At the initial outpatient follow-up after this PCI, symptoms had improved. He underwent subsequent PCI of high-grade disease in two separate OM branches in 2013, after coronary angiogram demonstrated occlusion of both SVGs, high grade stenosis in the native left circumflex (LCx), and CTO of the native RCA.
Prior history was notable for coronary artery bypass graft surgery in 2004, with a left internal mammary artery (LIMA) to the left anterior descending artery (LAD), saphenous vein graft (SVG) to the first obtuse marginal (OM1), and SVG to the right posterior descending artery (rPDA). Thus, he was referred for PCI of a right coronary artery (RCA) CTO. With the increasing number of CTO-PCI being performed, it is imperative for CTO operators to appropriately diagnose and manage potential complications, ranging from access-site hematoma to coronary perforation.Ī 67-year-old man with a history of diabetes mellitus type 2, hypertension, hyperlipidemia, and coronary artery disease (CAD) presented with persistent, daily exertional dyspnea despite optimal anti-anginal therapy. Given the complexity of these occlusions, modern algorithms advocate a thoughtful approach to CTO-PCI, with careful consideration of patient specific factors, lesion characteristics, and collateral circulation, with judicious attempts at antegrade or retrograde approaches. CTOs may be present in up to 30% of patients with CAD in clinical practice, suggesting a potential increase in the number of CTO-PCI procedures. However, new data suggests that with modern techniques and emerging technology, CTO-PCI can be performed with success rates approaching 90%.
Traditionally, percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) was performed in relatively few patients, with success rates as low as 70%. Conscientious evaluation of hemodynamics and clinical status should guide patient care.This case and review highlight the diagnosis and management of coronary perforation and subepicardial hematoma.Subepicardial hematoma is a rare complication of CTO-PCI, with high mortality.It is imperative for CTO operators to appropriately diagnose and manage complications.With modern techniques, CTO-PCI can be performed with success approaching 90%.This review evaluates the complications of CTO-PCI, with a focus on subepicardial hematomas, discussing diagnosis and management of this highly morbid complication. Thus, with close clinical observation, the patient did not undergo pericardiocentesis or other invasive procedures, and was discharged home safely. Despite these dramatic findings, the patient remained hemodynamically stable and pain-free, with resolving ECG changes. He later developed evidence of myocardial ischemia, and imaging, including angiogram, echocardiogram, and cardiac computed tomography revealing active dye extravasation from the previously normal RV marginal branches, in addition to a large subepicardial hematoma. Cardiovascular Revascularization Medicine,, Volume 19, Issue 5, Pages 553-557, Copyright © 2018 Elsevier Inc.Ī 67-year-old man with coronary artery disease and previous coronary underwent successful Guideliner reverse CART percutaneous coronary intervention of a chronic total occlusion of the right coronary artery.
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