Cardiac tamponade following perforation of the left anterior descending coronary system during percutaneous transluminal coronary angioplasty: Successful treatment by pericardial drainage

Abstract

Percutaneous transluminal coronary angioplasty (PTCA) is an effective and increasingly utilized modality in the treatment of coronary artery disease. Its complications include prolonged angina, myocardial infarction, coronary occlusion, dissection, spasm, embolism, and perforation.’ When these complications occur, immediate aortocoronary bypass surgery is usually performed. We report the occurrence of perforation of a diagonal branch of the left coronary artery with associated cardiac tamponade treated successfully in the Cardiac Catheterization Laboratory without surgical repair of the perforated artery. A 69-year-old white man had a 3-week history of chest pain at rest, which was relieved by nitroglycerin. The patient had nonsustained ventricular tachycardia on an otherwise negative exercise thallium examination. Coronary arteriography revealed a 90% stenosis in the mid-left anterior descending coronary artery and multiple areas of noncritical disease in branches of the left circumflex coronary artery (Fig. 1). PTCA of the left anterior descending artery was performed. Following the intra-arterial administration of 10,000 units of heparin, the standard technique employing a No. 9 FL 4 USC1 (USCI, Billerica, Mass.) guiding catheter was used via the right femoral artery. The left anterior descending coronary artery was entered with a standard steerable ACS (Advanced Cardiovascular Systems, Inc., Temeculla, Calif.) guidewire (size 0.014 inch diameter, 175 cm long) and a 2.5 mm ACS dilatation catheter crossed the lesion. Four dilatations, at a maximum pressure of 8 atm and maximum duration of 15 seconds, were performed. In order to better opacify the area of dilatation and in anticipation of the use of a larger-sized dilatation catheter, with the tip of the dilatation catheter held distal to the area of angioplasty, the steerable guidewire was replaced with a 300 cm long ACS exchange guidewire (0.018 inch diameter). The original dilatation catheter was removed. Angiography of the left coronary artery demonstrated successful angioplasty of the left anterior descending lesion and extravasation of contrast into the pericardial cavity at a site near the tip of the exchange guidewire, several centimeters distal to the area of angioplasty and in the area of a small diagonal branch (Fig. 2). The patient was stable hemodynamically,