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Embolic coronary artery occlusion in percutaneous transfemoral coronary arteriography
Embolic coronary artery transfemoral coronary
occlusion in percutaneous arteriography
Angel de la Torre, M.D.* Dajriel Jacobs, M.D.** Juan Aleman, M.D.“** George A. Anderson, M.D.**** Jacksonville. Fla.
A
lthough the technique of selective coronary angiography as described by Sones and Shirey’ has been in popular use since 1962 and has enjoyed a record of relative freedom from major complications, its few limitations including occasional poor coronary opacification, difficulty with catheter introduction associated with anatomic arterial variations or the inherent complexity of the procedure, together with the advent of coronary bypass surgery with the resultant demand for increasing numbers of studies, have led to a search for newer, more reliable techniques. Among the alternatives, the technique of percutaneous transfemoral artery bilateral selective coronary arteriography as described by Judkins2 has, indeed, seemed to resolve most of the problems previously encountered. With a recent exception,3 previous reports of a major complication of coronary artery
occlusion with myocardial infarction due to emboli introduced with this technique did not prepare us for its startling frequency in our laboratory.3r6-g Methods
and
materials
Selective coronary arteriography was carried out in 215 patients from April, 1970, to May, 1972 (147 men and 68 women, whose ages ranged from 30 to 70 years with a mean age of 52 years). The Sones technique was used in 76 and the Judkins technique was used in 139. During the Judkins technique a No. 18 gauge thinwalled arterial needle was employed for percutaneous entry of the common femoral artery. Teflon-coated 145 cm. guide wires were used and, where necessary, a Safety-J guide was employed. A short 7-F Teflon catheter was inserted into the artery over the guide before inserting the pig-tail catheter used for the
From the Department of Medicine, University Hospital, Jacksonville, Fla. Supported in part by a research grant from the Northeast Florida Heart Association. Received for publication Dec. 4. 1972. Reprint requests to: Dr. George A. Anderson, 2005 Riverside Avenue. Jacksonville. Fla. 32204. *Associate Professor of Medicine, Division of Cardiology JHEP, University of Florida, University Hospital, ville, Fla.; Currently Chief, Cardiovascular Laboratory. St. Vincent’s Hospital, Jacksonville, Fla. **Assi,stant Professor of Medicine, Division of Cardiology JHEP, University of Florida, University Hospital, ville, Fla. ***Fellow in Cardiology. University Hospital, Jacksonville, Fla. ****Clinical Associate Professor of Medicine, Division of Cardiology, JHEP, University of Florida, University Jacksonville, Fla.
Vol.
86, No. 4, pp. 467-473
October,
1973
American Heart Journal
JacksonJackson-
Hospital,
467
gram \\ as taken the follo\ving clay before the patient was (lischarged. If, l~cause of clinical angiographic or electrocardiographic findings, a c.ardiac complication \v;ts suspected, serial tflZS’IlleS and electrocardiogranls \vere obtained. Results
Fig. 1. Patient No. 1, Percutancolk Lr,~n~fcmor,d left coronary arteriogrnphy, left 2nlcrior olrli~~w position. Injection of the left main coror~~ry ;Irtery revealed total obstruction proximal to bifurwtion into the left anterior descendins sued circumlles branches.
left ventriculogram. Ducor Judkins preshaped disposable right and left coronary catheters were used for the coronary study.2 Selective studies were done with the patient in different oblique projections. Contrast material was injected by hand syringe and pressures were monitored by the stop cock systent described by Sones and Shirey.* Flushing of the coronary catheter which was continuously infused with heparinized saline was made at the level of the descending aorta before it was advanced toward the ascending aorta. At the present time the left coronary catheter is removed from the coronary ostiunt after each injection, aspirated, and is flushed before reinsertion. If right-side cardiac catheterization is not performed. an intravenous catheter is placed in the left arm before the procedure for use in emergency situations. Pressures were monitored with 1’23111~ Statham pressure transducers and mean artery pressure \vas obtained by electronic filtering. Lead II of the electrocardiogram \vas continon all records. All tracings uously inscribed were inscril)ed by a 16 channel Electronics for hledicine UK-16 physiological Recorder. Following the procedure the patients were admitted to the Coronary Care ITnit for 24 hours, during which time they \vere monitored continuously and vital signs were taken periodically. An electrocardio-
We have done 139 selective coronary studies via the percutaneous transfemoral artery approach from April, 1970, to 1\Iay, 1972. Approximately 1,112 injections were made into the coronary arteries during these studies. Iluring the procedure acute myocardial infarction, probably due to embolic occlusion within the left coronary artery system occurred in 6 patients. Of these, patients No. 1 and 2 died \vith total occlusion of the left main coronary artery shortly after the procedure. Postmortem examination, obtained in Patient 1, disclosed a fresh clot obstructing the left main coronary artery at the site of severe atherosclerotic narrowing. In the case of Patient 2, consent for autopsy was not obtained. Patient 3 developed total occlusion 1 cm. distal to the origin of the left anterior descending coronary artery after the first injection. Patient 4 also developed total occlusion of the left anterior descending coronary artery at the junction Ijetween its middle and distal thirds. Both patients experienced uneventful recovery from clinical evidence of acute myocardial infarction. 