- Email: [email protected]
Successful Outcome of Emergency Coronary Artery Bypass Grafting and Retrieval of Entrapped Stent, Angioplasty Balloon, and Guidewire
1032
CASE REPORT KARTHIK ET AL EMERGENCY RETRIEVAL OF ENTRAPPED STENT, BALLOON, AND GUIDEWIRE
interrupted mattress fashion with a patch of Dacron (DuPont, Wilmington, DE). To obtain access to the opening, the posterior papillary muscle had to be divided and was subsequently repaired with a Gore-Tex suture (W. L. Gore and Associates, Flagstaff, AZ). The patient was weaned off bypass, on 5 g · kg⫺1 · min of dopamine. Transesophageal echocardiography showed satisfactory repair with minimal mitral regurgitation. She remained stable and was extubated 12 hours postoperatively. Her left-sided weakness had worsened. She was discharged to her local hospital at 10 days for rehabilitation. At 3-month follow-up, her clinical status had improved considerably. Echocardiography showed satisfactory repair, with shrinkage of the aneurysm and no mitral regurgitation.
Comment
FEATURE ARTICLES
Posterior submitral LV aneurysm is a rare entity. The majority of cases are congenital and seen in patients of African origin presenting in their 20s or 30s. These aneurysms, which are often multiloculated, tend to grow into the pericardial space expanding behind the left atrium or the LV. The posterior mitral leaflet becomes incorporated in the roof of the aneurysm, causing regurgitation [1]. These aneurysms are different from those caused by ischemia. Characteristically, in the congenital variety, the aneurysms have large cavities separated from the left ventricle by a well-defined neck, situated posterior to the mitral valve annulus. Although the aneurysm in this case was due to ischemia, it resembled the congenital variety. The first successful repair of an aneurysm of the base of the LV was reported in 1963, in which the neck of the aneurysm was exposed through its free wall and the defect was primarily closed [2]. In the congenital variety due to the variable direction of expansion of the aneurysm and the presence of pericardial adhesions, the conventional ventricular approach is difficult. In the patient described, because of the presence of severe adhesions and the very close proximity to the mitral valve, the ventricular approach and excision of the aneurysm were not feasible. Therefore, access to the neck was obtained through the mitral orifice. However, there are successful reports of repair using the LV approach and excision [3, 4]. Antunes [1] described a transatrial approach whereby a left atriotomy is made, and then an incision is made parallel to the posterior part of the annulus that exposes the aneurysmal cavity and neck. The neck of the aneurysm is then closed from inside the cavity without disrupting the valvar apparatus. Using this approach, access to the neck is unimpeded by the chordae, in contrast to that obtained through the valve. However, this approach is not always suitable for all subvalvar aneurysms because of the variability of the relationship of the aneurysm neck to the valve. Antunes [1] used direct closure successfully in 9 patients. We used patch repair to avoid distortion of the mitral valve. There are reports of primary closure causing mitral incompetence and necessitating mitral valve replacement in posterior subvalvar aneurysms [5] and causing both mitral and aortic insufficiency in anterior subvalvar aneurysms [6]. We have reported a patient with ischemic submitral © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;79:1032– 4
pseudoaneurysm resembling the congenital variety. Because of the proximity of the mitral valve apparatus to the aneurysm, excision of the aneurysm was not feasible. The patient underwent patch closure of the neck of the aneurysm and made a satisfactory recovery.
References 1. Antunes M. Submitral left ventricular aneurysms. J Thorac Cardiovasc Surg 1987;94:24105. 2. Shrire V, Barnard CN. The surgical cure of a cardiac aneurysm of unknown cause. J Cardiovasc Surg 1963;4:5–9. 3. Sorensen MB, Moat NE, Mohiaddin RH. False left ventricular aneurysm documented by magnetic resonance imaging. Circulation 2002;105:1734. 4. Konstantinov I, Mickleborough LL, Graba J, Merchant N. Intraventricular mitral annuloplasty technique for use with repair of posterior left ventricular aneurysm. J Thorac Cardiovasc Surg 2001;122:1244 –7. 5. Wolpowitz A, Arman B, Barnard MS, Barnard CN. Annular subvalvular idiopathic left ventricular aneurysms in the black African. Ann Thorac Surg 1979;27:350 –5. 6. Kriuthoff WA, Akl BF, Blacky AR. Surgical repair of an anterior mitral subvalvular aneurysm. Ann Thorac Surg 1995; 59:1001–3.
