Spontaneous resolution of iatrogenic coronary artery to right ventricular fistula secondary to percutaneous coronary intervention

医学 右冠状动脉 经皮冠状动脉介入治疗 心脏病学 内科学 狭窄 胸痛 动脉 心包积液 穿孔 放射科 支架 瘘管 血管成形术 外科 心肌梗塞 冠状动脉造影 冲孔 材料科学 冶金
作者
Xing‐Biao Qiu,Lan Liu,Xu-min HOU,Wen-zheng HAN,Ying Ye,Jinjie Dai,Hongyu Shi,Weiyi Fang
出处
期刊:Chinese Medical Journal [Ovid Technologies (Wolters Kluwer)]
卷期号:126 (11): 2195-2196 被引量:2
标识
DOI:10.3760/cma.j.issn.0366-6999.20121157
摘要

Iatrogenic coronary artery fistula (ICAF) is a rare complication and could happen during endomyocardial biopsy, open heart surgery or percutaneous coronary intervention. The treatment of ICAF is not well established and is dependent upon the patient's haemodynamic situation. Here we report a case of spontaneous resolution of ICAF during such angioplasty. Following repeated exertion and associated chest pain in May 2011, a man aged 52 years with hypertension was referred for coronary angiography, which revealed a 90% stenosis in the proximal segment of left anterior descending coronary artery and a 75% diffuse, tortuous stenosis in the proximal to middle segment of right coronary artery (Figure 1). The left anterior descending lesion was treated with a 3.5 mm×18 mm sirolimus eluting stent. Because of the tortuous diffused right coronary lesion, two 0.35 mm guide wires were passed across the middle segment of the artery. Unfortunately, the working wire was located in the acute marginal artery and a 2.0 mm × 15.0 mm balloon was inflated by error up to 1215.9 kPa (12 atm) in the LAO view. The angiographic appearances of coronary artery perforation were noted (Figure 2). Prolonged inflation was performed intermittently in the segment with the same balloon at 810.6 kPa (8 atm) for 120 minutes, but the perforation persisted. Yet, the angiogram showed the contrast clearing rapidly with no remaining pericardial staining. The patient remained haemodynamically stable with no clinical or echocardiographic features of pericardial effusion. The diagnosis of an ICAF was made based on leakage into the right ventricle. The right lesion was treated subsequently with three overlapping, sirolimus eluting stents with satisfactory result despite the coronary fistula remaining (Figure 3). The cardiac enzyme was within normal limits and no pericardial effusion or wall motion abnormalities were found by echocardiogram postprocedure. He was discharged three days later without chest pain. Seven months later an angiogram (Figure 4) showed no coronary cameral fistula or instent restenosis of left or right coronary arteries.Figure 1.: Coronary angiogram showing a 75% diffuse tortuous stenosis at the proximal to middle segment of right coronary artery.Figure 2.Coronary artery fistula within the acute marginal (white arrow) showing runoff into a cardiac chamber (black arrow), with wires in this vessel and the right posterior descending artery.Figure 3.Coronary artery fistula within the acute marginal (white arrow) showing runoff into a cardiac chamber (black arrow), after stents implanted at the proximal to middle segment of RCA.Figure 4.Coronary angiogram after 7 months showing no coronary artery fistula or instent restenosis of proximal to mid-segment of the right coronary artery (arrow).Coronary artery perforation is a rare but serious complication of percutaneous coronary intervention that may lead to tamponade, myocardial infarction, emergency surgical intervention or death. The incidence of iatrogenic coronary perforation has been reported as between 0.4% and 0.5%1,2 and slightly higher with the use of atheroablative procedures such as atherectomy, thrombectomy and excimer laser angioplasty. Additional perforation risk factors include hydrophilic guidewire technique, the use of oversized balloons and stents, small vessel size, diffuse vessel disease, chronic total occlusion, old age and female gender. The cardiac tamponade rate is 19%-24% and the death rate is 9%.1,2 In the current case, the cause of coronary perforation was dilating the acute marginal artery by error with the oversized balloon. It implied that several different views are necessary to position accurately the guide wire in the target vessel. Ellis et al2 developed an angiographic classification of three types of perforation. Each successive type is associated with decreasing risks of tamponade, myocardial infarction and death. Type I perforations were associated with high rates of tamponade (63%), urgent bypass surgery (63%) and death (19%). However, type III perforations with cavity spilling (ICAF, which account to 5% of coronary perforations) were associated with far less consequences (no deaths, myocardial infarctions or tamponades). It implied that ICAF might have very different pathophysiological mechanisms, such as shunting of blood from coronary arterial bed. Shunting may lead to cardiac volume load and angina if it is severe enough. The management of ICAF is not well established. The strategy for iatrogenic coronary perforations, depending on the type and severity of perforation, generally involves initial conservative management, with prolonged balloon inflation and consideration of reversing anticoagulation depending on patient's stability. If the perforation is distal, embolization with coils, glue or thrombin should be considered. Proximal lesions are likely managed with a covered stent, with a reported 96.4% successful closure rate,3 but the long term patency of covered stent is not certain. Even so, up to one third of iatrogenic coronary perforations may require surgical intervention. ICAFs drainage into the right ventricle, which occurred in 14 of the 176 heart transplant patients who underwent endomyocardial biopsy,4 favour nonsurgical management because of the lack of untoward events, the generally small size of the fistulas and the occurrence of spontaneous resolution. Iatrogenic left coronary artery fistulas were detected in 9 of the 40 study patients with hypertrophic cardiomyopathy underwent surgical myectomy:5 only one patient's fistula did not heal spontaneously and cause symptoms requiring therapeutic intervention. As to ICAF complicating percutaneous coronary intervention, reported cases show variable courses from stable state to rapid detoriation. Spontaneous resolution of ICAF has been reported but it is rare. The management in this case involved an acute coronary perforation resulting in ICAF. The limited evidence in this area suggests that a small perforation into a cardiac chamber in a haemodynamically stable patient should be managed with observation alone. The angiographic results of seven months follow-up verified the decision. In conclusion, the case presented is instructive for two reasons. First, the diagnosis of ICAF should be considered in patients who remain free of clinical and echocardiographic features of tamponade after percutaneous coronary intervention complicated by coronary perforation. Second, angiographic appearances of these fistulas generally can be initially observed in asymptomatic patients.