6 I)oth suffered total I’atients 5 and occlusion of the left circumflex coronary artery. In both there \~as also uneventful recovery from clinical e\-idence of acute myocardial infarction. Case reports Patient 1. .A 62-year-old white woman, diwnosed in 1967 ;I> havinz ., Turner’s svndrome (SO45-XX-46 mosaic by chromosome analyks), was followed at the L)uval Medical Center since 1965 for mild congestive heart failure associated with chest pain relieved within 5 to 10 minutes by nitroglycerin. In 1967, n short, late, systolic murmur with midsystolic click was described. Although the electrocardiogram was within normal limits, Masters test demonstrated subendocardinl injury during and immediately after exercise. ;\s she wu felt to have ballooning mitral \.a[\-e
Volume Number
56 4
and/or ischemic papillary muscle dysfunction, she was admitted to the hospital in October, 1971, for cardiac catheterization and selective coronary arteriography. During selective injection of the left coronary artery using the percutaneous transfemoral approach, she suddenly developed chest pain accompanied by cardiovascular collapse. She was found to have a block of the left main coronary artery at its bifurcation into the circumflex and anterior descending branches (Fig. 1). Resuscitation attempts precluded recording her electrocardiogram at this particular time and despite all efforts, the patient died on the catheterization table. Postmortem. examination revealed an atherosclerotic narrowing of greater than 80 per cent prior at the bifurcation of the left main coronary artery into the left anterior descending and circumflex branches which was occluded by a fresh clot. Findings compatible with the syndrome of ballooning mitral valve were present. Patient 2. A 56-year-old white man was first admitted to the Duval Medical Center in August, 1969, presenting a six month history of progressively more severe and frequent substernal chest pain which radiated to the left arm and was usually relieved by rest. Physical examination was within normal limits and, after serial electrocardiograms and enzyme determinations were unremarkable, he was discharged with a diagnosis of “coronary insufficiency.” After readmission in April, 1970, using the Sones technique bilatleral selective coronary arteriography demonstrated ‘70 per cent narrowing of the right coronary artery and complete occlusion of the left anterior descentding artery beyond the first diagonal branch with retrograde filling from the right coronary artery. In June, 1970, an aorto-left anterior descending artery saphenous vein bypass procedure was performed successfully. After one year free of angina] symptoms, he was readmitted in August, 1971, for restudy of his bypass graft. Using the percutaneous transfemoral approach, injection into the bypass revealed graft patency but injection into his left main coronary artery was followed immediately by bradycardia and complete AV block, accompanying embolic occlusion of the left main coronary artery (Figs. 2 and 3). 4 pacemaker was positioned in the catheterization laboratory; however, after transfer, he died in the Coronary Care Unit in cardiogenic shock. Permission for autopsy was not granted. Patient 3. In January, 1970, a 32-year-old white man began experiencing severe substernal chest pain which radiated to both shoulders, was occasionally accompanied by pallor, bore no relationship to exertion, and was rarely relieved by nitroglycerin. He smoked one package of cigarettes daily for 20 years and family history contained evidence of coronary artery disease. In April, 1970, after a normal admission physical examination, percutaneous transfemoral selective coronary arteriography was carried out. On injection into the left coronary artery, the distal left anterior descending artery seemed to be totally blocked about 2 cm. beyond its origin (Fig. 4). Accompanying this, the monitor revealed pronounced anterior
Embolic coronary artery occlusion
469
Fig. 2. Patient No. 2. Percutaneous transfemoral injection of the bypass graft, left anterior oblique projection. Prior to injection of the left main coronary artery, all three branches of the left coronary system were patent.
Fig, 3. Patient No. 2. Percutaneous transfemoral left coronary arteriography, left anterior oblique projection. Injection into main left coronary artery demonstrated complete block of the left main coronary artery. (Catheter was retracted after injection.) ST segment and T wave elevation; and, because of the persistent pain, the procedure was terminated without injection of the right coronary artery. He was transferred to the Coronary Care Unit and had an uneventful recovery from an anterior myocardial infarction confirmed by electrocardiogram, but he continued to complain of substernal chest pain identical to that for which he was first admitted. Patient 4. A 53-year-old Negro male construction worker was admitted to the University Hospital in May, 1972, presenting a history of precordial chest pain, relieved within 10 minutes by nitroglycerin, for approximately five years, more frequent since December, 1971. He had smoked more than two packages of cigarettes daily for more than 20 years before stopping 6 to 8 years prior to admission and was spaknown to be hypertensive for 4 years, treated radically. Physical examination disclosed a blood
470
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et cri.