Successful Outcome of Emergency Coronary Artery Bypass Grafting and Retrieval of Entrapped Stent, Angioplasty Balloon, and Guidewire Shishir Karthik, MBBS, MCh, Paul Silverton, MD, FRCP, Jonathan A. Blaxill, FRCP, and David J. O’Regan, MD, FRCS(C-Th) Departments of Cardiothoracic Surgery and Cardiology, Leeds General Infirmary, Leeds, United Kingdom
A 42-year-old man presented with worsening of angina after a recent angioplasty and stenting. Repeat angiography revealed further untreated lesions in the left anterior descending coronary artery. The patient underwent reangioplasty and stenting. After stent deployment, the guidewire and balloon got entrapped in the left anterior descending coronary artery, which was associated with hypotension and ischemic changes of the anterolateral wall on electrocardiogram. The patient was stabilized with the insertion of an intraaortic balloon pump, and he underwent emergency coronary artery bypass grafting and removal of the entrapped equipment. He had an uneventful postoperative recovery. (Ann Thorac Surg 2005;79:1032– 4) © 2005 by The Society of Thoracic Surgeons Accepted for publication Sept 11, 2003. Address reprint requests to Dr Karthik, Department of Cardiothoracic Surgery, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.09.117
Ann Thorac Surg 2005;79:1032– 4
CASE REPORT KARTHIK ET AL EMERGENCY RETRIEVAL OF ENTRAPPED STENT, BALLOON, AND GUIDEWIRE
1033
T
A 42-year-old man presented with worsening angina, uncontrolled with medication. He was a hypercholesteremic without any other major risk factors for coronary artery disease. Coronary angiogram revealed triplevessel disease for which he had multi-vessel angioplasty and stenting of the left anterior descending coronary artery (LAD) and first obtuse marginal branch using BiodivYsio stents (Biocompatibles Ltd, Farnham, UK). The procedure and recovery were uneventful. However he had unstable angina develop a few months later requiring repeat angioplasty and stenting of the LAD and the first diagonal branch. He remained asymptomatic for a further 3 months and then had class III angina develop again. Repeat angiogram revealed restenosis in the LAD and untreated distal disease (Fig 1A). The first obtuse marginal branch stent was widely patent. Repeat angioplasty and stenting of the LAD was undertaken using a Cypher stent (Cordis Corp, Miami Lakes, FL) (Fig 1B). The deployment itself was uneventful; however, the wire and balloon could not be removed. At this stage the patient became hypotensive (systolic blood pressure, 80 mm Hg) and tachycardic (130 beats/ min). The distal LAD could not be visualized and the patient became critically ischemic. Hemodynamic stability was achieved by inserting an intraaortic balloon pump. The intraaortic balloon pump was set at 1:1 and there was an immediate improvement in the electrocardiogram with resolution of the tachycardia and a rise in the blood pressure (augmented blood pressure, 110 mm of Hg). He was prepared for emergency coronary artery bypass grafting and removal of the guidewire and balloon. The total time lapse from the onset of hypotension and electrocardiogram changes to skin incision was about 70 minutes. After the sternotomy, the left internal mammary artery was harvested because the patient was young and hemodynamically stable. The long saphenous vein was also harvested. Cardiopulmonary bypass was instituted with an aortic and two-stage venous cannula. The patient was cooled to 32°C, the ascending aorta was cross clamped, and immediate diastolic arrest was achieved with antegrade cold blood cardioplegia. A large, fresh hematoma was noted over the proximal LAD and the first diagonal branch, about 3.5 cm from the left main ostium. The native vessel, guidewire, and balloon could not be seen or palpated. A 2-cm aortotomy was made and the guidewire and balloon catheter was visualized. The guidewire was cut and removed from the left coronary orifice under direct vision by applying steady traction with two forceps. The wire, the
FEATURE ARTICLES
he need for emergency coronary artery bypass grafting after percutaneous interventions has decreased; however the mortality and morbidity associated with these procedures remains quite high [1]. Coronary artery dissection, tear, hemopericardium, or acute thrombosis are the usual indications for emergency surgery after failed percutaneous interventions. Entrapment of a guidewire or an intact angioplasty balloon is a rare event. We present an unusual case of emergency coronary artery bypass grafting with retrieval of an entrapped stent, balloon, and guidewire.
