Journal Of Indian College Of Cardiology

CASE REPORT
Year
: 2021  |  Volume : 11  |  Issue : 4  |  Page : 205--207

Perforation of Coronary Artery Side Branch: A Lesson for Novice Interventionist during Angiography


Rakesh Kumar Ola, Manish Ruhela 
 Department of Cardiology, Noble Care Hospital, Sikar, Rajasthan, India

Correspondence Address:
Dr. Rakesh Kumar Ola
Department of Cardiology, Noble Care Hospital, Sikar, Rajasthan
India

Abstract

In the modern era of cardiology, coronary angiography is a relatively safe procedure. Complication rate occurs in < 1% of cases. We report a case of coronary artery side branch perforation during coronary angiography using 5 French tiger radial catheter. Contrast injection into a side branch following accidental superselective intubation leads to the perforation at the tip and contrast extravasation. We were able to manage the patient conservatively because there is no hemodynamic compromise or pericardial effusion. Check angiography was done after 7 days and there was no leak. During angiography, pressure tracing should always be monitored and dye injection should be stopped if there is superselective intubation of the branch.



How to cite this article:
Ola RK, Ruhela M. Perforation of Coronary Artery Side Branch: A Lesson for Novice Interventionist during Angiography.J Indian coll cardiol 2021;11:205-207


How to cite this URL:
Ola RK, Ruhela M. Perforation of Coronary Artery Side Branch: A Lesson for Novice Interventionist during Angiography. J Indian coll cardiol [serial online] 2021 [cited 2022 Jun 30 ];11:205-207
Available from: https://www.joicc.org/text.asp?2021/11/4/205/329148


Full Text



 Introduction



Coronary artery perforation is a rare complication of coronary angiography. The risk of major complication during cardiac catheterization is < 1%. Coronary artery perforation is a common complication during percutaneous coronary intervention, but it is rare during diagnostic coronary angiography. The management of coronary perforation includes balloon occlusion of the vessel, use of covered stent, distal fat or coil embolization, and sometimes surgery. Cardiac catheterization using a 5 F tiger coronary catheter is an accepted and safe procedure. In this case report, we present a case of 55-year-old gentleman who had a coronary artery branch perforation during a diagnostic coronary angiogram and it was managed conservatively.

 Case Report



A 55-year-old man was admitted with unstable angina, starting 1 day prior to admission, including 15 min diffuse retrosternal chest pain at rest with sweating. His complete blood count and renal and liver function tests were normal. Electrocardiography was suggestive ST/T changes. Left ventricle function was normal in two-dimensional (2D) echocardiography. He was initially managed with oral antiplatelets, statin, angiotensin-converting enzyme inhibitors, nitrates, beta-blockers, and intravenous unfractionated heparin.

Diagnostic coronary angiography was planned. The right radial artery was taken and 5 French Tiger (Termo, Japan) catheter was used. Left coronary angiogram was suggestive of proximal left anterior descending 50% tubular concentric stenosis. The right coronary ostium was hooked, pressure tracing showed no dampening, and ostial position was confirmed by a small puff of dye. Plain left anterior oblique view was taken which was suggestive distal right coronary artery (RCA) 50% tubular concentric stenosis [Figure 1]. In anterior–posterior (AP) cranial view, again, pressure waveform showed no dampening and catheter position was confirmed by a small test of injection. During the visualization of the RCA angiogram in the AP cranial view, the catheter superselectively intubated the side branch of RCA and 2 mL dye was injected before stopping the injection. Due to superselective intubation of side branch of RCA, the distal tip of this branch perforated, leading to extravasation of the dye into myocardium as shown [Figure 2]. The patient's vitals remained stable and 2D echocardiogram showed no pericardial effusion. Heparin reversal was done with protamine sulfate. Check angiogram was done after 10 min, and there was no further leak from perforation site and confirmed the persistence of dye staining of the myocardium as shown [Figure 3]. Postcoronary angiography, he was kept under observation for 72 h and repeated echocardiogram was done for pericardial effusion. During the hospital course, his vitals were stable and no pericardial effusion developed. The patient was advised medical therapy and discharged after 72 h. Seven days later, a repeat angiogram was done. There was no contrast extravasation at the previous site and the patient was advised to continue medical management.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Coronary angiography is a relatively safe procedure with a major complication rate being < 1%, mortality: 0.1%, and myocardial infarction 0.1%.[1] Minor complications include vascular complications such as distal embolization, acute thrombosis, bleeding, pseudoaneurysm, arteriovenous fistula, acute kidney injury due to contrast-induced nephropathy, allergic reactions to contrast or local anesthetics, infection, and radiation exposure.[1],[2] Perforation of the artery generally occurs secondary to invasive procedures such as percutaneous coronary balloon angioplasty, atherectomy, and excimer laser angioplasty. The incidence of perforation following angioplasty varies from 0.2% to 0.6%,[3] ranging from perceptible to severe life-threatening tamponade requiring urgent pericardiocentesis and other interventions such s balloon tamponade, deployment of covered stent, use of coil or fat embolization, and sometimes, emergent or urgent cardiac surgery.[4]