Fig. J. Patient No. 3. Percutaneous transfemoral left coronary arteriography, left .rnterior oblique projection. Injection into the left main coronary artery disclosed total block of left anterior descending coronary artery. It should be noted the left main coronary artery and the left circumflex coronary arteries are patent.
Fi.:. 5. Patient No. 1. Percutaneous tmn+femoral coronary arteriogmphy, right anterior obliqrie jection Normal left coronuy system.
left pro-
Fig. 6. Patient No. 4. Percutaneous transfemoral left coronuy arteriogmphv, right anterior oblique projection. Third injeciion demonstrated complete block of left anterior descending coronary artery.
presure of 160/90, an accentuated, though physiologically split, second sound, an audible fourth sound, and a nonradiating, Grade I, short, systolic murmur at the cardiac apex. Having, during bilateral selective coronary nrteriography via the percutaneous transfemornl approach, demonstrated normal right, left main, and circumflex coronary arteries, the patient developed substernal chest pain after the third injection into the left main coronary artery. Acute occlusion of the distal left anterior descending coronary artery was found (Figs. 5 and 6), accompanied by ST segment elevation in the anterior and inferior leads followed later by evolving electrocardiographic changes. Following the procedure he was admitted to the Coronary Care Unit and recovered uneventfully from an acute myocardial infarction, due to embolic occlusion of the anterior descending branch of the left coronary artery. Patient 5. A 56-year-old white man was admitted to 1Tniversity Hospital in January, 1972, for selective coronary arteriography having, in 1960, begun experiencing substernal chest pain which radiated into the left arm, occurred with exertion and anxiety, and was relieved within 5 to 10 minutes by nitroglycerin. For two and one-half years he had had symptoms compatible with paroxysmal nocturnal dyspnea, two or three pillow orthopnea, and occasional exertional dyspnen, during which time he was maintained on digitalis and diuretics. Hypertension, known present for four years, had been treated for three years. He had smoked 2 to 3 packages of cigarettes daily for 12 years, stopping 10 years prior to admission. He was said to have had an elevated cholesterol and an abnormal glucose tolerance test. A brother and sister, both 58, reportedly died of myocardial infarction, and a brother, 60, was said to have angina, examination blood pressure was 0 n physical 140/80, the optic fundi presented Grade II nrteriosclerotic changes, and there was an apical fourth sound. On undergoing percutaneous transfernornl bilateral selective coronary arteriogtaphy in which the right coronary artery was within normal limits and the left anterior descending coronary artery displayed mild disease, he sustained an embolus to the left circumflex artery on the fourth injection into the left main coronary artery (Figs. 7 and 8). He was admitted to the Coronary Care I.Jnit and after 14 hospital days was transferred to the 1.eternn’s Administration Hospital for continued convnlescence from myocnrdial infarction. The acute episode was unaccompanied by dingnostic electrocardiographic changes, but infarction was reflected by marked rise in the serum enzymes. Patient 6. A 52-year-old white man \vas admitted to another hospital in December, 1971, because of acute onset of substernal chest pun. Serial electrocardiogr.rms demon-;trated stable nonspecific ST-T change2; and after the usual studie5 ruled out acute myocatdial infarction, he was felt to hale an
Embolic coronary artery occlzbon
471
Fig. 7. Patient No. 5. Percutaneous transfemoral left coronary arteriography, right anterior oblique projection. First injection demonstrated patency of all three vessels of the left coronary system. Note minimal disease of left anterior descending coronary artery.
Fig. 9. Patient No. 6. Percutaneous transfemoral left coronary arteriography, left anterior oblique projection. First injection demonstrated all three branches of the left coronary artery system to be patent.
Fig. 8. Patient No. 5. Percutaneous transfemoral left coronary arteriography, right anterior oblique projection. Fourth injection demonstrated block of left circumflex coronary artery.
Fig. 10. Patient No. 6. Percutaneous transfemoral left coronary arteriography, left anterior oblique projection. Third injection demonstrated block of left circumflex coronary artery.
In January, 1972, following a normal physical examination, percutaneous transfemoral bilateral selective coronary arteriography was carried out in which a small right coronary artery was found occluded and the left anterior descending coronary artery was found to be mildly diseased. Following the third injection into the left main coronary artery, he developed hypotension and bradycardia accompanied by electrocardiographic evidence of inferior wall injury. There was noted to be complete obstruction of the left circumflex coronary artery which had not been seen in the previous injections in the same projection (Figs. 9 and 10). He was transferred to the Coronary Care Unit where his serial enzymes rose and electrocardiographic evidence of I-‘o.stero-di;lphral:matic myocardial infarction developed.
Discussion
We had used, almost exclusively, the technique of selective coronary arteriography described by Sones and Shirey,’ but in 1970 we started using the percutaneous transfemoral technique3s4 in the following situations: 1. tortuous subclavian-innominate arteries 2. difficulty in obtaining satisfactory coronary opacification 3. previous cut-downs in the brachial artery with faint pulse
472
de la Torre et al.
