Percutaneous Intervention to a Right Coronary Artery Vein Graft Complicated by Perforation Into the Right Heart
A 79-year-old woman was admitted to our center with troponin-positive acute coronary syndrome. The ECG on admission showed inferior ST changes. She had undergone coronary artery bypass graft surgery 12 years previously. Diagnostic coronary angiography was performed and revealed a tight lesion in the distal right coronary artery vein graft, which was directly stented. The first image taken after deployment revealed Thrombosis In Myocardial Infarction (TIMI) grade 0 flow. Subsequent views showed graft perforation with free extravasation of contrast into the right atrium and into the right ventricle (Figure). The patient remained cardiovascularly stable. The area of perforation was sealed with the use of 2 covered stents, with rapid cessation of contrast extravasation and restoration of TIMI grade 3 flow. Transthoracic echocardiography excluded a pericardial collection. She remained well and was discharged 3 days later after serial echocardiography continued to exclude a pericardial effusion. Coronary perforation complicating percutaneous intervention is rare, with an estimated incidence of 0.2% to 0.6%.1 It tends to occur in the elderly and women and in association with atheroablative procedures.2 It is believed that patients having undergone coronary artery bypass grafting are protected from the development of cardiac tamponade because surgery generally involves a pericardiotomy. However, a case of tamponade complicating percutaneous intervention on a proximal right vein graft lesion has recently been reported.3 An explanation for the perforation occurring directly into the right heart is that the right coronary artery graft overlies the right atrium, where, after 12 years, it was adherent. The perforation preferentially occurred in the area of least resistance and into the lower pressure right atrium. We believe this to be the first case of a class III1 vein graft perforation after percutaneous intervention with extravasation directly into the right heart, thereby occurring without development of a hemopericardium and risk of cardiac tamponade.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/114/17/e549/DC1.
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