Fig 1. (A) Pre-angioplasty angiogram of the left coronary arterial system and right anterior oblique view shows disease in the mid-left anterior descending coronary artery (LAD). (B) Post-angioplasty and stenting with stent in the LAD with a poor flow through the stent.
balloon, and the stent came out en-masse along with some atheromatous tissue (Fig 2). The aortotomy was closed with 4-0 polypropelene. Coronary grafting was done using reversed saphenous grafts to the first obtuse marginal branch of the circumflex artery and the first diagonal branch and left internal mammary artery to the LAD. After the removal of the aortic cross clamp, the heart regained sinus rhythm spontaneously. The proximal aortocoronary anastomoses were performed with a side-biting clamp on the aorta as the patient was being rewarmed. The remainder of the guidewire was removed from the right groin. Cardiopulmonary bypass was discontinued without any need for inotropic
1034
CASE REPORT REDDI ET AL TRAUMATIC INNOMINATE ARTERY ANEURYSM
Ann Thorac Surg 2005;79:1034 – 6
guidewire and remove the entire equipment under direct vision. We did consider the use of retrograde cardioplegia, but we were able to achieve a uniform and immediate cardiac arrest with antegrade cardioplegia. After the extraction, the extent of intracoronary damage could only be imagined. Hence, all the left-sided vessels were grafted. We believe this is an extremely unusual case of entrapped guidewire and balloon. We removed the whole apparatus under direct vision through an aortotomy with triple bypass surgery with gratifying results, preventing further ischemic injury. The intraaortic balloon pump is an invaluable tool in such circumstances.
References Fig 2. Extracted balloon catheter with guidewire passing through the stent eccentrically.
FEATURE ARTICLES
agents as the cardiac index measured 3.6. The chest was closed in the usual fashion. Postoperative recovery was unremarkable, and the patient was extubated 5 hours after surgery. The intraaortic balloon pump was removed after 14 hours and he was discharged to the ward the next day. He made an uneventful recovery and was discharged on postoperative day 7 on aspirin and clopidogrel (75 mgs each), bisoprolol (5 mg), simvastatin (10 mg), and analgesics. Although the troponin I level was 28.13 mg/L on postoperative day 1 (any levels ⬎ 0.50 mg/L may be used to confirm a diagnosis of acute myocardial infarction if consistent with symptoms and electrocardiogram changes), there was no evidence of acute myocardial infarction postoperatively. At follow-up after 7 weeks, the electrocardiogram was normal. Echocardiogram did not reveal any evidence of regional wall motion abnormality.