4. young females with spastic brachial arteries. However, because the procedure is quickly learned by trainees, fluoroscopic time is abbreviated, and good coronary visualization is obtained, its use in our laboratory had recently been greatly expanded. With one exception,3 our incidence of the procedural complication of myocardial infarction due apparently to embolic occlusion within the left coronary artery system appears to differ significantly from that reported by others, though the problem may have been associated with left anterior descending artery occlusion described by Gau and colleagues5 and left circumflex coronary artery occlusion reported by Cheng and associates.” This potentially hazardous complication has, however, been previously reported.3Bfi-g In order to minimize the risk it was first recommended that the catheter be energetically flushed prior to advancing the tip from the descending to the ascending aorta and, later, if more than the usual time between the injections is required, if persistent electrocardiographic changes occur, or if the patient’s position must be changed, the catheter should be removed from the ostium of the coronary artery, aspirated, and flushed before another injection is carried out.’ However, since two more cases have recently occurred in our laboratory despite meticulous observation of these modifications in technique, we have elected to repeat this maneuver after each injection. The severity of the infarction apparently bears close relationship to the size of the embolus, the level of the obstruction, and the previous state of the coronary arteries. A small fibrin clot will probably not obstruct the main coronary artery or the initial segments of the primary branches unless there is a severe narrowing at these levels as was the case in Patients 1 and 2. In none of our patients was damping of the pressure noted prior to injection of contrast media into the left coronary arterlr-indicating that the presence of a good pressure is not a reliable sign of the absence of a clot in the catheter tip. The high incidence of this complication in our laboratory may, in part, be explained
I)y the fact that during the first part of this study, none of the recently suggested precautions were employed. Holvever, since the last cases occurred despite the use of all theretofore recommended modifications, it is felt this type of accident may be related to the nature of the left coronary catheter, (possibly the increased angulation of the catheter tip), or to the sequence in \\-hich it is used. The problem might be reduced by withdrawal and flushing of the catheter between each injection. This xvould, however, negate much of the procedural advantage (that of minimizing fluoroscopic and procedure time), and would increase the time in which a fibrin clot might form, as well as predispose to other complications such as subintimal coronary dissection,5s10 or perforation of the coronary artery.” Recently, use of the guide wire andior insertion of the second catheter has been causally implicated. ITse of Teflon sheaths rather than wires and systemic anticoagulation have therefore been suggested as reasonable modifications with which to reduce the incidence of this complication.3 At the present time we are, however, again, limiting the transfemoral approach to only the indications previously outlined and would suggest this procedure might be less innocuous than its previous acceptance indicates. Summary
A review is presented of 139 selecti1.e coronary artery studies during a 25 month period in which 1,112 coronary artery injections were performed using the percutaneous transfemoral artery approach as described by Judkins in 1967.2 Six patients (four per cent) developed acute occlusion of the left coronary artery or one of its branches during the procedure, and tlvo of these died with occlusion of the left main coronary artery shortly thereafter. It is felt that since in all cases of this series and most of those of others, embolic occlusion within the left coronary artery system occurred, the complication is related to the thrombogenic properties of the left coronary catheter or to the procedure in which introduction of the second catheter is required.
Volume Ntmber
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REFERENCES 1. Sones, F. M., Jr., and Shirey, E. K.: Cine coronary arteriography, Mod. Concepts Cardiovasc. Dis. 31:7, 1962. 2. Judkins, M. P.: Selective coronary arteriography I. A percutaneous transfemoral technique, Radiology 89:815, 1967. 3. Kangilaski, J.: Medical news, J.A.M.A. 221:547, 1972. 4. Spellburg, R. D., and Ungar, I.: The percutaneous fsemoral artery approach to selective coronary arteriography, Circulation 36:739, 19fi7.
5.
6.
Gau, G. T., Oakley, C. M., Rahimtoola, S. H., Raphael, M. J., and Steiner, R. E.: Selective coronary arteriography. A review of 18 months’ experience, Clin. Radio]. 21:275, 1970. Cheng, T. O., Bashour, T., Singh, B. K., and Kelser, G. A.: Myocardial infarction in the absence of coronary arteriosclerosis, Am. J. Cardiol. 30:680, 1972.
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7. Green, G. S., McKinnon, C. M., Rosch, J., and Judkins, M. P.: Complications of selective percutaneous transfemoral coronary arteriography and their prevention. A review of 445 consecutive examinations, Circulation 15:552, 1972. 8. Cheng, T. 0.: Fatal thromboembolism following selective coronary arteriography, Chest 62:1, 1972. 9. Wilson, W. J., Lee, G. B., and Amplatz, K.: Biplane selective coronary arteriography via percutaneous transfemoral approach, Am, J. Roentgenol. 100:332, 1967. 10. Haas, J. M., Peterson, C. R., and Jones, R. C.: Subintimal dissection of the coronary arteries. A complication of selective coronary arteriography and the transfemoral percutaneous approach, Circulation 38:678, 1968. 11. Morettin, L. B., and Wallace, J. M.: Uneventful perforation of a coronary artery during selective arteriography, Am. J. Roentgenol. 110:185, 1970.
occlusion in percutaneous arteriography
Angel de la Torre, M.D.* Dajriel Jacobs, M.D.** Juan Aleman, M.D.“** George A. Anderson, M.D.**** Jacksonville. Fla.
