into the pericardial space, followed by a guidewire and pigtail catheter. Over a 2minute period, 300 ml of pericardial blood was withdrawn with prompt recovery of systolic blood pressure to 140 mm Hg. Reinjection into the graft after pericardiocentesis showed jet-like spurting of contrast into the pericardial space (Fig. 4). Over the subsequent 24 hours, there was minimal drainage from the pericardial catheter. One day after the procedure, the creatinine kinase level increased to 1,318 mIU/mm (9% MB] without electrocardiographic appearance of Q waves. On day 5, after the procedure, a 2-dimensional echocardiogram showed no residual pericardial effusion. Eight days after the procedure, repeat angiography showed total occlusion of the vein graft. Left ventricular angiography revealed a limited posterobasal region of hypokinesia with otherwise normal left ventricular contractility. Successful PTCA is usually accomplished by disruption and splitting of the atheromatous plaque, with stretching of the media and adventitia.2 Prolonged balloon inflation at high pressures may cause extension of
FIGURE 1. Left anterior oblique projection. A high-grade tubular zone of narrowing is evident within the body of the vein graft to the distal right coronary artery. There is an additional subtotal occlusion just proximal to the graft insertion site with contrast filling only a posterolateral branch.
FIGURE 2. Left anterior oblique loon rupture, contrast injection rapidly expanding accumulation pericardiai space.
projection. Immediately after into the vein graft demonstrates of blood and contrast within
bata the
378
BRIEF
REPORTS
FIGURE 3. Left anterior oblique projection. This frame from the tine film was taken approximately 10 seconds after the frame in Figure 2. It shows larger accumulation of blood and contrast within the pericardium.
this split into the media and adventitia, resulting in vessel rupture. Using a relatively oversized balloon may also contribute to vessel rupture. One previously reported case of arterial rupture during PTCA was attributed to the use of a balloon larger than the coronary artery itself.3 However, in this case, as in our present case, vessel rupture was also coincident with balloon rupture. In our patient, balloon rupture observed by fluoroscopy was immediately associated with a line of dye spurting into the pericardial space. Although balloon oversize could have contributed to the vein graft rupture, we suspect that an extremely high pressure jet of dye resulting from balloon rupture caused localized vessel perforation. Successful management of cardiac tamponade due to graft rupture during PTCA with pericardiocentesis alone has not been previously reported. The single previous case report of coronary arterial rupture resulted in fatal cardiac tamponade despite pericardial drainage.3 Four previously reported patients with vessel perforation (by guidewire) before balloon inflation survived. Three had small, hemodynamically insignificant pericardial effusions.4,5 One had cardiac tamponade that responded to pericardiocentesis followed by urgent thoracotomy.6 Indications for urgent surgery after vessel rupture include hemodynamic compromise due to cardiac tamponade unresponsive to peri-
FIGURE 4. Right anterior oblique projection. After drainage of the pericardial space with a pigtail catheter, the vein graft was reinjected. Arrow points to a jet of dye spurting from the ruptured mldgraft into the pericardial space.
cardiocentesis and the need for revascularization of the myocardiumperfused by the ruptured vessel. In this patient, the quantity of myocardium supplied by the small distal right coronary artery was considered too small to justify urgent surgery. Reversal of heparin and pericardiocentesis restored hemodynamic function and thoracotomy was not needed. This case demonstrates that PTCA-induced vessel rupture can be managed nonoperatively if percutaneous pericardial drainage restores hemodynamic stability and surgical revascularization is not indicated. Furthermore, this case implicates balloon rupture, once considered a relatively benign event, in the genesis of a serious PTCA complication. 1. Cowley M, Dorros G, Kelsey S, Van Raden M, Detre K. Acute coronary events associated with percutaneous transluminal coronary angioplasty. Am J Cardiol 1984;53:12C-l6C. 2. Block P. Mechanism of transluminal angioplasty. Am J Cardiol 1984;53: 69C-71C. 3. Saffitz J, Rose T, Oaks J, Roberts W. Coronary arterial rupture during coronary angioplasty. Am J Cardiol 1983;51:902-904. 4. Meier B. Benign coronary perforation during percutaneous transluminal coronary angioplasty. Br Heart J 1985;54:33-35. 5. Grollier G, Bories H, Commeau P, Foucault J, Potier J. Coronary artery perforation during coronary angioplasty. Clin Cardiol 1986;9:28-29. 6. Kimbiris D, Iskandrian A, Goel I, Bemis C, Gehl L, Owens J, Segal B. Transluminal coronary angioplasty complicated by coronary artery perforation. Cathet Cardiovasc Diagn 1982;8:481-487.