Coronary Extramural Haematoma Caused by Perforation during Left Main Coronary Artery Intervention

Abstract

A year-old male patient with a background of quintuple coronary artery by-pass graft surgery 16 years ago presented to our department with symptoms consistent with unstable angina pectoris. Previous angiography performed in 2001 revealed occluded saphenous vein grafts to the left anterior descending (LAD), right coronary, obtuse The presence of pericardial effusion was immediately ruled out by echocardiography and because of absence of myocardial contrast staining heparin was not reversed. Subsequent intravascular ultrasound (IVUS) examination revealed a minimal lumen area of ≥11.00 mm2 throughout the stented segment despite stent underexpansion at marginal and first diagonal (DA) arteries, and patent left internal mammary artery (LIMA) graft to a second DA. At the same session he underwent percutaneous coronary intervention with bare metal stent implantation for significant mid to distal LAD artery disease. Since then, the patient was stable with Canadian angina class I. During this admission, his echocardiogram revealed an ejection fraction of 40%, akinesia of the inferior wall which was known to be predominantly infarcted and hypokinesia of the basal and mid anterior septum. Coronary angiography (Fig. 1) showed subocclusive calcified and angulated distal left main coronary artery (LMCA) disease, significant ostial LAD artery disease, collateralised occlusion of the distal LAD, left circumflex (LCx) and right coronary arteries, tight proximal disease of a first DA and patent LIMA graft to a second DA. Given these findings we proceeded with stent angioplasty to the LMCA-ostial LAD artery lesion. After a series of predilations with semicompliant balloons, a 4.0 mm × 24 mm drug-eluting stent was the LMCA opposite to the LCx artery ostium and at the LAD artery ostium. Cross-sections of IVUS at the site of perforation revealed an echo-dim pattern suggesting an extramural haematoma and local stent underexpansion with a compression effect by the haematoma whereas the site of blood entry into the adventitia was identified at the distal margin of the haematoma adjacent to a fibrocalcific plaque (Fig. 2). Given the adequate minimal lumen area further stent postdilation was not performed to avoid the risk of frank coronary perforation. The patient was maintained on dual antiplatelet therapy and discharged home after a two-day uneventful hospital course. He remained stable eight months post stenting with Canadian angina class I and no evidence of a cardiovascular event. Extramural haematoma that is accumulation of blood outside the arterial wall in the adventitia tissue is a rare complication of percutaneous coronary intervention and is thought to develop secondary to adventitial dissection implanted from the ostium of the LMCA across the stenosis into the LAD artery at 8 atms. Control angiography after [1–3]. It presents with an echo-dim pattern due to the dilution of the red blood cells and dissemination throughout