A
lthough the technique of selective coronary angiography as described by Sones and Shirey’ has been in popular use since 1962 and has enjoyed a record of relative freedom from major complications, its few limitations including occasional poor coronary opacification, difficulty with catheter introduction associated with anatomic arterial variations or the inherent complexity of the procedure, together with the advent of coronary bypass surgery with the resultant demand for increasing numbers of studies, have led to a search for newer, more reliable techniques. Among the alternatives, the technique of percutaneous transfemoral artery bilateral selective coronary arteriography as described by Judkins2 has, indeed, seemed to resolve most of the problems previously encountered. With a recent exception,3 previous reports of a major complication of coronary artery
occlusion with myocardial infarction due to emboli introduced with this technique did not prepare us for its startling frequency in our laboratory.3r6-g Methods
and
materials
Selective coronary arteriography was carried out in 215 patients from April, 1970, to May, 1972 (147 men and 68 women, whose ages ranged from 30 to 70 years with a mean age of 52 years). The Sones technique was used in 76 and the Judkins technique was used in 139. During the Judkins technique a No. 18 gauge thinwalled arterial needle was employed for percutaneous entry of the common femoral artery. Teflon-coated 145 cm. guide wires were used and, where necessary, a Safety-J guide was employed. A short 7-F Teflon catheter was inserted into the artery over the guide before inserting the pig-tail catheter used for the
From the Department of Medicine, University Hospital, Jacksonville, Fla. Supported in part by a research grant from the Northeast Florida Heart Association. Received for publication Dec. 4. 1972. Reprint requests to: Dr. George A. Anderson, 2005 Riverside Avenue. Jacksonville. Fla. 32204. *Associate Professor of Medicine, Division of Cardiology JHEP, University of Florida, University Hospital, ville, Fla.; Currently Chief, Cardiovascular Laboratory. St. Vincent’s Hospital, Jacksonville, Fla. **Assi,stant Professor of Medicine, Division of Cardiology JHEP, University of Florida, University Hospital, ville, Fla. ***Fellow in Cardiology. University Hospital, Jacksonville, Fla. ****Clinical Associate Professor of Medicine, Division of Cardiology, JHEP, University of Florida, University Jacksonville, Fla.
Vol.
86, No. 4, pp. 467-473
October,
1973
American Heart Journal
JacksonJackson-
Hospital,
467
gram \\ as taken the follo\ving clay before the patient was (lischarged. If, l~cause of clinical angiographic or electrocardiographic findings, a c.ardiac complication \v;ts suspected, serial tflZS’IlleS and electrocardiogranls \vere obtained. Results
Fig. 1. Patient No. 1, Percutancolk Lr,~n~fcmor,d left coronary arteriogrnphy, left 2nlcrior olrli~~w position. Injection of the left main coror~~ry ;Irtery revealed total obstruction proximal to bifurwtion into the left anterior descendins sued circumlles branches.
left ventriculogram. Ducor Judkins preshaped disposable right and left coronary catheters were used for the coronary study.2 Selective studies were done with the patient in different oblique projections. Contrast material was injected by hand syringe and pressures were monitored by the stop cock systent described by Sones and Shirey.* Flushing of the coronary catheter which was continuously infused with heparinized saline was made at the level of the descending aorta before it was advanced toward the ascending aorta. At the present time the left coronary catheter is removed from the coronary ostiunt after each injection, aspirated, and is flushed before reinsertion. If right-side cardiac catheterization is not performed. an intravenous catheter is placed in the left arm before the procedure for use in emergency situations. Pressures were monitored with 1’23111~ Statham pressure transducers and mean artery pressure \vas obtained by electronic filtering. Lead II of the electrocardiogram \vas continon all records. All tracings uously inscribed were inscril)ed by a 16 channel Electronics for hledicine UK-16 physiological Recorder. Following the procedure the patients were admitted to the Coronary Care ITnit for 24 hours, during which time they \vere monitored continuously and vital signs were taken periodically. An electrocardio-
We have done 139 selective coronary studies via the percutaneous transfemoral artery approach from April, 1970, to 1\Iay, 1972. Approximately 1,112 injections were made into the coronary arteries during these studies. Iluring the procedure acute myocardial infarction, probably due to embolic occlusion within the left coronary artery system occurred in 6 patients. Of these, patients No. 1 and 2 died \vith total occlusion of the left main coronary artery shortly after the procedure. Postmortem examination, obtained in Patient 1, disclosed a fresh clot obstructing the left main coronary artery at the site of severe atherosclerotic narrowing. In the case of Patient 2, consent for autopsy was not obtained. Patient 3 developed total occlusion 1 cm. distal to the origin of the left anterior descending coronary artery after the first injection. Patient 4 also developed total occlusion of the left anterior descending coronary artery at the junction Ijetween its middle and distal thirds. Both patients experienced uneventful recovery from clinical evidence of acute myocardial infarction. 6 I)oth suffered total I’atients 5 and occlusion of the left circumflex coronary artery. In both there \~as also uneventful recovery from clinical e\-idence of acute myocardial infarction. Case reports Patient 1. .A 62-year-old white woman, diwnosed in 1967 ;I> havinz ., Turner’s svndrome (SO45-XX-46 mosaic by chromosome analyks), was followed at the L)uval Medical Center since 1965 for mild congestive heart failure associated with chest pain relieved within 5 to 10 minutes by nitroglycerin. In 1967, n short, late, systolic murmur with midsystolic click was described. Although the electrocardiogram was within normal limits, Masters test demonstrated subendocardinl injury during and immediately after exercise. ;\s she wu felt to have ballooning mitral \.a[\-e
