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Pericardial tamponade after chronic total occlusion revascularization: a case report and literature review
Jinjing Li1, Mingming Zhang1, Xiaohui Kang1
1Department of Cardiology, Tangdu Hospital, Fourth Military Medical University, Xi'an, China.
Insights
Pericardial tamponade after coronary intervention can be fatal. This case highlights that coronary artery rupture may occur even without contrast leakage, emphasizing the value of advanced imaging for safer procedures.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Pericardial tamponade is a life-threatening complication of percutaneous coronary intervention (PCI), particularly in complex chronic total occlusion revascularization (CTO-PCI).
- Coronary artery rupture following PCI can lead to hypotension, shock, and fatal pericardial tamponade.
- Standard diagnostic methods for coronary artery rupture, such as contrast angiography, may not always detect subtle leaks.
Observation:
- A 67-year-old woman presented with symptoms suggestive of chronic total occlusion of the right coronary artery (RCA).
- Following successful RCA CTO-PCI, the patient developed pericardial effusion and hypotension, indicative of tamponade.
- Despite the clinical signs of tamponade, initial coronary angiography did not reveal any contrast agent extravasation from the RCA.
Findings:
- Emergency thoracotomy revealed a significant hematoma on the surface of the RCA, confirming rupture despite negative angiographic findings.
- This case underscores that coronary artery rupture is possible even when coronary angiography shows no contrast leakage post-PCI.
- Intravascular ultrasound (IVUS) in conjunction with coronary angiography may enhance diagnostic accuracy and procedural safety during CTO-PCI.
Implications:
- The findings suggest a need for heightened clinical suspicion for coronary artery rupture in patients developing tamponade post-PCI, irrespective of angiographic evidence.
- Integrating IVUS into the CTO-PCI workflow could improve the detection of subtle vessel injuries and reduce the incidence of complications.
- This case emphasizes the importance of a multidisciplinary approach, involving interventional cardiology and cardiac surgery, for managing complex PCI complications.
Abstract:
Pericardial tamponade is a complication of percutaneous coronary intervention (PCI) with extremely high mortality. The rupture of coronary artery causes hypotension and shock, eventually resulting in death due to pericardial tamponade. Because of the complex operation in revascularization of chronic total occlusion (CTO-PCI) lesion, the incidence of pericardial tamponade increases. Usually, we use coronary angiogram to identify the rupture of coronary artery after PCI by the contrast agent. We presented a 67-year-old woman with pericardial tamponade after CTO revascularization. She had chest pain and out of breath for nearly two years. The coronary angiogram showed three branch lesion and CTO lesion of the right coronary artery (RCA). After revascularization of the RCA CTO lesion, the pericardial effusion and low blood pressure occurred, but we didn't find the leak of contrast agents during the final angiography. Then the patient was transferred to cardiac surgery department for emergency thoracotomy. They found the hematoma on the surface of the RCA and finally discharged without any symptoms. Our case approved: (I) there was still the possibility of coronary artery rupture even the coronary angiogram showed no contrast agent leakage from the coronary artery after PCI; (II) the combined use of IVUS and coronary angiogram may improve the accuracy and safety of CTO revascularization procedure.
