Abstract

We report a patient with retained metal coronary bulldog clips in the mediastinum during coronary artery bypass surgery which was recognized during coronary angiography following the diagnosis of unstable angina pectoris after an uncomplicated period of five years. This case suggests that conservative management of patients with postoperatively recognized retained foreign material should be kept in mind as an alternative to reoperation.

We report a patient with retained metal coronary bulldog clips found in the mediastinum during coronary artery bypass graft surgery which were recognized after an uncomplicated period of five years.

Case Presentation

A 78-year-old man was admitted to our hospital with exertional chest pain which had begun two months before. He had received coronary artery bypass graft surgery five years ago with saphenous vein grafts to the left anterior descending artery and right coronary artery. His physical examination was normal. In a chest X-ray, a radiopaque, dense, metal material was observed (Figure 1). In lateral chest X-ray, the material was shown in the posterior mediastinum (Figure 2). Apical hypokinesia was revealed in transthoracic echocardiography. Erythrocyte sedimentation rate and C reactive protein levels were normal.

Figure 1: In posterior anterior chest X-ray a radiopaque metal dense material was observed.

Figure 2: In lateral chest X-ray the material was shown in posterior mediastinum.

His coronary angiography demonstrated patent saphenous vein grafts (Figure 3, 4) and a new lesion in the circumflex coronary artery with 95% diameter stenosis (Figure 5). Metal coronary bulldog clips were observed in the posterior mediastinum without any association with vessels. The circumflex coronary artery lesion was treated with provisional stenting without complication. The patient was informed about the patency of the saphenous vein grafts and the harmless foreign material. In the six-month control, the patient was healthy and free from angina.

Figure 3: Saphenous vein grafts to anterior descending artery is patent and not associated with bulldog clips.

Figure 4: Saphenous vein grafts to right coronary artery are also patent and not associated with bulldog clips.

Figure 5: Circumflex coronary artery viewed before percutaneous intervention, which is not associated with bulldog clips.

Discussion

Surgical material inadvertently left inside the patient is an important complication in surgical procedures. Retained foreign items not only can cause serious or even fatal injuries, but also lead to increased costs and bad reputations for clinicians and treating institutions. The rate of retained foreign material is 1/7000 in coronary bypass surgeries.[1] This is the first case reporting coronary clips left inadvertently in the mediastinum during surgery.

In this case, metal bulldog clips retained in the mediastinum did not result in any complication. Metal surgical materials incidentally found to be retained soon after surgery may be followed up without reoperation if they do not result in hemodynamic compromise, foreign body reaction, or risk of infection.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

References

1) Egorova NN, Moskowitz A, Gelijns A, Weinberg A, Curty J, Rabin-Fastman B, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg 2008;247:13-8.