During diagnostic coronary angiography, perforation is a very rare complication. Only four cases were reported in the literature. RCA was involved in three cases and one case side branch of the left main coronary artery was involved.[5],[6],[7] In our case, we used 5fr Tiger (Terumo, Japan) catheter to inject contrast into RCA. In the AP cranial view, the catheter tip was confirmed by pressure tracing and small puff of dye. During the cine catheter tip accidentally intubated the branch of RCA leading to the perforation of the tip of the branch, however, the position was confirmed before contrast injection. Following perforation, there was an accumulation of contrast in the myocardium. 2D echocardiography was done immediately, there was no pericardial effusion. The patient had not developed any hemodynamic compromise or effusion during observation for 3 days in the hospital course. In our case, we conclude that conservative can help in some cases where perforation was limited to the myocardium and no effusion was noted.

From our case, we learned that pressure tracing should always be carefully monitored during angiography and contrast injection should be stopped immediately when there is deep intubation of the catheter in a branch.

 Conclusion



During the diagnostic coronary angiography side, branch perforation can occur due to selective cannulation of the catheter. Pressure tracing should always be carefully monitored during every cine and contrast injection should be stopped immediately if there is deep cannulation of the catheter in any side branch. We conclude that such a patient can be managed conservatively if there is no hemodynamic instability or pericardial effusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Tavakol M, Ashraf S, Brener SJ. Risks and complications of coronary angiography: A comprehensive review. Glob J Health Sci 2012;4:65-93.
2King KM, Ghali WA, Faris PD, Curtis MJ, Galbraith PD, Graham MM, et al. Sex differences in outcomes after cardiac catheterization: Effect modification by treatment strategy and time. JAMA 2004;291:1220-5.
3Gruberg L, Pinnow E, Flood R, Bonnet Y, Tebeica M, Waksman R, et al. Incidence, management, and outcome of coronary artery perforation during percutaneous coronary intervention. Am J Cardiol 2000;86:680-22.
4Briguori C, Nishida T, Anzuini A, Di Mario C, Grube E, Colombo A. Emergency polytetrafluoroethylene-covered stent implantation to treat coronary ruptures. Circulation 2000;102:3028-31.
5Schöbel WA, Voelker W, Karsch KR. Perforation of a side branch of the right coronary artery during selective coronary angiography using 5 French Judkins catheters. Cathet Cardiovasc Diagn 1995;36:156-9.
6Timurkaynak T, Ciftci H, Cemri M. Coronary artery perforation: A rare complication of coronary angiography. Acta Cardiol 2001;56:323-5.
7Kumar SB, Pruthvi CR, Krishna P. Perforation of a side branch of coronary artery during coronary angiography: A rare complication. J Cardiovasc Med Cardiol 2020;7:136-7.