Comment In this case, the guidewire and the whole balloon had become entrapped in the LAD after deployment in contrast with other reports in which the guidewire or the balloon had gotten entrapped and fragmented [2–5]. The hemodynamic instability and myocardial ischemia secondary to the entrapped equipment necessitated emergency removal and revascularization, which alleviated the ischemic changes. Several methods of percutaneous removal have been described; however, these have been applied only to cases in which a fragment of the guidewire had gotten lodged in the coronary arterial tree, avoiding the need for surgery [2, 5, 6]. However, the coronary arteries are likely to suffer damage at site of impaction. Nishiwaki and colleagues [3] report a case of balloon catheter entrapment in the circumflex coronary artery. They removed this fragment through a coronary arteriotomy. We were dealing with more than a meter long entrapped guidewire. Furthermore, the site was obscured by the hematoma and would not have been ideal for coronary arteriotomy. An aortotomy was necessary to amputate the © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Seshadri N, Whitlow PL, Acharya N, Houghtaling P, Blackstone EH, Ellis SG. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Circulation 2002;106:2346 –50. 2. Madronero JL, Hein F, Bergbauer M. Removal of a ruptured, detached, and entrapped angioplasty balloon after coronary stenting. J Invasive Cardiol 2000;12(2):102–4. 3. Nishiwaki N, Kawano Y, Furukawa K, Nakayama Y. A case report of entrapment of PTCA balloon catheter caused by its rupture. Nippon Kyobu Geka Gakkai Zasshi 1991;39(8):1226 – 30. 4. Yajima T, Sakakibara T, Ida T, Tsunemoto H, Ootaki E, Suzuki S. Entrapment of broken guidewire in the right coronary artery during percutaneous transluminal coronary angioplasty. Nippon Kyobu Geka Gakkai Zasshi 1991;39(9):1813– 1815. 5. Savas V, Schreiber T, O’Neill W. Percutaneous extraction of fractured guidewire from distal right coronary artery. Cathet Cardiovasc Diagn 1991;22(2):124 –126. 6. Patel T, Shah S, Pandya R, Sanghvi K, Fonseca K. Broken guidewire fragment: a simplified retrieval technique. Catheter Cardiovasc Interv 2000;51(4):483–6.
Traumatic Innominate Artery Aneurysm 26 Years After Stab Injury Anunathan A. Reddi, FCS(SA), Mandhir M. Munasur, MBCHB, Rishendran R. Naidoo, MBCHB, and Dion D. Steer, MBCHB Department of Cardiothoracic Surgery, Wentworth Hospital, University of Natal, Durban, South Africa
We report the case history of a 46-year-old African man with a false aneurysm of the innominate artery subsequent to a stab wound in the right supraclavicular area 26 years previously, presenting with stridor. (Ann Thorac Surg 2005;79:1034 – 6) © 2005 by The Society of Thoracic Surgeons Accepted for publication Sept 18, 2003. Address reprint requests to Dr Reddi, Department of Cardiothoracic Surgery, Inkosi Albert Luthuli Central Hospital, Private Bag X03, Mayville 4058, Durban, South Africa; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.09.140
CASE REPORT KARTHIK ET AL EMERGENCY RETRIEVAL OF ENTRAPPED STENT, BALLOON, AND GUIDEWIRE
interrupted mattress fashion with a patch of Dacron (DuPont, Wilmington, DE). To obtain access to the opening, the posterior papillary muscle had to be divided and was subsequently repaired with a Gore-Tex suture (W. L. Gore and Associates, Flagstaff, AZ). The patient was weaned off bypass, on 5 g · kg⫺1 · min of dopamine. Transesophageal echocardiography showed satisfactory repair with minimal mitral regurgitation. She remained stable and was extubated 12 hours postoperatively. Her left-sided weakness had worsened. She was discharged to her local hospital at 10 days for rehabilitation. At 3-month follow-up, her clinical status had improved considerably. Echocardiography showed satisfactory repair, with shrinkage of the aneurysm and no mitral regurgitation.
