- Email: [email protected]
Entrapped catheter in the left ventricular posterior venous radicle of the coronary sinus in a case of hemianomalous pulmonary venous connection of left pulmonary veins to coronary sinus
International Journal of Cardiology 117 (2007) 270 – 272 www.elsevier.com/locate/ijcard
Letter to the Editor
Entrapped catheter in the left ventricular posterior venous radicle of the coronary sinus in a case of hemianomalous pulmonary venous connection of left pulmonary veins to coronary sinus N. Krishnakumar a,⁎, M. Misra b , Santosh Dora a , Shomu R. Bohora a a
b
Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum-695001, Kerala, India Department of Cardiac Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum-695001, Kerala, India Received 23 December 2005; accepted 24 February 2006 Available online 2 March 2007
Abstract A 25-year old acyanotic lady with unclear pulmonary venous drainage and a dilated coronary sinus was catheterized. Left pulmonary veins drained into coronary sinus in a left pulmonary vein angiogram done through the coronary sinus with a National Institute of Health 7F catheter. After the angiogram, the catheter got entrapped in a coronary sinus tributary and could be removed only by surgery. The left pulmonary veins were rerouted into the left atrium by unroofing the coronary sinus. Surgery is the treatment of choice for entrapped catheters when the primary condition itself merits surgical correction. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary sinus; Catheter entrapment; Hemianomalous pulmonary venous connection
1. Introduction Cardiac catheterization is now relatively safe. We report in this paper probably the first case report of a catheter getting entrapped in a coronary sinus radicle. 2. Case report A 25-year old acyanotic lady with a dilated coronary sinus (no left superior vena cava) and unclear left pulmonary vein drainage was catheterized. Left to right shunt was 1.9:1. Left pulmonary veins drained into the coronary sinus as seen in a left upper pulmonary vein angiogram done through the coronary sinus with a NIH (National Institute of Health) 7 French catheter. After the pulmonary vein angiogram, the catheter refluxed into the posterior left ventricular tributary ⁎ Corresponding author. Residence: “Krishnasree”, TC 15/267(3), Althara Road, Vellayambalam, Trivandrum-695010, Kerala, India. Tel.: +91 471 2443152; fax: +91 471 2446433. E-mail address: [email protected] (N. Krishnakumar). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.02.016
of the coronary sinus and got entrapped. Nitroglycerine through the entrapped catheter and through a second Goodale–Lubin catheter taken through another venous puncture did not help (Fig. 1panel a). At emergency surgery, a small hematoma 2 × 3 cm was seen on the posterolateral left ventricle (Fig. 2 panel b). The proximal 5 cm of the catheter was deep inside the posterior left ventricular tributary of the coronary sinus. With manipulation, the catheter could be pulled out. The left pulmonary veins were rerouted to the left atrium by unroofing the coronary sinus. She was discharged in normal sinus rhythm and stable hemodynamics. 3. Discussion The major causes of catheter breakage and entrapment include fatigue due to multiple manipulations, kinking and physical properties of the catheter system itself [1]. The incidence of broken catheters is 6 in 12,367 [2]. Karbhase JN reported seven cases (5 broken catheters, 2 perforations) of
N. Krishnakumar et al. / International Journal of Cardiology 117 (2007) 270–272
271
Fig. 1. Panel A shows the entrapped NIH catheter (arrow 1) in the coronary sinus radicle. A Goodale–Lubin catheter (arrow 2) was introduced through a second femoral venous puncture into the coronary sinus. Hand injection of contrast through this catheter did not show any antegrade filling of the coronary sinus tributary indicating severe spasm. Panel B: The levophase of a left pulmonary artery angiogram with a 6 French pigtail catheter (arrow 3) is seen which fills the left upper pulmonary vein (arrow 4) and the left lower pulmonary vein (arrow 5) which then drain into a dilated coronary sinus(arrow 7). The entrapped NIH catheter (arrow 1) is clearly not in any pulmonary vein. The tip (arrow 6) of this catheter is in a coronary sinus tributary which is not filling indicating severe spasm.
serious complications following 8000 cardiac catheterizations and aortograms (1972–84) from a medical college hospital [2]. Though emergency removal is almost always indicated [2],there is no consensus regarding the optimal approach indicating lack of consistent success with any one technique. Vigorous efforts at percutaneous removal may actually create further endothelial injury to an already diseased vessel [3]. Also, when surgical correction of the pathology is indicated, as in our case, where the patient needed correction of the hemianomalous pulmonary venous connection, surgery is the best option.
