PO-01-045 INJURY TO THE LEFT INTERNAL THORACIC ARTERY DURING PERCUTANEOUS EPICARDIAL ACCESS FOR CATHETER ABLATION: PREVENTION AND MANAGEMENT

Abstract

Damaging the left internal thoracic artery (LITA) is considered to be a possible complication of percutaneous epicardial catheter ablation. The LITA typically courses approximately 1cm from the sternal margin and bifurcates around the sixth intercostal space and may be located in the epicardial needle trajectory. However, reports of this complication are scarce. We report two cases of epicardial ablation: one with an uncommon LITA injury complication during epicardial access (EA) and another showing its preventive measures. N/A Case 1. A 39 year-old man with Brugada syndrome underwent epicardial catheter ablation. Since the initial EA from the subxiphoid region failed, we alternatively performed a parasternal intercostal EA at the fifth intercostal space 2cm from the sternal margin and placed a guidewire in the pericardial space. Shortly after the puncture needle was removed, we observed active bleeding from the puncture site and a drop in the blood pressure. We replaced the guidewire with an 8F drainage catheter and removed the arterial blood from the pericardial space, which stopped the bleeding and stabilized the blood pressure. The arteriography revealed a penetration of the LITA by the drainage catheter (Fig 1A). We secured the pericardial space with a second guidewire (GW2) inserted from an adjacent site. Then, we performed a percutaneous coil embolization of the LITA (VortX™ 18 Diamond Shape Fibered Platinum Coils, Boston Scientific). During the procedure, when the drainage catheter was removed, we confirmed the extravasation of the contrast medium from the injured site (Fig 1B). Finally, hemostasis was achieved (Fig 1C). A sheath was advanced into the pericardial space with a GW2 and the epicardial catheter ablation was successfully performed (Fig 1D). No blood transfusion was required. Case 2. A 25 year-old man with Brugada syndrome underwent epicardial catheter ablation with a subxiphoid anterior EA. Bi-plane angiography performed prior to the EA clearly delineated a tortuous and branching LITA (Fig 1E). The EA was securely obtained with the on-site anatomical information. Case 1 demonstrated direct evidence of a LITA injury occurring during an EA. Angiography immediately before an EA can visualize the detailed LITA anatomy and may ensure safety during a subsequent EA. If a LITA injury occurs, a coil embolization of the LITA may be a feasible and effective treatment.