indian heart journal 67 (2015) 493–494
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Images in Cardiology
Successful coil embolization of a bleeding internal thoracic artery that caused severe hypotension immediately after permanent pacemaker placement Kevin Kang, Robert Maholic, Gurjaipal Kang * UPMC Hamot Hospital, Erie, PA, USA
article info Article history: Received 1 April 2015 Accepted 8 June 2015 Available online 5 August 2015 Keywords: Angiography Peripheral/renal Complications Vascular access Peripheral intervention
A 66-year-old male received a dual-chamber defibrillator (ICD) implant. Left subclavian artery (SCA) was inadvertently entered while attempting subclavian venous stick, and Jguidewire was passed into the vessel because the plan was to get the wire deep enough in the vessel that a sheath could be passed over the wire and then ICD lead passed through the sheath. The J-wire got stuck in the vessel and the wire was removed by pulling it back with minor difficulty. Subsequently, the ICD was implanted by sticking the vein, but the patient developed hypotension immediately after the procedure and an emergent chest CT scan was read as showing a large hematoma in left upper thorax. The bleeding source was suspected to be SCA at the stick site and the patient
emergently came to the cardiac catheterization laboratory where an interventional cardiologist placed a Viabahn (Gore) covered stent in the SCA at the suspected site of bleeding. However, the active bleeding was soon identified to come from a large and free perforation in the proximal left internal thoracic artery (ITA) (Fig. 1, video 1). A 7-French guiding catheter was placed selectively in the ITA, and the ITA was successfully occluded with 3 cm 5 cm and 4 cm 10 cm AZUR (Terumo Interventional Systems, Somerset, New Jersey) coils (Fig. 2). There was no residual bleeding from the ITA. In retrospect, the CT scan showed the bleeding ITA (Fig. 3). This is the first reported case of hemodynamically significant ITA bleeding indirectly related to ICD placement.
* Corresponding author. Tel.: +1 814 450 8160. E-mail address: [email protected] (G. Kang). http://dx.doi.org/10.1016/j.ihj.2015.06.016 0019-4832/# 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
[(Fig._1)TD$IG]
494
indian heart journal 67 (2015) 493–494
[(Fig._3)TD$IG]
Fig. 1 – Subclavian artery angiography showing ITA bleeding from the wire injury.
[(Fig._2)TD$IG]
Fig. 3 – Chest CT with a large thoracic hematoma and in retrospect, actively bleeding ITA.
Conflicts of interest The authors have none to declare.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ihj.2015.06.016.
Fig. 2 – ITA is coiled successfully and the active bleeding has stopped on angiography.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ihj
Images in Cardiology
Successful coil embolization of a bleeding internal thoracic artery that caused severe hypotension immediately after permanent pacemaker placement Kevin Kang, Robert Maholic, Gurjaipal Kang * UPMC Hamot Hospital, Erie, PA, USA
article info Article history: Received 1 April 2015 Accepted 8 June 2015 Available online 5 August 2015 Keywords: Angiography Peripheral/renal Complications Vascular access Peripheral intervention
A 66-year-old male received a dual-chamber defibrillator (ICD) implant. Left subclavian artery (SCA) was inadvertently entered while attempting subclavian venous stick, and Jguidewire was passed into the vessel because the plan was to get the wire deep enough in the vessel that a sheath could be passed over the wire and then ICD lead passed through the sheath. The J-wire got stuck in the vessel and the wire was removed by pulling it back with minor difficulty. Subsequently, the ICD was implanted by sticking the vein, but the patient developed hypotension immediately after the procedure and an emergent chest CT scan was read as showing a large hematoma in left upper thorax. The bleeding source was suspected to be SCA at the stick site and the patient
emergently came to the cardiac catheterization laboratory where an interventional cardiologist placed a Viabahn (Gore) covered stent in the SCA at the suspected site of bleeding. However, the active bleeding was soon identified to come from a large and free perforation in the proximal left internal thoracic artery (ITA) (Fig. 1, video 1). A 7-French guiding catheter was placed selectively in the ITA, and the ITA was successfully occluded with 3 cm 5 cm and 4 cm 10 cm AZUR (Terumo Interventional Systems, Somerset, New Jersey) coils (Fig. 2). There was no residual bleeding from the ITA. In retrospect, the CT scan showed the bleeding ITA (Fig. 3). This is the first reported case of hemodynamically significant ITA bleeding indirectly related to ICD placement.
* Corresponding author. Tel.: +1 814 450 8160. E-mail address: [email protected] (G. Kang). http://dx.doi.org/10.1016/j.ihj.2015.06.016 0019-4832/# 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.
[(Fig._1)TD$IG]
494
indian heart journal 67 (2015) 493–494
[(Fig._3)TD$IG]
Fig. 1 – Subclavian artery angiography showing ITA bleeding from the wire injury.
[(Fig._2)TD$IG]
Fig. 3 – Chest CT with a large thoracic hematoma and in retrospect, actively bleeding ITA.
Conflicts of interest The authors have none to declare.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ihj.2015.06.016.
Fig. 2 – ITA is coiled successfully and the active bleeding has stopped on angiography.
