Abstract

Percutaneous coronary interventions which are widely performed for atherosclerotic heart diseases have become almost an outpatient practice. However, being an invasive intervention, coronary angiography and percutaneous coronary interventions may have some serious complications. In this article, we report an 81-year-old male case with a complication of percutaneous coronary intervention where the balloon catheter was entrapped in the right coronary artery and emergent coronary artery bypass grafting was required. This report aims to emphasize the need for a cardiovascular team in hospitals performing percutaneous coronary interventions although some respected guidelines do not require such a set-up.

Percutaneous coronary interventions (PCIs) are accepted as effective treatment modalities in coronary artery atherosclerotic diseases with balloon angioplasty or stent applications. In the recent literature, the complication rates of PCI requiring emergency cardiac surgery have been decreased from approximately 6-4% to as low as 0.6-0.3% with the advancements in the interventional techniques.[1] Primary PCIs are considered to be reasonable in hospitals without on-site cardiac surgery in accordance with the 2011 ACCF/AHA/SCAI (American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Interventions) PCI Guidelines (Class IIa, level of evidence B)[2] Although the complication rates requiring surgery are low, it cannot be excluded totally. Therefore, current guidelines may be questioned for the present suggestions.

Case Presentation

An 81-year-old man was admitted to our hospital with chest pain. He was hospitalized with the diagnosis of non-ST elevated myocardial infarction and atrial fibrillation. Elective coronary angiography revealed non-stenotic aterosclerotic plaques on the left anterior descending artery, 70% and 80% stenosis on the proximal circumflex artery and optional diagonal artery, 80% and 99% stenosis on the right coronary artery (RCA) proximally, and distal to the right ventricular branch. Percutaneous coronary intervention to the RCA was planned. Balloon dilatation to the distal lesion of the RCA was performed successfully. Nevertheless, balloon dilatation of the proximal lesion failed, as the catheter was entrapped in the artery. Neither deflation nor pulling out the balloon catheter could be accomplished. The patient was referred for emergency operation and was managed by routine coronary artery bypass graft (CABG) operations using saphenous vein grafts.

Cardiopulmonary bypass was established in a standard fashion. The inflated balloon catheter was seen in the proximal part of the RCA. The balloon was deflated with a purified protein derivative (PPD) needle from the outside of the vessel wall. An attempt to pull out the catheter from femoral region was made, however it failed and a small aortotomy incision was done. The catheter was seen in the aorta going into RCA and was pulled out gently (Figure 1). The aortotomy was closed and saphenous vein bypass to the RCA with a sequential graft to obtuse marginal and optional diagonal artery was performed. Cardiopulmonary bypass was terminated and the patient was taken into intensive care unit. The follow-up was uneventful and the patient was discharged on the sixth postoperative day.

Figure 1: An image of the balloon catheter pulled out from the right coronary artery through aortotomy incision.

Discussion

Despite technical improvements and increased experience in PCIs over time, mechanical complications like catheter entrapment, as seen in our case, do still occur in the current era.[3,4] Some other complications including myocardial infarction (MI),[5] bleeding, or vascular access complications,[6] stent deployment failure,[7] contrast nephropathy, stroke, tamponade, stent thrombosis and radiation skin injury[8] are also associated with the use of PCIs. High rates ranging from 5% to 30% of patients undergoing PCI, are reported to have evidence of a peri-procedural MI.[5] Being an invasive procedure, PCI may lead to mechanical complications requiring emergent cardiac surgery. In such cases, prompt management of the patient along together with cardiovascular surgery is mandatory. Coronary artery perforation is one of these serious mechanical complications requiring emergent cardiac surgery which may lead to cardiac tamponade. Fukui et al.[9] reported the incidence of coronary artery perforation during PCI to be between 0.2% and 0.8% with a reported rate of 2.9% by Patel et al.[8] Device entrapment, as seen in our case, also requires emergent cardiac surgery in most cases.[10] Despite low complication rates, these complications still occur. Therefore, it would be unreasonable to perform these invasive procedures without surgical back-up. Such an approach chould be justified only if the complication rates were zero.

We believe that cardiac surgery and interventional cardiology are complementary to each other for the best care of the patients with coronary artery disease. Since complications still do occur, surgical back-up is essential in hospitals where PCIs are performed. Although primary PCI is considered to be reasonable in hospitals without on-site cardiac surgery in 2011 ACCF/AHA/SCAI PCI Guidelines (Class IIa, level of evidence B), our case is a good example of the definite need for surgical back-up and may be the one of many other similar cases that are not reported by surgeons and cardiologists.

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

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