Comment
FEATURE ARTICLES
Posterior submitral LV aneurysm is a rare entity. The majority of cases are congenital and seen in patients of African origin presenting in their 20s or 30s. These aneurysms, which are often multiloculated, tend to grow into the pericardial space expanding behind the left atrium or the LV. The posterior mitral leaflet becomes incorporated in the roof of the aneurysm, causing regurgitation [1]. These aneurysms are different from those caused by ischemia. Characteristically, in the congenital variety, the aneurysms have large cavities separated from the left ventricle by a well-defined neck, situated posterior to the mitral valve annulus. Although the aneurysm in this case was due to ischemia, it resembled the congenital variety. The first successful repair of an aneurysm of the base of the LV was reported in 1963, in which the neck of the aneurysm was exposed through its free wall and the defect was primarily closed [2]. In the congenital variety due to the variable direction of expansion of the aneurysm and the presence of pericardial adhesions, the conventional ventricular approach is difficult. In the patient described, because of the presence of severe adhesions and the very close proximity to the mitral valve, the ventricular approach and excision of the aneurysm were not feasible. Therefore, access to the neck was obtained through the mitral orifice. However, there are successful reports of repair using the LV approach and excision [3, 4]. Antunes [1] described a transatrial approach whereby a left atriotomy is made, and then an incision is made parallel to the posterior part of the annulus that exposes the aneurysmal cavity and neck. The neck of the aneurysm is then closed from inside the cavity without disrupting the valvar apparatus. Using this approach, access to the neck is unimpeded by the chordae, in contrast to that obtained through the valve. However, this approach is not always suitable for all subvalvar aneurysms because of the variability of the relationship of the aneurysm neck to the valve. Antunes [1] used direct closure successfully in 9 patients. We used patch repair to avoid distortion of the mitral valve. There are reports of primary closure causing mitral incompetence and necessitating mitral valve replacement in posterior subvalvar aneurysms [5] and causing both mitral and aortic insufficiency in anterior subvalvar aneurysms [6]. We have reported a patient with ischemic submitral © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;79:1032– 4
pseudoaneurysm resembling the congenital variety. Because of the proximity of the mitral valve apparatus to the aneurysm, excision of the aneurysm was not feasible. The patient underwent patch closure of the neck of the aneurysm and made a satisfactory recovery.
References 1. Antunes M. Submitral left ventricular aneurysms. J Thorac Cardiovasc Surg 1987;94:24105. 2. Shrire V, Barnard CN. The surgical cure of a cardiac aneurysm of unknown cause. J Cardiovasc Surg 1963;4:5–9. 3. Sorensen MB, Moat NE, Mohiaddin RH. False left ventricular aneurysm documented by magnetic resonance imaging. Circulation 2002;105:1734. 4. Konstantinov I, Mickleborough LL, Graba J, Merchant N. Intraventricular mitral annuloplasty technique for use with repair of posterior left ventricular aneurysm. J Thorac Cardiovasc Surg 2001;122:1244 –7. 5. Wolpowitz A, Arman B, Barnard MS, Barnard CN. Annular subvalvular idiopathic left ventricular aneurysms in the black African. Ann Thorac Surg 1979;27:350 –5. 6. Kriuthoff WA, Akl BF, Blacky AR. Surgical repair of an anterior mitral subvalvular aneurysm. Ann Thorac Surg 1995; 59:1001–3.
Successful Outcome of Emergency Coronary Artery Bypass Grafting and Retrieval of Entrapped Stent, Angioplasty Balloon, and Guidewire Shishir Karthik, MBBS, MCh, Paul Silverton, MD, FRCP, Jonathan A. Blaxill, FRCP, and David J. O’Regan, MD, FRCS(C-Th) Departments of Cardiothoracic Surgery and Cardiology, Leeds General Infirmary, Leeds, United Kingdom
A 42-year-old man presented with worsening of angina after a recent angioplasty and stenting. Repeat angiography revealed further untreated lesions in the left anterior descending coronary artery. The patient underwent reangioplasty and stenting. After stent deployment, the guidewire and balloon got entrapped in the left anterior descending coronary artery, which was associated with hypotension and ischemic changes of the anterolateral wall on electrocardiogram. The patient was stabilized with the insertion of an intraaortic balloon pump, and he underwent emergency coronary artery bypass grafting and removal of the entrapped equipment. He had an uneventful postoperative recovery. (Ann Thorac Surg 2005;79:1032– 4) © 2005 by The Society of Thoracic Surgeons Accepted for publication Sept 11, 2003. Address reprint requests to Dr Karthik, Department of Cardiothoracic Surgery, Leeds General Infirmary, Great George St, Leeds LS1 3EX, UK; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.09.117
Ann Thorac Surg 2005;79:1032– 4
