Coronary artery rupture and pseudoaneurysm formation resulting from percutaneous coronary angioscopy

Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention

Coronary perforation is a rare but serious complication that occurs during percutaneous coronary intervention (PCI). This study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat perforations, and describes the long-term prognosis of patients who have developed coronary perforation during PCI. Coronary perforations were found in 69 (0.93%) of 7,443 consecutive PCI procedures, occurring more often after use of a new device (0.86%) than after use of balloon angioplasty (0.41%) (p<0.05). Coronary perforation was attributable solely to the coronary guidewire in 27 (0.36%) cases. Coronary perforations were divided into 2 types: (1) Those with epicardial staining without ajet of contrast extravasation (type I, n=51), and (2) those with a jet of contrast extravasation (type II, n= 18). Patients with type I and type II perforations were managed by observation only (35% and 0%, respectively), reversal of anticoagulation (57% and 94%), pericardiocentesis and drainage (27% and 61%), and prolonged perfusion balloon angioplasty (16% and 100%). Two patients with type II perforations required emergency coronary artery bypass surgery. There were no in-hospital deaths. Late pseudoaneurysms developed in 18 (28.6%) patients during the 13.4 +/- 11.3 months' follow-up period, and were more common in patients with type II perforations (72.2% vs 11.1% with type I perforations; p<0.001). During the follow-up period, no patient had evidence of coronary rupture. The results suggest that coronary perforation is uncommon after PCI, and can be managed without cardiac surgery in the majority of cases. Late pseudoaneurysms developed in some patients, particularly in patients with type II perforations, but there were no late consequences of coronary perforation after PCI.

Occurrence of a saccular pseudoaneurysm formation two weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction

We describe the occurrence of a localized saccular pseudoaneurysm in a 69-year-old patient 2 weeks after perforation of the left anterior descending coronary artery during balloon angioplasty in acute myocardial infarction. The therapy of perforations requires prolonged balloon inflations, perfusion balloons, covered stents, or surgery. Coronary peudoaneurysm formations are rare; their therapy requires covered stents or surgery. Cathet. Cardiovasc. Intervent. 47:341-346, 1999.

[Perforation and rupture of coronary arteries]

Spontaneous rupture of coronary arteries as well as coronary perforation during percutaneous interventions are rare but potentially life-threatening incidents often resulting in emergency surgery. Frequency of acute perforation due to therapeutic catheterization varies according to the devices employed. With conventional balloon angioplasty it is estimated to be 0.1 to 0.2% whereas substantially higher rates of up to 3% have been reported with the use of so-called "new devices" (i.e. directional atherectomy, rotablation, excimer laser angioplasty or extractional atherectomy). Interventional strategies for nonsurgical treatment of acute coronary perforations during catheterization procedures have been developed. In recent times, availability of coronary stent-grafts allows for a percutaneous resolution of acute perforations while maintaining vessel patency. Whereas iatrogenic perforations in the catheterization laboratory may thus be treated immediately at the site of their occurrence, rupture of pre-existing but potentially unknown coronary pathology frequently is associated with a diagnostic interval, giving rise to serious clinical events (i.e. myocardial infarction, cardiac tamponade, malign arrhythmias or sudden death). It may be warranted to advocate prophylactic treatment of rupture-prone coronary conditions even on incidental diagnosis. This can either be performed by cardiothoracic surgery or, in suitable cases, by interventional therapy. Implantation of coronary stent-grafts could prove to become the therapy of choice due to its technical facility, safety and the short length of hospital stay associated with it. Before general recommendations can be made, however, as to the extension of indication for these novel coronary devices, further clinical studies encompassing long-term clinical and angiographic follow-up are needed.

[Encapsulated coronary rupture following stent implantation]

We report a case of coronary encapsulated rupture following stent implantation in the distal anastomosis of a saphenous by-pass graft to the left anterior descending coronary artery that evolved well with conservative treatment. The patient did not require pericardiocentesis and was treated with prolonged inflations with low pressure autoperfusion balloon at the rupture point. Pericardial adherences related to a previous coronary surgery probably limited the bleeding process avoiding hemodynamic collapse.

