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Left internal mammary artery graft perforation due to permanent pacemaker implantation
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 5 5 e5 7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
Left internal mammary artery graft perforation due to permanent pacemaker implantation Rahul Samanta* The Canberra Hospital, Yamba Drive, Garran, Canberra, ACT 2605, Australia
article info
abstract
Article history:
Permanent pacemaker implantation via subclavian vein puncture is associated with a wide
Received 2 July 2014
spectrum of complications. We describe a case of perforation of the left internal mammary
Accepted 22 July 2014
artery (LIMA) Graft perforation as a complication of permanent pacemaker implantation
Available online 18 August 2014
and its successful treatment by percutaneous intervention. To our knowledge this is the first such case to be described in literature.
Keywords:
Copyright © 2014, Indian College of Cardiology. All rights reserved.
Implant complication Left internal mammary artery Coronary stenting
1.
Introduction
Permanent pacemaker implantation via subclavian vein puncture is a common approach. Venous access for lead implantation can also be via a cephalic venotomy or axillary vein puncture. A blind puncture during subclavian access can lead to serious complications, such as pneumothorax, haemopneumothorax, subclavian artery puncture, brachial nerve plexus injury, thoracic duct injury and injury to the internal mammary artery.1 We describe a case of perforation of the left internal mammary artery (LIMA) Graft as a complication of permanent pacemaker implantation and its successful treatment by percutaneous intervention. To our knowledge this is the first such case to be described in literature.
2.
Case
A 78 year male was admitted for insertion of permanent pacemaker. He had several presyncopal episodes with long
pauses up to 3.5 s reported on Holter monitor. His background history included that of single vessel coronary artery bypass (Left Internal Mammary Graft to Left Anterior Descending Artery) in 1995. He underwent dual chamber permanent pacemaker implantation via a left subclavian vein approach. Soon after the procedure the patient started complaining of shortness of breath. A Chest X ray showed a left sided apical pneumothorax with widening of the mediastinal shadow suggestive of a haemothorax. His ECG was normal. His haemoglobin had dropped to 89 from 130 g/L. An intercostal catheter was introduced via a seldinger technique immediately draining fresh blood. This was then replaced by a wide bore chest drain. He was subsequently transferred for a CT angiogram which revealed a large mediastinal haematoma. There was contrast extravasation in the arterial phase with bleeding medial to the internal mammary artery graft. Left Subclavian angiography demonstrated a bleeding point approximately 1.5e2 cms distal to the origin of the left internal mammary artery on its medial aspect. A selective angiogram of the LIMA graft accessed via the right femoral approach showed extravasation of contrast from the proximal
* Tel.: þ61 0433271417. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jicc.2014.07.006 1561-8811/Copyright © 2014, Indian College of Cardiology. All rights reserved.
56
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 5 5 e5 7
LIMA graft to LAD into the thoracic cavity with a distinct point of perforation (Fig. 1). The perforation was partially sealed with a covered stent(Abbott Vascular Graftmaster - 3.0 x16). Following this a drug eluting stent (Xience Prime e 3 18) was deployed in the covered stent which resulted in full closure of the perforation. The final angiographic result was good and TIMI 3 flow maintained in the LIMA graft (Fig. 2). An Echocardiogram a day after the procedure showed preserved left ventricular systolic function with normal anterior wall motion. The patient had a gradual recovery and was discharged after 10 days stay in hospital.
3.
Discussion
The internal mammary artery arises from the proximal part of the subclavian artery entering the thorax between the cartilage of the first rib and the parietal pleura. It is commonly used as a conduit in coronary artery bypass surgery. Due to the close proximity of central veins to the arterial structures there may be a risk of arterial puncture during pacemaker insertion via subclavian approach. Laceration of the LIMA graft can cause mediastinal bleeding and also lead to myocardial infarction.2 Perforation of LIMA has been reported in association with pacemaker insertion via subclavian approach,3e5 central venous line4,6 and Swan-Ganz Catheter insertion.7 There is one case report describing occlusion of LIMA graft as a complication of pacemaker implantation via subclavian approach.8 Perforation of LIMA graft has also been reported in relation to ICD implantation.2 Our case brings to light two major issues. First given the serious implications of LIMA graft perforation/occlusion it would seem more reasonable to gain subclavian access from the opposite side in patients with arterial grafts. The second issue relates to the optimal treatment of LIMA graft perforation. In the past LIMA graft perforation has been treated with
Fig. 2 e Resolution of the contrast extravasation after deployment of stents.
emergency surgical repair9 or by placement of PTFE e covered stents.2,10 LIMA perforation/pseudoaneurysm has been successfully treated with coil embolisation.4,5,7 We used a PTFA covered stent followed by a DES resulting in TIMI III flow and no residual extravasation of contrast. To our knowledge this is the first case where LIMA graft perforation has been reported as a complication of pacemaker implantation. In summary patients with LIMA grafts who undergo pacemaker insertion via subclavian route carry a risk of graft perforation. This serious complication can be avoided by cannulating the subclavian vein on the opposite side. In case of graft perforation we found that stenting with PTFE covered stent is a valid option although immediate full closure was only achieved with an additional drug-eluting stent. This latter choice of stent was motivated by the mild persisting arterial leak and the high rate of in-stent restenosis for covered-stents.