Catheters, biotomes and forceps have all been used to remove retained catheters [2]. However, the most widely adopted techniques include loop snare catheters or Dormia basket retrievers. These devices are best for larger fragments in easily accessible sites, are difficult to use in small and distal vessels and require larger sheaths [1]. Though coronary venous catheter entrapment is unreported, the incidence of entrapment or fragmentation of coronary artery angioplasty hardware ranges from 0.2% to 0.8% [3–6], actually just 39 reported cases in the past 13 years [3]. Of these, in 8 cases, the wire fragments were left
Fig. 2. Panel A: Surgeon's view with the right atrial free wall opened shows the entrapped NIH catheter (arrow 2) entering the coronary sinus ostium. Right atrial appendage (arrow 3) and inferior vena caval (arrow 1) canulae are seen. Panel B: Surgeon's view shows myocardial contusion (arrow 4) on the posterior surface of the heart.
272
N. Krishnakumar et al. / International Journal of Cardiology 117 (2007) 270–272
in situ. Percutaneous retrieval was successful in 14 cases and surgical intervention in another 17 cases [3]. Also, a larger sized catheter (7 French) is best avoided if the same information can be obtained using a smaller catheter. 4. Conclusion Catheter entrapment in a coronary venous radicle has hitherto been unreported. Surgical removal is the management of choice in such cases when the primary condition itself merits surgical correction. References [1] Harikrishna S, Rajeev E, Nair K, Tharakan J. Retrieval of friable catheter fragments. Int J Cardiol 2006;2:284–94.
[2] Karbhase JN, Panday SR, Parulkar GB, Kelkar MD. Complications of cardiac catheterization needing emergency surgery. J Postgrad Med 1984;30:237–40. [3] Chang TM, Pellegrini D, Ostrovsky A, Marrangoni AG. Surgical management of entrapped percutaneous transluminal coronary angioplasty hardware. Texas Heart Inst J 2002;29:329–32. [4] Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260–4. [5] Lotan C, Hasin Y, Stone D, Meyers S, Applebaum A, Gotsman MS. Guide wire entrapment during PTCA: a potentially dangerous complication. Catheter Cardiovasc Diagn 1987;13:309–12. [6] Doorey AJ, Stillabower M. Fractured and retained guidewire fragment during coronary angioplasty — unforeseen late sequelae. Catheter Cardiovasc Diagn 1990;20:238–40.
Letter to the Editor
Entrapped catheter in the left ventricular posterior venous radicle of the coronary sinus in a case of hemianomalous pulmonary venous connection of left pulmonary veins to coronary sinus N. Krishnakumar a,⁎, M. Misra b , Santosh Dora a , Shomu R. Bohora a a
b
Department of Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum-695001, Kerala, India Department of Cardiac Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum-695001, Kerala, India Received 23 December 2005; accepted 24 February 2006 Available online 2 March 2007
Abstract A 25-year old acyanotic lady with unclear pulmonary venous drainage and a dilated coronary sinus was catheterized. Left pulmonary veins drained into coronary sinus in a left pulmonary vein angiogram done through the coronary sinus with a National Institute of Health 7F catheter. After the angiogram, the catheter got entrapped in a coronary sinus tributary and could be removed only by surgery. The left pulmonary veins were rerouted into the left atrium by unroofing the coronary sinus. Surgery is the treatment of choice for entrapped catheters when the primary condition itself merits surgical correction. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary sinus; Catheter entrapment; Hemianomalous pulmonary venous connection
1. Introduction Cardiac catheterization is now relatively safe. We report in this paper probably the first case report of a catheter getting entrapped in a coronary sinus radicle. 2. Case report A 25-year old acyanotic lady with a dilated coronary sinus (no left superior vena cava) and unclear left pulmonary vein drainage was catheterized. Left to right shunt was 1.9:1. Left pulmonary veins drained into the coronary sinus as seen in a left upper pulmonary vein angiogram done through the coronary sinus with a NIH (National Institute of Health) 7 French catheter. After the pulmonary vein angiogram, the catheter refluxed into the posterior left ventricular tributary ⁎ Corresponding author. Residence: “Krishnasree”, TC 15/267(3), Althara Road, Vellayambalam, Trivandrum-695010, Kerala, India. Tel.: +91 471 2443152; fax: +91 471 2446433. E-mail address: [email protected] (N. Krishnakumar). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.02.016
