Coronary Rupture during Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction

Case description. A 60-year-old female patient was admitted to our institution for acute inferior myocardial infarction 4 hours after symptom onset. She had no previous history of coronary artery disease and her risk factors included diabetes mellitus and dyslipidemia. Her history included chronic glucocorticoid therapy for 25 years to treat inflammatory arthritis. After antithrombotic therapy (aspirin, clopidogrel, heparin and abciximab), coronary angiography was urgently performed and showed mild disease of the left coronary system and occlusion of the right coronary artery (RCA) (Figure 1A). After straightforward wiring and thrombus aspiration (Export Catheter, Medtronic, Inc., Minneapolis, Minnesota), direct stenting was performed with a bare-metal stent (Driver Stent 4.0 x 20 mm, Medtronic) deployed at 12 atm. The control injection revealed a coronary rupture at the level of the stent in the RCA with contrast extravasation in the pericardium (Figure 1D). After administration of protamine and withdrawal of glycoprotein IIb/IIIa antagonists, a balloon was quickly inflated on the site of the rupture. The patient remained stable with normal blood pressure, and echocardiography showed a moderated pericardial effusion. Then, we implanted a covered stent (Jostent, Abbott Vascular, Germany) 3.5 x 16 mm at the level of the rupture at 16 atm. The control injection showed a good result with thrombolysis in myocardial infarction (TIMI)-3 flow and no residual contrast extravasation (Figure 1E). The patient remained stable and control coronary angiography was performed the next day confirming the good result. She was discharged 1 week later and remained symptom-free at 1-month follow up. This case illustrates a very unusual clinical setting for coronary rupture, which is usually related to chronic total occlusion or atherectomy procedures. For this patient, chronic treatment with glucocorticoids might have been a risk factor for coronary rupture. Moreover, this case confirms that the combination of medical treatment including protamine and a covered stent is very effective for this rare but potentially dramatic complication. _________________________ From the Department of Cardiology, CHU Timone, Marseille, France. Manuscript submitted December 30, 2008 and accepted January 13, 2009. The authors have disclosed no conflicts of interest regarding the content herein. Address for correspondence: Thomas Cuisset, MD, Department Cardiology, CHU Timone, Marseille, Cardiology Unit, Boulevard Jean Moulin, Marseille, France. E-mail: thomascuisset@voila.fr