Conflicts of interest The author has none to declare.
references
Fig. 1 e Selective angiogram of the LIMA graft demonstrating extravasation of contrast from the proximal LIMA graft into the thoracic cavity.
1. Mandawat A, Curtis JP, Mandawat A, Njike VY, Lampert R. Safety of pacemaker implantation in nonagenarians an analysis of the healthcare cost and utilization projectenationwide inpatient sample. Circulation. 2013;127:1453e1465. 2. Murphy JC, Mathur M, Choong C, Ward M. An unusual cause of myocardial ischaemia. Int J Cardiol. 2012;158:e7. 3. Aguilar-Shea AL, Gallardo-Mayo C. Pacemakers and internal mammary artery pseudoaneurysm. J Emerg Med. 2011;41:e115ee116. 4. Chemelli A, Chemelli-Steingruber I, Bonaros N, et al. Coil embolization of internal mammary artery injured during
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 5 5 e5 7
central vein catheter and cardiac pacemaker lead insertion. Eur J Radiol. 2009;71:269e274. lez-Ferrer JJ, Villacastı´n JP, Macaya C. 5. Pozo E, Gonza Diaphragm paralysis due to pseudoaneurysm of internal mammary artery after pacemaker implantation. Europace. 2011;13:592e593. 6. Mazeh H, Alaiyan B, Vald O, et al. Internal mammary artery injury during central venous catheter insertion for tpn: rare but fatal. Nutrition. 2010;26:849e851. 7. Kulkarni R, Moreyra AE. Left internal mammary artery perforation during swan-ganz catheter insertion. Catheter Cardiovasc Diagn. 1998;44:317e319.
57
8. Chou TM, Jim MH, Boncutter A, Milechman G. Acute occlusion of left internal mammary artery graft during dual-chamber pacemaker implantation. Catheter Cardiovasc Interv. 2000;51:65e68. 9. Sharifi M, Turrentine MW, Mahomed Y, Pompili VJ, Dillon JC. Left internal mammary artery graft perforation due to highpressure stent deployment. Catheter Cardiovasc Interv. 1999;47:199e202. 10. Albiero R, Nishida T, Corvaja N, Vaghetti M, Di Mario C, Colombo A. Left internal mammary artery graft perforation repair using polytetrafluoroethylene-covered stents. Catheter Cardiovasc Interv. 2000;51:78e82.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
Left internal mammary artery graft perforation due to permanent pacemaker implantation Rahul Samanta* The Canberra Hospital, Yamba Drive, Garran, Canberra, ACT 2605, Australia
article info
abstract
Article history:
Permanent pacemaker implantation via subclavian vein puncture is associated with a wide
Received 2 July 2014
spectrum of complications. We describe a case of perforation of the left internal mammary
Accepted 22 July 2014
artery (LIMA) Graft perforation as a complication of permanent pacemaker implantation
Available online 18 August 2014
and its successful treatment by percutaneous intervention. To our knowledge this is the first such case to be described in literature.
Keywords:
Copyright © 2014, Indian College of Cardiology. All rights reserved.
Implant complication Left internal mammary artery Coronary stenting
1.
Introduction
Permanent pacemaker implantation via subclavian vein puncture is a common approach. Venous access for lead implantation can also be via a cephalic venotomy or axillary vein puncture. A blind puncture during subclavian access can lead to serious complications, such as pneumothorax, haemopneumothorax, subclavian artery puncture, brachial nerve plexus injury, thoracic duct injury and injury to the internal mammary artery.1 We describe a case of perforation of the left internal mammary artery (LIMA) Graft as a complication of permanent pacemaker implantation and its successful treatment by percutaneous intervention. To our knowledge this is the first such case to be described in literature.
2.
Case
A 78 year male was admitted for insertion of permanent pacemaker. He had several presyncopal episodes with long
pauses up to 3.5 s reported on Holter monitor. His background history included that of single vessel coronary artery bypass (Left Internal Mammary Graft to Left Anterior Descending Artery) in 1995. He underwent dual chamber permanent pacemaker implantation via a left subclavian vein approach. Soon after the procedure the patient started complaining of shortness of breath. A Chest X ray showed a left sided apical pneumothorax with widening of the mediastinal shadow suggestive of a haemothorax. His ECG was normal. His haemoglobin had dropped to 89 from 130 g/L. An intercostal catheter was introduced via a seldinger technique immediately draining fresh blood. This was then replaced by a wide bore chest drain. He was subsequently transferred for a CT angiogram which revealed a large mediastinal haematoma. There was contrast extravasation in the arterial phase with bleeding medial to the internal mammary artery graft. Left Subclavian angiography demonstrated a bleeding point approximately 1.5e2 cms distal to the origin of the left internal mammary artery on its medial aspect. A selective angiogram of the LIMA graft accessed via the right femoral approach showed extravasation of contrast from the proximal
* Tel.: þ61 0433271417. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jicc.2014.07.006 1561-8811/Copyright © 2014, Indian College of Cardiology. All rights reserved.
