A 70-year-old male was admitted to our hospital for perioperative cardiac evaluation of abdominal aortic aneurysm.
The patient had undergone coronary artery bypass grafting (CABG) for severe stenosis of the left main coronary artery (LMCA) 4 years before, which consisted of the right internal thoracic artery (RITA) to the left anterior descending artery (LAD) and saphenous vein graft (SVG) to the left circumflex artery (LCX).
Due to continual growth of the abdominal aortic aneurysm over the years, surgery was indicated.
Left coronary angiogram showed 90 % stenosis of the LMCA and total occlusion of both grafts.
PCI was performed for LMCA stenosis (Fig.1).
A 7-Fr sheath was inserted into the right femoral artery, and a CLS4 guiding catheter (Boston Scientific, Natick, MA, USA) was engaged into the left coronary artery (LCA) ostium.
A guidewire (SION Blue, Asahi Intecc, Aichi, Japan) was inserted into the distal LAD, and another guidewire (Hi-Torque Pilot 50, Abbott Vascular, Santa Clara, California, USA) was inserted into the distal LCX.
Intravascular ultrasound (IVUS) (Intra-focus WR, Terumo Corp, Tokyo, Japan) demonstrated heavy circumferential calcification in the LMCA lesion.
After a 4.0 × 15-mm Quantum Maverick balloon catheter (Boston Scientific) was inflated in the lesion, LCA angiogram revealed a large dissection (Fig.2).
A 4.0 × 28-mm Multi-Link Vision stent (Abbott Vascular) was immediately deployed.
Angiographic image of the residual dissection disappeared and the stent was dilated by a 5.0 × 15-mm Quantum Maverick balloon catheter.
The absence of residual dissection was confirmed by angiography after stent implantation.
Next, LMCA-LAD and LMCA-LCX kissing balloon angioplasty was initiated using a 4.0 × 28-mm stent delivery balloon in the LAD and a 3.0 mm × 15-mm Ikazuchi balloon (Kaneka Medics, Tokyo, Japan) in the LCX.
The final angiographic imaging showed optimal results, and IVUS imaging of the lesion showed completely sealing by the stent (Fig.3).
A large hematoma at the femoral puncture site and local bleeding was observed after removal of the femoral sheath and manual compression was applied for haemostasis.
The hematoma did not appear to have spread the next day and the patient was discharged from the hospital on the fifth day after PCI.
Unexpectedly, the patient was admitted to our emergency room with new-onset chest pain and dyspnoea the next day after the discharge.
His vital signs indicated cardiogenic shock.
Electrocardiogram showed ST elevation in leads V1-V3.
Although echocardiography could not detect left ventricular asynergy, a large mass on the outflow tract of right ventricular chamber was observed (Fig.4).
Contrast-enhanced computed tomography showed a 40-mm hematoma compressing the main pulmonary artery trunk and the right ventricle (Fig.5).
During examination, the patient suffered sudden cardiopulmonary arrest.
He received immediate cardiopulmonary resuscitation and returned to spontaneous circulation after the insertion of a percutaneous cardiopulmonary support device.
The patient underwent emergent surgery for the removal of the hematoma after informed consent was obtained from the patient's family.
During surgery, large, dark red clots between the pulmonary artery trunk and aorta were observed.
The suspected origin of the epicardial hematoma was blood oozing from the LMCA stent site.
Despite successful surgical repair, the patient died from aortic rupture induced by external cardiac massage.