CASE REPORT KARTHIK ET AL EMERGENCY RETRIEVAL OF ENTRAPPED STENT, BALLOON, AND GUIDEWIRE
1033
T
A 42-year-old man presented with worsening angina, uncontrolled with medication. He was a hypercholesteremic without any other major risk factors for coronary artery disease. Coronary angiogram revealed triplevessel disease for which he had multi-vessel angioplasty and stenting of the left anterior descending coronary artery (LAD) and first obtuse marginal branch using BiodivYsio stents (Biocompatibles Ltd, Farnham, UK). The procedure and recovery were uneventful. However he had unstable angina develop a few months later requiring repeat angioplasty and stenting of the LAD and the first diagonal branch. He remained asymptomatic for a further 3 months and then had class III angina develop again. Repeat angiogram revealed restenosis in the LAD and untreated distal disease (Fig 1A). The first obtuse marginal branch stent was widely patent. Repeat angioplasty and stenting of the LAD was undertaken using a Cypher stent (Cordis Corp, Miami Lakes, FL) (Fig 1B). The deployment itself was uneventful; however, the wire and balloon could not be removed. At this stage the patient became hypotensive (systolic blood pressure, 80 mm Hg) and tachycardic (130 beats/ min). The distal LAD could not be visualized and the patient became critically ischemic. Hemodynamic stability was achieved by inserting an intraaortic balloon pump. The intraaortic balloon pump was set at 1:1 and there was an immediate improvement in the electrocardiogram with resolution of the tachycardia and a rise in the blood pressure (augmented blood pressure, 110 mm of Hg). He was prepared for emergency coronary artery bypass grafting and removal of the guidewire and balloon. The total time lapse from the onset of hypotension and electrocardiogram changes to skin incision was about 70 minutes. After the sternotomy, the left internal mammary artery was harvested because the patient was young and hemodynamically stable. The long saphenous vein was also harvested. Cardiopulmonary bypass was instituted with an aortic and two-stage venous cannula. The patient was cooled to 32°C, the ascending aorta was cross clamped, and immediate diastolic arrest was achieved with antegrade cold blood cardioplegia. A large, fresh hematoma was noted over the proximal LAD and the first diagonal branch, about 3.5 cm from the left main ostium. The native vessel, guidewire, and balloon could not be seen or palpated. A 2-cm aortotomy was made and the guidewire and balloon catheter was visualized. The guidewire was cut and removed from the left coronary orifice under direct vision by applying steady traction with two forceps. The wire, the
FEATURE ARTICLES
he need for emergency coronary artery bypass grafting after percutaneous interventions has decreased; however the mortality and morbidity associated with these procedures remains quite high [1]. Coronary artery dissection, tear, hemopericardium, or acute thrombosis are the usual indications for emergency surgery after failed percutaneous interventions. Entrapment of a guidewire or an intact angioplasty balloon is a rare event. We present an unusual case of emergency coronary artery bypass grafting with retrieval of an entrapped stent, balloon, and guidewire.
Fig 1. (A) Pre-angioplasty angiogram of the left coronary arterial system and right anterior oblique view shows disease in the mid-left anterior descending coronary artery (LAD). (B) Post-angioplasty and stenting with stent in the LAD with a poor flow through the stent.
balloon, and the stent came out en-masse along with some atheromatous tissue (Fig 2). The aortotomy was closed with 4-0 polypropelene. Coronary grafting was done using reversed saphenous grafts to the first obtuse marginal branch of the circumflex artery and the first diagonal branch and left internal mammary artery to the LAD. After the removal of the aortic cross clamp, the heart regained sinus rhythm spontaneously. The proximal aortocoronary anastomoses were performed with a side-biting clamp on the aorta as the patient was being rewarmed. The remainder of the guidewire was removed from the right groin. Cardiopulmonary bypass was discontinued without any need for inotropic
1034
CASE REPORT REDDI ET AL TRAUMATIC INNOMINATE ARTERY ANEURYSM
Ann Thorac Surg 2005;79:1034 – 6
guidewire and remove the entire equipment under direct vision. We did consider the use of retrograde cardioplegia, but we were able to achieve a uniform and immediate cardiac arrest with antegrade cardioplegia. After the extraction, the extent of intracoronary damage could only be imagined. Hence, all the left-sided vessels were grafted. We believe this is an extremely unusual case of entrapped guidewire and balloon. We removed the whole apparatus under direct vision through an aortotomy with triple bypass surgery with gratifying results, preventing further ischemic injury. The intraaortic balloon pump is an invaluable tool in such circumstances.
References Fig 2. Extracted balloon catheter with guidewire passing through the stent eccentrically.