科研通智能强力驱动
Strongly Powered by AbleSci AI
更新
大幅提高文件上传限制,最高150M (2024-4-1)

科研通是完全免费的文献互助平台,具备全网最快的应助速度,最高的求助完成率。 对每一个文献求助,科研通都将尽心尽力,给求助人一个满意的交代。
实时播报
lyy完成签到 ,获得积分10
刚刚
刚刚
2秒前
福尔摩云完成签到,获得积分10
3秒前
小学猹发布了新的文献求助10
4秒前
6秒前
鱼叔发布了新的文献求助10
6秒前
6秒前
wpeng发布了新的文献求助10
7秒前
CSUST科研一哥应助colin采纳,获得10
8秒前
8秒前
9秒前
小蘑菇应助有Data发Paper采纳,获得10
9秒前
温乐萱发布了新的文献求助10
10秒前
高高访云发布了新的文献求助10
12秒前
heerkeli发布了新的文献求助30
12秒前
英姑应助义气绿柳采纳,获得10
13秒前
14秒前
14秒前
Minerva完成签到,获得积分10
14秒前
CSUST科研一哥应助张张张采纳,获得10
15秒前
zhang0403完成签到,获得积分10
16秒前
专注迎蕾完成签到,获得积分10
18秒前
18秒前
wpeng完成签到,获得积分10
20秒前
星辰大海应助义气采纳,获得30
21秒前
24秒前
24秒前
24秒前
24秒前
AUK完成签到,获得积分20
26秒前
鱼鱼鱼完成签到 ,获得积分10
26秒前
27秒前
深情安青应助科研通管家采纳,获得10
27秒前
领导范儿应助科研通管家采纳,获得10
27秒前
27秒前
Lucas应助科研通管家采纳,获得10
27秒前
27秒前
27秒前
wuyoucaoxin完成签到,获得积分10
28秒前
高分求助中
进口的时尚——14世纪东方丝绸与意大利艺术 Imported Fashion:Oriental Silks and Italian Arts in the 14th Century 800
Glucuronolactone Market Outlook Report: Industry Size, Competition, Trends and Growth Opportunities by Region, YoY Forecasts from 2024 to 2031 800
Zeitschrift für Orient-Archäologie 500
The Collected Works of Jeremy Bentham: Rights, Representation, and Reform: Nonsense upon Stilts and Other Writings on the French Revolution 320
Equality: What It Means and Why It Matters 300
A new Species and a key to Indian species of Heirodula Burmeister (Mantodea: Mantidae) 300
Apply error vector measurements in communications design 300
热门求助领域 (近24小时)
化学 医学 生物 材料科学 工程类 有机化学 生物化学 物理 内科学 纳米技术 计算机科学 化学工程 复合材料 基因 遗传学 物理化学 催化作用 细胞生物学 免疫学 冶金
热门帖子
关注 科研通微信公众号,转发送积分 3346345
求助须知:如何正确求助?哪些是违规求助? 2973142
关于积分的说明 8657815
捐赠科研通 2653539
什么是DOI,文献DOI怎么找? 1453184
科研通“疑难数据库(出版商)”最低求助积分说明 672782
邀请新用户注册赠送积分活动 662665