International Journal of Cardiovascular ResearchISSN: 2324-8602

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Case Report, Int J Cardiovasc Res Vol: 5 Issue: 2

Complication of Coronary Angioplasty; leading to Surgical Emergency: A Case Report

Sandeep Kumar Kar*, Deepanwita Das and Chaitali Sen Dasgupta
Department of Cardiac Anaesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, India
Corresponding author : Dr. Sandeep Kumar Kar
Department of Cardiac Anesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, India
Tel: +919477234900
E-mail: [email protected]
Received: February 04, 2016 Accepted: March 21, 2016 Published: March 28, 2016
Citation: Kar SK, Das D, Dasgupta CS (2016) Complication of Coronary Angioplasty; leading to Surgical Emergency: A Case Report. Int J Cardiovasc Res 5:2. doi:10.4172/2324-8602.1000260

Abstract

Complication of Coronary Angioplasty; leading to Surgical Emergency: A Case Report

Dislodgement of coronary stent-balloon catheter before deployment during percutaneous coronary intervention though is rare but life threatening complication. A 47-year-old male presented with unstable angina for five years. Angiography revealed that there was a stenosis (90%) in the LAD and significant plaque in the circumflex artery. During PTCA a stent- balloon was dislodged in LMCA (Left Main Coronary Artery). Under cardiopulmonary bypass, with cardioplegic arrest, the stent-balloon-catheter was extracted through coronary arteriotomy with repair of ruptured LIMA (Left Internal Mammary Artery). Coronary revascularization was done with reversed saphenous vein grafts to the LMCA and D1 coronary arteries.

Keywords: Coronary angioplasty; Percutaneous coronary intervention; Angiography; Coronary revascularization

Keywords

Coronary angioplasty; Percutaneous coronary intervention; Angiography; Coronary revascularization

Introduction

Percutaneous coronary stenting procedure for coronary artery disease is common but can sometimes result in life threatening complications. Balloon angioplasty can lead to different catastrophic complications like acute stent thrombosis, coronary perforations and dissection of coronary arteries [1,2]. Severe dissection with abrupt closure can cause even death of the patient.
Recently the authors have encountered a case in which coronary angioplasty balloon got stucked in the left main coronary artery (LMCA) in a completely dilated stent during angioplasty.

Case Report

A 48 year old, diabetic, hypertensive, chronic smoker was presented with exertional chest pain for last 2 years. He had family history of hypertension and diabetes. His resting electrocardiogram revealed sinus rhythm and T-wave inversion in V4-V6. The transthoracic echocardiogram showed left ventricular (LV) relaxation abnormality and ejection fraction of 48%. Coronary angiography was done. It showed significant plaque in the circumflex coronary artery proximal to the origin of OM1 and significant lesion in LAD with 90% obstruction in just after origin of 1st diagonal branch.
Patient was on Beta-blocker, Isosorbid dinitrate, Clopidogrel and Aspirin. Pre-procedure pulse rate was 70/min, noninvasive blood pressure 140/90 mmHg, SpO2 100 in room air. After insertion of right femoral sheath, guide wire was inserted. An angioplasty balloon catheter was railroaded over it to place the stent at LAD after balloon dilatation. But accidentally following balloon dilatation, it could not be deflated and was impacted in the LMCA. Patient was complaining of severe oppressive substernal pain that was radiating to the back, followed by severe dyspnea and profuse sweating and restlessness. Patient’s vitals started deteriorating and BP fell to 90/60 mmHg. ECG revealed different types of ill sustained arrhythmias and ST segment elevation in all anterior leads. Multiple attempts were taken to deflate the balloon and to remove it but failed. Fluroscopic angiography showed the partially inflated balloon in the LMCA and there was leakage of dye from LMCA suggesting LMCA rupture (Figures 1-6).
Figure 1: Spillage of dye suggesting LMCA rupture.
Figure 2: Balloon in LMCA.
Figure 3: Extravassation of dye.
Figure 4: Dye coming outside.
Figure 5: Showing partially inflated balloon in LMCA.
Figure 6: Spillage confirms balloon rupture.
Hemodynamics of the patient was deteriorating rapidly and it was decided to shift for surgical emergency. Immediately the patient was shifted to Cardiothoracic & Vascular surgery Operating room. Nor adrenaline infusion was used to maintain blood pressure and the patient was posted for life saving coronary revascularization surgery.
Under cardiopulmonary bypass the aorta was cross clamped and heart was arrested with retrograde cardioplegia. The partially inflated balloon was removed out by coronary arteriotomy and the ruptured part of LMCA was repaired. LAD and D1 were revascularised with reversed saphenous vein grafts. After weaning from CPB, there was ill sustained ventricular arrhythmia; controlled by lignocaine 1.5 mg/kg intravenous injection. Following stable hemodynamics in the postoperative period, the patient was extubated after 8 hours and discharged from ICU on 5th postoperative day without any complications.

