Recurrent Cardiac Tamponade Following Unusual Micro Leak after Successful Closure of the Primary Leak

ABSTRACT: Although uncommon, coronary artery perforation is one of the most dreadful complications of percutaneous coronary intervention, which requires prompt, aggressive, and effective management. Perforations induced by coronary guidewires are usually located in the distal part of a coronary artery and commonly managed with embolization. This is an unusual case report of guidewire-induced coronary perforation with recurrent cardiac tamponade, which was managed successfully by coil embolization of both ipsilateral and contralateral coronary arteries via transradial approach.

J INVASIVE CARDIOL 2012;24(3):E47-E49

Key words: coronary perforation, cardiac tamponade, embolization

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Coronary artery perforation is a rare but serious complication of percutaneous coronary intervention (PCI). It occurs when a dissection or intimal tear propagates outward sufficient to completely penetrate the arterial wall. Cardiac tamponade in this context is an emergency and needs prompt attention to prevent major cardiac events. In current interventional practice, due to significant advances in complex PCI, there has been a significant use of stiff-tipped and hydrophilic guidewires, which may lead to higher incidence of guidewire-induced coronary perforation. These wires commonly cause distal coronary artery perforations that may require distal vessel embolization performed with particles,¹ or with microcoils.² We report an unusual case of guidewire-induced coronary perforation causing recurrent cardiac tamponade, which was successfully managed by coil embolization using transradial approach.

Case Report. A 69-year-old hypertensive and diabetic male patient presented with history of angina at rest and on minimal exertion of 5 days duration. On general examination, his pulse rate was 96 bpm; regular and right upper limb blood pressure was 160/86 mm Hg. Cardiovascular and other systemic examination did not reveal any significant abnormalities. His 12-lead ECG showed deep T-wave inversion in leads V1 to V6, and transthoracic echocardiogram revealed mild apical hypokinesia of the left ventricle with ejection fraction of 57%. Hematological evaluation by the troponin-T marker study was positive for myocardial necrosis.

Coronary angiogram from right radial approach showed normal left main; 100% occlusion of LAD just after the first septal branch; 100% proximal occlusion of left circumflex artery (Figure 1A); and 90% discrete lesion of RCA with multiple disease of the posterior left ventricular branch (Figure 1B). The patient underwent percutaneous coronary angioplasty from right radial approach.

Left anterior descending artery angioplasty. A 6 Fr extra back up guide catheter was used to cannulate the left main artery. LAD lesion was crossed with a 0.14˝ hydrophilic guidewire (Whisper, Abbott Vascular), and the lesion was stented with 3 mm x 33 mm sirolimus eluting stent (Cypher Select+, Cordis). Immediate result was good with TIMI III flow.

RCA angioplasty. The right coronary artery was engaged with a 6 Fr Judkins right guide catheter, and the lesion was directly stented using 3.5 mm x 18 mm bare metal stent at 14 atm pressure with acceptable result. Immediately after shifting to ICCU, the patient developed chest pain with hypotension, and ECG revealed pericardial effusion with cardiac tamponade. Pericardiocentesis was started and coronary angiogram showed contrast leak from a tiny distal branch of LAD (Figure 2A). Retrospective review of angiogram revealed that the guidewire was sitting deep into the same branch during LAD angioplasty. Prolonged balloon inflation at the origin of the culprit vessel did not yield satisfactory result. Therefore, we decided to perform microcoil embolization of the distal LAD. A MiraFlex microcatheter (Cook) with inner diameter of .021-inch was positioned near the origin of the feeding vessel and embolization was performed using an 18-2-2 MCWE HILAL microcoil (Cook). The result was total occlusion of the distal LAD including the culprit branch (Figure 2B). The patient experienced angina of moderate severity, which subsided gradually. About 6 H later, he developed hypotension and echocardiogram revealed re-accumulation of pericardial fluid with evidence of cardiac tamponade. The patient was shifted to the catheterization laboratory, and left coronary angiogram confirmed total occlusion of the distal LAD, and no evidence of reopening of the coronary leak. Pericardiocentesis was continued, which showed aspiration of fresh blood, indicating ongoing bleeding into the pericardial cavity. Therefore, RCA injection was also performed to rule out any leak from the right side. To our surprise, a marginal branch of the RCA was seen supplying the same culprit vessel on left through collateral causing continuous loss of blood (Figure 3A). Selective microcoil embolization of the marginal branch using 18-2-2 MCWE HILAL microcoil (Cook) could successfully close it, resulting in total cessation of blood loss (Figure 3B). Recovery of the patient was mostly uneventful except for transient elevation of serum creatinine level.

Discussion. Coronary artery perforations during PCI are rare but potentially catastrophic complications.^3,4 With conventional PCI, the incidence of coronary artery perforation is estimated to be 0.1%-0.2%, and rise to 3% with the use of devices intended to remove or ablate tissue, such as transluminal extraction coronary atherectomy, excimer-laser angioplasty, directional atherectomy, and high-speed mechanical rotational atherectomy.^5,6,7 With technological advancement in the field of interventional cardiology, more cases that are complex are being treated using a percutaneous approach. This necessitates more frequent use of stiff-tipped and hydrophilic guidewires such as the Whisper (Abbot Vascular) or the Choice PT (Boston Scientific), resulting in higher incidence of distal vessel perforations.^8,9

Coronary artery perforations are treated surgically, non-surgically, or using both. It depends on 2 important factors such as the type of perforation and presence or absence of cardiac tamponade.¹⁰ Perforations caused by coronary guidewires are usually located in the distal part of a coronary artery, and for which treatment may differ from other type III perforations related to balloons, stents, and devices. The routine non-surgical management options for a perforated coronary artery include the reversal of heparin effect and prolonged balloon dilatation. In our case, both failed to seal the perforation. The other option in this case is deploying a PTFE-coated covered stent, which was not possible in this case due to the distal location of perforation, and the small caliber vessel size at the site of perforation. Therefore, we decided to deploy microcoil to seal the perforation. MCWE HILAL microcoils (Cook) are available in different sizes and should be selected according to the vessel caliber. Deployment requires a good guiding support and careful positioning of the microcatheter into the selected vessel before embolizing coils. Necessary care should be taken to prevent prolapse of the microcatheter into the main vessel while pushing and deploying coils. Other agents, which can also be used in guidewire-induced coronary perforations, are polyvinyl particles¹¹ and sterile synthetic glue.¹² However, optimal precautions are required while using polyvinyl particles, as there is of risk of spill over into the main vessel with catastrophic results. Moreover, synthetic glue (Histoacryl) sets as soon as it meets Na ions of tissue fluids. While using this through microcatheter, one must preflush the entire system with dextrose solution and then inject the synthetic glue rather rapidly so that it does not come into contact with blood anywhere in transit. In this respect, microcoils are quite safe and effective, though difficult to embolize selectively in a tiny branch of coronary artery.

This case report highlights 2 important facts:

1. Hydrophilic-coated guidewires (especially extra-support wire) are prone to inadvertent coronary artery perforation, and should be used very carefully;
2. An unusual and rare phenomenon of collateral supply to the same bleeder should be kept in mind in case of recurrent cardiac tamponade. 

To the best of our knowledge, recurrent cardiac tamponade due to supply from collateral artery has not been reported previously.

References

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From the Department of Cardiology, Apollo Hospitals, Visakahapatnam, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted August 10, 2011 and accepted September 21, 2011.
Address for correspondence: Dr. D.K. Baruah, Director Cath Lab, Apollo Hospitals, Waltair Main Road, Visakhapatnam, Andhra Pradesh, India. Email: baruahdk_9@yahoo.com