Volume Number
56 4
and/or ischemic papillary muscle dysfunction, she was admitted to the hospital in October, 1971, for cardiac catheterization and selective coronary arteriography. During selective injection of the left coronary artery using the percutaneous transfemoral approach, she suddenly developed chest pain accompanied by cardiovascular collapse. She was found to have a block of the left main coronary artery at its bifurcation into the circumflex and anterior descending branches (Fig. 1). Resuscitation attempts precluded recording her electrocardiogram at this particular time and despite all efforts, the patient died on the catheterization table. Postmortem. examination revealed an atherosclerotic narrowing of greater than 80 per cent prior at the bifurcation of the left main coronary artery into the left anterior descending and circumflex branches which was occluded by a fresh clot. Findings compatible with the syndrome of ballooning mitral valve were present. Patient 2. A 56-year-old white man was first admitted to the Duval Medical Center in August, 1969, presenting a six month history of progressively more severe and frequent substernal chest pain which radiated to the left arm and was usually relieved by rest. Physical examination was within normal limits and, after serial electrocardiograms and enzyme determinations were unremarkable, he was discharged with a diagnosis of “coronary insufficiency.” After readmission in April, 1970, using the Sones technique bilatleral selective coronary arteriography demonstrated ‘70 per cent narrowing of the right coronary artery and complete occlusion of the left anterior descentding artery beyond the first diagonal branch with retrograde filling from the right coronary artery. In June, 1970, an aorto-left anterior descending artery saphenous vein bypass procedure was performed successfully. After one year free of angina] symptoms, he was readmitted in August, 1971, for restudy of his bypass graft. Using the percutaneous transfemoral approach, injection into the bypass revealed graft patency but injection into his left main coronary artery was followed immediately by bradycardia and complete AV block, accompanying embolic occlusion of the left main coronary artery (Figs. 2 and 3). 4 pacemaker was positioned in the catheterization laboratory; however, after transfer, he died in the Coronary Care Unit in cardiogenic shock. Permission for autopsy was not granted. Patient 3. In January, 1970, a 32-year-old white man began experiencing severe substernal chest pain which radiated to both shoulders, was occasionally accompanied by pallor, bore no relationship to exertion, and was rarely relieved by nitroglycerin. He smoked one package of cigarettes daily for 20 years and family history contained evidence of coronary artery disease. In April, 1970, after a normal admission physical examination, percutaneous transfemoral selective coronary arteriography was carried out. On injection into the left coronary artery, the distal left anterior descending artery seemed to be totally blocked about 2 cm. beyond its origin (Fig. 4). Accompanying this, the monitor revealed pronounced anterior
Embolic coronary artery occlusion
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Fig. 2. Patient No. 2. Percutaneous transfemoral injection of the bypass graft, left anterior oblique projection. Prior to injection of the left main coronary artery, all three branches of the left coronary system were patent.
Fig, 3. Patient No. 2. Percutaneous transfemoral left coronary arteriography, left anterior oblique projection. Injection into main left coronary artery demonstrated complete block of the left main coronary artery. (Catheter was retracted after injection.) ST segment and T wave elevation; and, because of the persistent pain, the procedure was terminated without injection of the right coronary artery. He was transferred to the Coronary Care Unit and had an uneventful recovery from an anterior myocardial infarction confirmed by electrocardiogram, but he continued to complain of substernal chest pain identical to that for which he was first admitted. Patient 4. A 53-year-old Negro male construction worker was admitted to the University Hospital in May, 1972, presenting a history of precordial chest pain, relieved within 10 minutes by nitroglycerin, for approximately five years, more frequent since December, 1971. He had smoked more than two packages of cigarettes daily for more than 20 years before stopping 6 to 8 years prior to admission and was spaknown to be hypertensive for 4 years, treated radically. Physical examination disclosed a blood
470
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Fig. J. Patient No. 3. Percutaneous transfemoral left coronary arteriography, left .rnterior oblique projection. Injection into the left main coronary artery disclosed total block of left anterior descending coronary artery. It should be noted the left main coronary artery and the left circumflex coronary arteries are patent.