56
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 5 5 e5 7
LIMA graft to LAD into the thoracic cavity with a distinct point of perforation (Fig. 1). The perforation was partially sealed with a covered stent(Abbott Vascular Graftmaster - 3.0 x16). Following this a drug eluting stent (Xience Prime e 3 18) was deployed in the covered stent which resulted in full closure of the perforation. The final angiographic result was good and TIMI 3 flow maintained in the LIMA graft (Fig. 2). An Echocardiogram a day after the procedure showed preserved left ventricular systolic function with normal anterior wall motion. The patient had a gradual recovery and was discharged after 10 days stay in hospital.
3.
Discussion
The internal mammary artery arises from the proximal part of the subclavian artery entering the thorax between the cartilage of the first rib and the parietal pleura. It is commonly used as a conduit in coronary artery bypass surgery. Due to the close proximity of central veins to the arterial structures there may be a risk of arterial puncture during pacemaker insertion via subclavian approach. Laceration of the LIMA graft can cause mediastinal bleeding and also lead to myocardial infarction.2 Perforation of LIMA has been reported in association with pacemaker insertion via subclavian approach,3e5 central venous line4,6 and Swan-Ganz Catheter insertion.7 There is one case report describing occlusion of LIMA graft as a complication of pacemaker implantation via subclavian approach.8 Perforation of LIMA graft has also been reported in relation to ICD implantation.2 Our case brings to light two major issues. First given the serious implications of LIMA graft perforation/occlusion it would seem more reasonable to gain subclavian access from the opposite side in patients with arterial grafts. The second issue relates to the optimal treatment of LIMA graft perforation. In the past LIMA graft perforation has been treated with
Fig. 2 e Resolution of the contrast extravasation after deployment of stents.
emergency surgical repair9 or by placement of PTFE e covered stents.2,10 LIMA perforation/pseudoaneurysm has been successfully treated with coil embolisation.4,5,7 We used a PTFA covered stent followed by a DES resulting in TIMI III flow and no residual extravasation of contrast. To our knowledge this is the first case where LIMA graft perforation has been reported as a complication of pacemaker implantation. In summary patients with LIMA grafts who undergo pacemaker insertion via subclavian route carry a risk of graft perforation. This serious complication can be avoided by cannulating the subclavian vein on the opposite side. In case of graft perforation we found that stenting with PTFE covered stent is a valid option although immediate full closure was only achieved with an additional drug-eluting stent. This latter choice of stent was motivated by the mild persisting arterial leak and the high rate of in-stent restenosis for covered-stents.
Conflicts of interest The author has none to declare.
references
Fig. 1 e Selective angiogram of the LIMA graft demonstrating extravasation of contrast from the proximal LIMA graft into the thoracic cavity.
1. Mandawat A, Curtis JP, Mandawat A, Njike VY, Lampert R. Safety of pacemaker implantation in nonagenarians an analysis of the healthcare cost and utilization projectenationwide inpatient sample. Circulation. 2013;127:1453e1465. 2. Murphy JC, Mathur M, Choong C, Ward M. An unusual cause of myocardial ischaemia. Int J Cardiol. 2012;158:e7. 3. Aguilar-Shea AL, Gallardo-Mayo C. Pacemakers and internal mammary artery pseudoaneurysm. J Emerg Med. 2011;41:e115ee116. 4. Chemelli A, Chemelli-Steingruber I, Bonaros N, et al. Coil embolization of internal mammary artery injured during
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y 5 ( 2 0 1 5 ) 5 5 e5 7
central vein catheter and cardiac pacemaker lead insertion. Eur J Radiol. 2009;71:269e274. lez-Ferrer JJ, Villacastı´n JP, Macaya C. 5. Pozo E, Gonza Diaphragm paralysis due to pseudoaneurysm of internal mammary artery after pacemaker implantation. Europace. 2011;13:592e593. 6. Mazeh H, Alaiyan B, Vald O, et al. Internal mammary artery injury during central venous catheter insertion for tpn: rare but fatal. Nutrition. 2010;26:849e851. 7. Kulkarni R, Moreyra AE. Left internal mammary artery perforation during swan-ganz catheter insertion. Catheter Cardiovasc Diagn. 1998;44:317e319.
57
8. Chou TM, Jim MH, Boncutter A, Milechman G. Acute occlusion of left internal mammary artery graft during dual-chamber pacemaker implantation. Catheter Cardiovasc Interv. 2000;51:65e68. 9. Sharifi M, Turrentine MW, Mahomed Y, Pompili VJ, Dillon JC. Left internal mammary artery graft perforation due to highpressure stent deployment. Catheter Cardiovasc Interv. 1999;47:199e202. 10. Albiero R, Nishida T, Corvaja N, Vaghetti M, Di Mario C, Colombo A. Left internal mammary artery graft perforation repair using polytetrafluoroethylene-covered stents. Catheter Cardiovasc Interv. 2000;51:78e82.