Delayed development of a pseudoaneurysm in the left circumflex artery following angioplasty and stent placement, treated with intravascular ultrasound-guided stenting

Three months following satisfactory angioplasty and stent placement, a patient developed restenosis and a pseudoaneurysm of a coronary artery segment proximal to the previously stented area. The restenosis and the pseudoaneurysm were successfully treated with intravascular ultrasound-guided primary stenting. The delay in the appearance of the pseudoaneurysm attests to the chronic nature of the lesion.

Coronary angioscopy. Clinical applications

Percutaneous coronary angioscopy is an invaluable alternative imaging modality that can not be used routinely in the interventional cardiac catheterization laboratory. The major value of angioscopy lies in its ability to determine safely, quickly, and accurately intraluminal morphologies before and after coronary interventions. The results from angioscopy can then be used to target more specific treatment strategies, given the vast array of interventional treatment strategies available. Percutaneous coronary angioscopy, however, requires meticulous attention for the proper preparation and use of the angioscope to minimize the potential risks associated with the imaging procedure.

Repair of a coronary pseudoaneurysm with percutaneous placement of a saphenous vein allograft attached to a biliary stent

Late coronary artery pseudoaneurysm formation is a rare complication of perforation following percutaneous intervention. While surgical intervention is the treatment of choice for large expanding pseudoaneurysms, the optimal treatment strategy for small-to-moderate pseudoaneurysms is unclear. We describe the percutaneous placement of a saphenous vein allograft for treatment of a coronary artery pseudoaneurysm presenting as a late complication of coronary perforation.

Perforation of a side branch of the right coronary artery during selective coronary angiography using 5 French Judkins catheters

In this case report the first known case of a perforation of a side branch of the right coronary artery during diagnostic coronary angiography using 5 French Judkins catheters is described which occurred by selective intubation. Although catheter placement was controlled by contrast test injection the catheter occasionally intubated the conus artery super selectively just prior to the diagnostic injection. Thus, perforation of small side branches may be encountered especially by the use of 5 French Judkins catheters.

Intraoperative angioscopy for coronary bypass surgery

Despite advances in coronary artery surgery, technical abnormalities remain a significant cause of early graft closure. The development of small fiberoptic angioscopes now allows direct intravascular magnified examination. Seventy-five distal anastomoses and vein grafts, and five selected coronary arteries were examined with 0.8- to 2.5-mm diameter angioscopes introduced through the proximal vein graft while irrigating with clear cardioplegia. Angioscopic findings were correlated with angiographic data, vessel morphology, graft flow, and postoperative course. Satisfactory images were obtained in 72 of 75 anastomotic inspections. Each examination took less than 2 minutes and required less than 100 cc of flush. Angioscopic abnormalities that did not require revision were noted in 17 of 72 anastomoses; intimal flaps in 9, thrombus on posterior wall plaque in 4, intimal irregularities in 4, bucking of posterior wall in 3, and valve near anastomoses in 1. No outflow obstruction nor misplaced sutures were noted. Average flow rate through the grafts with anastomotic angioscopic abnormalities was 33 cc/min versus 40 cc/min in the remaining grafts. However, regression analysis revealed that low-graft flow was correlated with vessel size and runoff but was not with angioscopic findings. Intracoronary angioscopy revealed discrepancy with angiographic findings in 4 of the 5 examinations. No complications occurred as a result of angioscopy. No graft closure has occurred during early follow-up. Intraoperative angioscopy can be done with minimal alteration of the usual routine. The 24% occurrence of minor angioscopic abnormalities did not appear to compromise graft flow or early patency.

Coronary artery aneurysms after angioplasty and atherectomy

Coronary artery aneurysm formation after percutaneous transluminal coronary angioplasty and directional coronary atherectomy is unusual. We report the case of a left anterior descending coronary artery aneurysm that formed in such a patient. The left anterior descending coronary artery was bypassed and the aneurysm was plicated with the aid of coronary angioscopy. The English-language medical literature on the topic of coronary artery aneurysms is reviewed.