Fi.:. 5. Patient No. 1. Percutaneous tmn+femoral coronary arteriogmphy, right anterior obliqrie jection Normal left coronuy system.
left pro-
Fig. 6. Patient No. 4. Percutaneous transfemoral left coronuy arteriogmphv, right anterior oblique projection. Third injeciion demonstrated complete block of left anterior descending coronary artery.
presure of 160/90, an accentuated, though physiologically split, second sound, an audible fourth sound, and a nonradiating, Grade I, short, systolic murmur at the cardiac apex. Having, during bilateral selective coronary nrteriography via the percutaneous transfemornl approach, demonstrated normal right, left main, and circumflex coronary arteries, the patient developed substernal chest pain after the third injection into the left main coronary artery. Acute occlusion of the distal left anterior descending coronary artery was found (Figs. 5 and 6), accompanied by ST segment elevation in the anterior and inferior leads followed later by evolving electrocardiographic changes. Following the procedure he was admitted to the Coronary Care Unit and recovered uneventfully from an acute myocardial infarction, due to embolic occlusion of the anterior descending branch of the left coronary artery. Patient 5. A 56-year-old white man was admitted to 1Tniversity Hospital in January, 1972, for selective coronary arteriography having, in 1960, begun experiencing substernal chest pain which radiated into the left arm, occurred with exertion and anxiety, and was relieved within 5 to 10 minutes by nitroglycerin. For two and one-half years he had had symptoms compatible with paroxysmal nocturnal dyspnea, two or three pillow orthopnea, and occasional exertional dyspnen, during which time he was maintained on digitalis and diuretics. Hypertension, known present for four years, had been treated for three years. He had smoked 2 to 3 packages of cigarettes daily for 12 years, stopping 10 years prior to admission. He was said to have had an elevated cholesterol and an abnormal glucose tolerance test. A brother and sister, both 58, reportedly died of myocardial infarction, and a brother, 60, was said to have angina, examination blood pressure was 0 n physical 140/80, the optic fundi presented Grade II nrteriosclerotic changes, and there was an apical fourth sound. On undergoing percutaneous transfernornl bilateral selective coronary arteriogtaphy in which the right coronary artery was within normal limits and the left anterior descending coronary artery displayed mild disease, he sustained an embolus to the left circumflex artery on the fourth injection into the left main coronary artery (Figs. 7 and 8). He was admitted to the Coronary Care I.Jnit and after 14 hospital days was transferred to the 1.eternn’s Administration Hospital for continued convnlescence from myocnrdial infarction. The acute episode was unaccompanied by dingnostic electrocardiographic changes, but infarction was reflected by marked rise in the serum enzymes. Patient 6. A 52-year-old white man \vas admitted to another hospital in December, 1971, because of acute onset of substernal chest pun. Serial electrocardiogr.rms demon-;trated stable nonspecific ST-T change2; and after the usual studie5 ruled out acute myocatdial infarction, he was felt to hale an
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Fig. 7. Patient No. 5. Percutaneous transfemoral left coronary arteriography, right anterior oblique projection. First injection demonstrated patency of all three vessels of the left coronary system. Note minimal disease of left anterior descending coronary artery.
Fig. 9. Patient No. 6. Percutaneous transfemoral left coronary arteriography, left anterior oblique projection. First injection demonstrated all three branches of the left coronary artery system to be patent.
Fig. 8. Patient No. 5. Percutaneous transfemoral left coronary arteriography, right anterior oblique projection. Fourth injection demonstrated block of left circumflex coronary artery.
Fig. 10. Patient No. 6. Percutaneous transfemoral left coronary arteriography, left anterior oblique projection. Third injection demonstrated block of left circumflex coronary artery.
In January, 1972, following a normal physical examination, percutaneous transfemoral bilateral selective coronary arteriography was carried out in which a small right coronary artery was found occluded and the left anterior descending coronary artery was found to be mildly diseased. Following the third injection into the left main coronary artery, he developed hypotension and bradycardia accompanied by electrocardiographic evidence of inferior wall injury. There was noted to be complete obstruction of the left circumflex coronary artery which had not been seen in the previous injections in the same projection (Figs. 9 and 10). He was transferred to the Coronary Care Unit where his serial enzymes rose and electrocardiographic evidence of I-‘o.stero-di;lphral:matic myocardial infarction developed.