of the coronary sinus and got entrapped. Nitroglycerine through the entrapped catheter and through a second Goodale–Lubin catheter taken through another venous puncture did not help (Fig. 1panel a). At emergency surgery, a small hematoma 2 × 3 cm was seen on the posterolateral left ventricle (Fig. 2 panel b). The proximal 5 cm of the catheter was deep inside the posterior left ventricular tributary of the coronary sinus. With manipulation, the catheter could be pulled out. The left pulmonary veins were rerouted to the left atrium by unroofing the coronary sinus. She was discharged in normal sinus rhythm and stable hemodynamics. 3. Discussion The major causes of catheter breakage and entrapment include fatigue due to multiple manipulations, kinking and physical properties of the catheter system itself [1]. The incidence of broken catheters is 6 in 12,367 [2]. Karbhase JN reported seven cases (5 broken catheters, 2 perforations) of
N. Krishnakumar et al. / International Journal of Cardiology 117 (2007) 270–272
271
Fig. 1. Panel A shows the entrapped NIH catheter (arrow 1) in the coronary sinus radicle. A Goodale–Lubin catheter (arrow 2) was introduced through a second femoral venous puncture into the coronary sinus. Hand injection of contrast through this catheter did not show any antegrade filling of the coronary sinus tributary indicating severe spasm. Panel B: The levophase of a left pulmonary artery angiogram with a 6 French pigtail catheter (arrow 3) is seen which fills the left upper pulmonary vein (arrow 4) and the left lower pulmonary vein (arrow 5) which then drain into a dilated coronary sinus(arrow 7). The entrapped NIH catheter (arrow 1) is clearly not in any pulmonary vein. The tip (arrow 6) of this catheter is in a coronary sinus tributary which is not filling indicating severe spasm.
serious complications following 8000 cardiac catheterizations and aortograms (1972–84) from a medical college hospital [2]. Though emergency removal is almost always indicated [2],there is no consensus regarding the optimal approach indicating lack of consistent success with any one technique. Vigorous efforts at percutaneous removal may actually create further endothelial injury to an already diseased vessel [3]. Also, when surgical correction of the pathology is indicated, as in our case, where the patient needed correction of the hemianomalous pulmonary venous connection, surgery is the best option.
Catheters, biotomes and forceps have all been used to remove retained catheters [2]. However, the most widely adopted techniques include loop snare catheters or Dormia basket retrievers. These devices are best for larger fragments in easily accessible sites, are difficult to use in small and distal vessels and require larger sheaths [1]. Though coronary venous catheter entrapment is unreported, the incidence of entrapment or fragmentation of coronary artery angioplasty hardware ranges from 0.2% to 0.8% [3–6], actually just 39 reported cases in the past 13 years [3]. Of these, in 8 cases, the wire fragments were left
Fig. 2. Panel A: Surgeon's view with the right atrial free wall opened shows the entrapped NIH catheter (arrow 2) entering the coronary sinus ostium. Right atrial appendage (arrow 3) and inferior vena caval (arrow 1) canulae are seen. Panel B: Surgeon's view shows myocardial contusion (arrow 4) on the posterior surface of the heart.
272
N. Krishnakumar et al. / International Journal of Cardiology 117 (2007) 270–272
in situ. Percutaneous retrieval was successful in 14 cases and surgical intervention in another 17 cases [3]. Also, a larger sized catheter (7 French) is best avoided if the same information can be obtained using a smaller catheter. 4. Conclusion Catheter entrapment in a coronary venous radicle has hitherto been unreported. Surgical removal is the management of choice in such cases when the primary condition itself merits surgical correction. References [1] Harikrishna S, Rajeev E, Nair K, Tharakan J. Retrieval of friable catheter fragments. Int J Cardiol 2006;2:284–94.
[2] Karbhase JN, Panday SR, Parulkar GB, Kelkar MD. Complications of cardiac catheterization needing emergency surgery. J Postgrad Med 1984;30:237–40. [3] Chang TM, Pellegrini D, Ostrovsky A, Marrangoni AG. Surgical management of entrapped percutaneous transluminal coronary angioplasty hardware. Texas Heart Inst J 2002;29:329–32. [4] Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987;60:1260–4. [5] Lotan C, Hasin Y, Stone D, Meyers S, Applebaum A, Gotsman MS. Guide wire entrapment during PTCA: a potentially dangerous complication. Catheter Cardiovasc Diagn 1987;13:309–12. [6] Doorey AJ, Stillabower M. Fractured and retained guidewire fragment during coronary angioplasty — unforeseen late sequelae. Catheter Cardiovasc Diagn 1990;20:238–40.