Case Title
Nightmare in Cathlab
Case History
This 68 yr old gentleman underwent bypass surgery in 1986. He received 2 vein grafts. One was supplied to OM3 and the other to the distal RCA.
Angiography showed following findings
Investigation Reports
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Large and long left main with a right angled circumflex.Lad seems to be free from significant disease. The CIRC has mild icythesia at a very proximal end and the first OM arising out of the CIRC has a tortuous 90% lesion. The lesion is about 10-12mm long and tortuous. |
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Confirms absence of any significant disease in the LAD. Right coronary fills retrogradely. |
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Patent venous graft to the 3rd OM no significant disease anywhere. |
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Total occlusion of RCA with bridging collaterals. |
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Note : Aortic root injection shows only the stumps of RCA graft whereas the vein graft to OM3 is well visualized. |
Strategy:
Long left main and right angled CIRC as in this case causes special problems. The vectorial transmission of any linear force is maximally small at 90 degree direction. Therefore the guide catheter in this case provide a very good backup support. The wire that one uses should be hydrophilic such as choice PT extrasupport. It should be able to travel through the various tortousity and through the tight lesion without prolapsing into the LAD. It should provide good support to the balloon.
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We therefore choose voda3.5 left guide catheter (Boston scientific TM) and choice PT extra support wire (TM- Boston scientific.) and 2mm soft and flexible balloon maverick2. The wire was carefully manipulated into the CIRC-OM and the balloon was threaded over it. There was a lot of resistance experienced while positioning the balloon across the lesion. A constant and steady gentle pressure was applied to the balloon with every heart beat the balloon gets pushed.There was a bit by bit forward movement of the balloon.Notice waste in the centre of the balloon. |
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Notice 2mm balloon at 12atm still showing the waste in the middle. |
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It shows a check shoot. Please note although lesion is dialated there is a rupture of the vessel wall. Although there is no free haemorrage a perforation at the site of the lesion with localised oozing. It is our experience that the patients have undergone bypass surgery have lot of adhesions that helped us to prevent free bleeding and pericardial temponade. |
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A check shot made after 15 mins shows the same haematoma but no further bleeding. |
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Stent has been deployed covering the site of perforation. 2.25mm non medicated stent was used (biodivisio-15mm) with fairly acceptable results. |
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Angio film taken after stent deployment shows very good results ,localised staining and haematoma continues.
Subsequent course of the patient in the hospital was continued. |
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Comments
When you see the rupture of the artrey post ballooning if there are free spurts into the pericardium we strongly recommend termination of the procedure, reversal of heparin, surgical alert & pericardiocentesis from subxyphoid area .in addition one inflates the balloon at low pressure to prevent further leaking. This last step may not be possible for significant length of time because of the fear of developing ischemia in the large live target artery.
In this case the patient had a previous bypass surgery with fair amount of adhesions expected. This would be helpful in preventing free bleeding. At this stage act was 250 & we decided not to reverse heparin. Morever the results were quite gratifying. Cloth covered stents like jomed or Boston scientific could be a great idea but we could not do that since fair amount of difficulties were anticipated because of significant tortousity of the proximal artery. We observed the patient for 15 more mins & found no continued bleeding with very stable haemodynamics & he was then sent back to the ICCU.
Following points are made:
- Recognize the perforation as early as possible by keeping high degree of suspicion while applying high pressure in the balloon to open the lesion.
- As soon as the perforation is recognized reverse heparin by protamine immediately.
- If the myocardial ischemia is not significant issue you may inflate the correct size balloon for 15-20 mins thus trying to seal the perforation.
- Cloth covered stents or a stent graft must always be in a cathlab however its use in preculeded if there is a marked tortousity as in this case.
- Sometimes i have tried injection of glue using over the wire balloon. Glue solidifies almost instaneousely after injecting with the over the wire balloon as soon as it comes in contact with the blood.
In this case the perforation was within the myocardium and therefore was of not much clinical significance.
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Courtesy
Dr. A.B. Mehta
Director Of Cardiology,
Jaslok Hospital,
Mumbai, India.
Website: http://www.drabmehta.com
Email: drabmehta@cardiovalens.com
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