FEATURE ARTICLES
agents as the cardiac index measured 3.6. The chest was closed in the usual fashion. Postoperative recovery was unremarkable, and the patient was extubated 5 hours after surgery. The intraaortic balloon pump was removed after 14 hours and he was discharged to the ward the next day. He made an uneventful recovery and was discharged on postoperative day 7 on aspirin and clopidogrel (75 mgs each), bisoprolol (5 mg), simvastatin (10 mg), and analgesics. Although the troponin I level was 28.13 mg/L on postoperative day 1 (any levels ⬎ 0.50 mg/L may be used to confirm a diagnosis of acute myocardial infarction if consistent with symptoms and electrocardiogram changes), there was no evidence of acute myocardial infarction postoperatively. At follow-up after 7 weeks, the electrocardiogram was normal. Echocardiogram did not reveal any evidence of regional wall motion abnormality.
Comment In this case, the guidewire and the whole balloon had become entrapped in the LAD after deployment in contrast with other reports in which the guidewire or the balloon had gotten entrapped and fragmented [2–5]. The hemodynamic instability and myocardial ischemia secondary to the entrapped equipment necessitated emergency removal and revascularization, which alleviated the ischemic changes. Several methods of percutaneous removal have been described; however, these have been applied only to cases in which a fragment of the guidewire had gotten lodged in the coronary arterial tree, avoiding the need for surgery [2, 5, 6]. However, the coronary arteries are likely to suffer damage at site of impaction. Nishiwaki and colleagues [3] report a case of balloon catheter entrapment in the circumflex coronary artery. They removed this fragment through a coronary arteriotomy. We were dealing with more than a meter long entrapped guidewire. Furthermore, the site was obscured by the hematoma and would not have been ideal for coronary arteriotomy. An aortotomy was necessary to amputate the © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Seshadri N, Whitlow PL, Acharya N, Houghtaling P, Blackstone EH, Ellis SG. Emergency coronary artery bypass surgery in the contemporary percutaneous coronary intervention era. Circulation 2002;106:2346 –50. 2. Madronero JL, Hein F, Bergbauer M. Removal of a ruptured, detached, and entrapped angioplasty balloon after coronary stenting. J Invasive Cardiol 2000;12(2):102–4. 3. Nishiwaki N, Kawano Y, Furukawa K, Nakayama Y. A case report of entrapment of PTCA balloon catheter caused by its rupture. Nippon Kyobu Geka Gakkai Zasshi 1991;39(8):1226 – 30. 4. Yajima T, Sakakibara T, Ida T, Tsunemoto H, Ootaki E, Suzuki S. Entrapment of broken guidewire in the right coronary artery during percutaneous transluminal coronary angioplasty. Nippon Kyobu Geka Gakkai Zasshi 1991;39(9):1813– 1815. 5. Savas V, Schreiber T, O’Neill W. Percutaneous extraction of fractured guidewire from distal right coronary artery. Cathet Cardiovasc Diagn 1991;22(2):124 –126. 6. Patel T, Shah S, Pandya R, Sanghvi K, Fonseca K. Broken guidewire fragment: a simplified retrieval technique. Catheter Cardiovasc Interv 2000;51(4):483–6.
Traumatic Innominate Artery Aneurysm 26 Years After Stab Injury Anunathan A. Reddi, FCS(SA), Mandhir M. Munasur, MBCHB, Rishendran R. Naidoo, MBCHB, and Dion D. Steer, MBCHB Department of Cardiothoracic Surgery, Wentworth Hospital, University of Natal, Durban, South Africa
We report the case history of a 46-year-old African man with a false aneurysm of the innominate artery subsequent to a stab wound in the right supraclavicular area 26 years previously, presenting with stridor. (Ann Thorac Surg 2005;79:1034 – 6) © 2005 by The Society of Thoracic Surgeons Accepted for publication Sept 18, 2003. Address reprint requests to Dr Reddi, Department of Cardiothoracic Surgery, Inkosi Albert Luthuli Central Hospital, Private Bag X03, Mayville 4058, Durban, South Africa; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.09.140