Discussion
We had used, almost exclusively, the technique of selective coronary arteriography described by Sones and Shirey,’ but in 1970 we started using the percutaneous transfemoral technique3s4 in the following situations: 1. tortuous subclavian-innominate arteries 2. difficulty in obtaining satisfactory coronary opacification 3. previous cut-downs in the brachial artery with faint pulse
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4. young females with spastic brachial arteries. However, because the procedure is quickly learned by trainees, fluoroscopic time is abbreviated, and good coronary visualization is obtained, its use in our laboratory had recently been greatly expanded. With one exception,3 our incidence of the procedural complication of myocardial infarction due apparently to embolic occlusion within the left coronary artery system appears to differ significantly from that reported by others, though the problem may have been associated with left anterior descending artery occlusion described by Gau and colleagues5 and left circumflex coronary artery occlusion reported by Cheng and associates.” This potentially hazardous complication has, however, been previously reported.3Bfi-g In order to minimize the risk it was first recommended that the catheter be energetically flushed prior to advancing the tip from the descending to the ascending aorta and, later, if more than the usual time between the injections is required, if persistent electrocardiographic changes occur, or if the patient’s position must be changed, the catheter should be removed from the ostium of the coronary artery, aspirated, and flushed before another injection is carried out.’ However, since two more cases have recently occurred in our laboratory despite meticulous observation of these modifications in technique, we have elected to repeat this maneuver after each injection. The severity of the infarction apparently bears close relationship to the size of the embolus, the level of the obstruction, and the previous state of the coronary arteries. A small fibrin clot will probably not obstruct the main coronary artery or the initial segments of the primary branches unless there is a severe narrowing at these levels as was the case in Patients 1 and 2. In none of our patients was damping of the pressure noted prior to injection of contrast media into the left coronary arterlr-indicating that the presence of a good pressure is not a reliable sign of the absence of a clot in the catheter tip. The high incidence of this complication in our laboratory may, in part, be explained
I)y the fact that during the first part of this study, none of the recently suggested precautions were employed. Holvever, since the last cases occurred despite the use of all theretofore recommended modifications, it is felt this type of accident may be related to the nature of the left coronary catheter, (possibly the increased angulation of the catheter tip), or to the sequence in \\-hich it is used. The problem might be reduced by withdrawal and flushing of the catheter between each injection. This xvould, however, negate much of the procedural advantage (that of minimizing fluoroscopic and procedure time), and would increase the time in which a fibrin clot might form, as well as predispose to other complications such as subintimal coronary dissection,5s10 or perforation of the coronary artery.” Recently, use of the guide wire andior insertion of the second catheter has been causally implicated. ITse of Teflon sheaths rather than wires and systemic anticoagulation have therefore been suggested as reasonable modifications with which to reduce the incidence of this complication.3 At the present time we are, however, again, limiting the transfemoral approach to only the indications previously outlined and would suggest this procedure might be less innocuous than its previous acceptance indicates. Summary
A review is presented of 139 selecti1.e coronary artery studies during a 25 month period in which 1,112 coronary artery injections were performed using the percutaneous transfemoral artery approach as described by Judkins in 1967.2 Six patients (four per cent) developed acute occlusion of the left coronary artery or one of its branches during the procedure, and tlvo of these died with occlusion of the left main coronary artery shortly thereafter. It is felt that since in all cases of this series and most of those of others, embolic occlusion within the left coronary artery system occurred, the complication is related to the thrombogenic properties of the left coronary catheter or to the procedure in which introduction of the second catheter is required.
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REFERENCES 1. Sones, F. M., Jr., and Shirey, E. K.: Cine coronary arteriography, Mod. Concepts Cardiovasc. Dis. 31:7, 1962. 2. Judkins, M. P.: Selective coronary arteriography I. A percutaneous transfemoral technique, Radiology 89:815, 1967. 3. Kangilaski, J.: Medical news, J.A.M.A. 221:547, 1972. 4. Spellburg, R. D., and Ungar, I.: The percutaneous fsemoral artery approach to selective coronary arteriography, Circulation 36:739, 19fi7.
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Gau, G. T., Oakley, C. M., Rahimtoola, S. H., Raphael, M. J., and Steiner, R. E.: Selective coronary arteriography. A review of 18 months’ experience, Clin. Radio]. 21:275, 1970. Cheng, T. O., Bashour, T., Singh, B. K., and Kelser, G. A.: Myocardial infarction in the absence of coronary arteriosclerosis, Am. J. Cardiol. 30:680, 1972.
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7. Green, G. S., McKinnon, C. M., Rosch, J., and Judkins, M. P.: Complications of selective percutaneous transfemoral coronary arteriography and their prevention. A review of 445 consecutive examinations, Circulation 15:552, 1972. 8. Cheng, T. 0.: Fatal thromboembolism following selective coronary arteriography, Chest 62:1, 1972. 9. Wilson, W. J., Lee, G. B., and Amplatz, K.: Biplane selective coronary arteriography via percutaneous transfemoral approach, Am, J. Roentgenol. 100:332, 1967. 10. Haas, J. M., Peterson, C. R., and Jones, R. C.: Subintimal dissection of the coronary arteries. A complication of selective coronary arteriography and the transfemoral percutaneous approach, Circulation 38:678, 1968. 11. Morettin, L. B., and Wallace, J. M.: Uneventful perforation of a coronary artery during selective arteriography, Am. J. Roentgenol. 110:185, 1970.