Discussion

Percutaneous transluminal coronary angioplasty is very popular and is being used with increasing success to dilate proximal as well as distal coronary artery. Though the modern imaging technique has increased the success rate of the procedure; it is not always safe. Sometimes angioplasty equipment is fragmented and left behind in the coronary artery [3,4] making the post-procedure period much more complicated. Usually this dislodgement or fragmentation may occur when a balloon catheter is inflated beyond its operating pressure range or undergoes mechanical stress like rotation, torsion during an attempt to dilate a resistant stenosis [5]. Fragmentation of balloon catheter or breakage of guidewire is rare. However, this complication can occur and fragmented part can remain in the coronary artery [5] leading to severe hemodynamic instability. The incidence of dissection in interventional cardiologyis less than 0.1% but in patient with LMCA disease it is much higher, nearly 1.05% [6-9].
Drug eluting stents have revolutionized interventional Cardiology these days, which may also dislodge from its mounted balloon or may have some problem during inflatation or deflation. In this case case, it was a sirolimus –eluting stent of 2.5×29 mm which was left in LMCA due to mechanical failure of removal and coupled to it there was a problem of deflating it. A serious complication arises when entrapment or embolization of angioplasty balloons or guidewire occlude a coronary artery specially LMCA. It results the near total obstruction of coronary flow leading to acute coronary thrombosis with acute myocardial infarction and may lead to cardiac arrest if prompt removal is not done. So, it is a catastrophic complication and a real surgical emergency.
Balloon rupture is another catastrophic complication though not very rare. It causes distal embolization of ruptured tip and also clot or calcific plaque dislodgement. In this case coronary artery may also rupture leading to hemorrhage as well as myocardial infarction. In the present case, multiple attempts of removal of balloon resulted in LMCA rupture, following that patient had suffered from neither severe hypotension which was managed by fluid resuscitation and also by nor adrenaline infusion. Leakage of dye was seen in fluoroscopic angiography as equivocal evidence. This led to emergency CABG and subsequent removal of balloon. It was mentioned in many cases previously that emergency surgery for removal of broken or stuck parts of angioplasty instruments [1,10-12] with emergency CABG was the last resort to save the patient.
As in this case all such patients receive Aspirin, Clopidogrel, Heparin and Glycopeptide IIb-IIIa inhibitors which increase the incidence of perioperative bleeding requiring multiple blood transfusions. As in emergency, vein graft is the choice of conduit in thermodynamically instable patient; this patient received reverse saphenous vein grafts. In this patient retrograde cardioplegia was delivered as partially inflated balloon in the LMCA might prevent the distribution of cardioplegia solution into the LAD and circumflex coronary artery [13]. It is really a nightmare to all interventional cardiologists as it is a life threatening complication if not promptly diagnosed and quickly treated with myocardial revascularization [6,8,9,14].

Conclusion

Accidental rupture of LMCA during percutaneous transluminal coronary angioplasty is a serious complication though rare. The essence of reporting this case is all interventional cardiologists must keep in mind that accidental rupture of LMCA during angioplasty can cause sudden death if not intervened immediately and should be surgically managed when all non-invasive resorts yield no results.

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