Fatal Cardiac Perforation after Percutaneous Treatment in Iliac Artery Occlusion

Abstract

IntroductionA 68-year-old male smoker was admitted to the hospitalwith a history of bilateral severe lower limb arterial dis-ease. He had claudication due to infrainguinal disease,mainly related to a left common iliac artery occlusion, asrevealed by arteriography (Fig. 1A–C). The patient wastreated with percutaneous transluminal angioplasty (PTA)(Fig. 1D) and stenting (Fig. 1E) through the left brachialartery using a metallic guide wire and a 6F long hydro-philic polytetrafluoroethylene-coated sheath.During the intervention, the radiologist used fluoroscopyto aid placement, but only for visualizing the occluded iliacartery without following the entire route taken by the guidewire. Therefore, he did not notice the erroneous pathwaytaken by the guide wire through the ascending aorta andreaching the cardiac chambers. In a second attempt, afterpulling the guide wire back, the radiologist correctlyredirected it, entering into the descending aorta andreaching the left common iliac artery, where the stent wassuccessfully placed, resulting in revascularization of theleft lower limb (Fig. 1F).Two hours after the intervention, the patient was foundlifeless in his hospital bed; all resuscitation efforts wereunsuccessful.ResultsGross Autopsy FindingsA complete postmortem examination was performed3 days after death. External examination was unremarkableexcept for the puncture site of the PTA in the left arm.The internal examination revealed cardiac tamponade(Fig. 2A); however, a definitive transmural myocardialdefect was not identified. There was evidence of hemor-rhagic infiltration beginning in the epicardium andcontinuing throughout the myocardium at the distal part ofthe left ventricle (Fig. 2B).At the aortic root, a small area of hemorrhagic infiltra-tion in contact with the fibrous pericardium was found.A correctly positioned stent was found in the left com-mon iliac artery. Other significant findings included mul-tiorgan vascular congestion and cerebral and pulmonaryedema.Histological StudiesHistological studies were performed with formalin-fixed,paraffin-embedded tissue sectioned at 4 lm and stainedwith hematoxylin and eosin. The examination of the heart,performed by making seven consecutive myocardial sec-tions, revealed hemorrhagic dissection of myocardial tissueat the level of the left ventricle, consistent with cardiacrupture. The transmural myocardial defect was found; thedefect was compatible with a lesion that could have been