Clinical Images

Septal Hematoma: A Rare But Potentially Serious Complication of Retrograde CTO-PCI

 Matthew W.P. Jackson, MB ChB, MRCP1;  David Lee, MB ChB, MRCP1;  Mohaned Egred, BSc (Hons), MBChB, MD1,2

 Matthew W.P. Jackson, MB ChB, MRCP1;  David Lee, MB ChB, MRCP1;  Mohaned Egred, BSc (Hons), MBChB, MD1,2

J INVASIVE CARDIOL 2019;31(3):E47-E48.

Key words: cardiac imaging, hematoma, septal perforation

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has increased dramatically following the introduction of the hybrid approach with many new techniques and equipment. This has resulted in higher success rates but also novel complications, particularly with the retrograde approach and the use of collaterals.

A 43-year-old male underwent CTO-PCI of the right coronary artery (RCA) for stable angina (Figure 1A). Antegrade wire escalation and dissection/re-entry techniques failed, so a retrograde strategy was adopted. A 0.014˝ Fielder FC guidewire (Asahi Intecc) was advanced into the second septal perforator and exchanged via a Corsair microcatheter (Asahi Intecc) for a Sion wire (Asahi Intecc), which was advanced to the distal RCA. Attempts to advance the Corsair microcatheter, a Caravel microcatheter (Vascular Perspectives), and a 1.2 x 10 mm Mini-trek balloon (Abbott Vascular) into the distal RCA were unsuccessful due to distal tortuosity, and subsequent angiography showed evidence of a septal perforation. The patient was hemodynamically stable and the procedure was abandoned.

Transthoracic echocardiography immediately post procedure demonstrated an echo-free space in the septum with no evidence of intracardiac shunting consistent with a septal hematoma (Figures 1B and 1C). This was confirmed on gated computed tomography scanning (Figure 1D). Electrocardiogram showed no evidence of cardiac conduction delay and the patient remained stable and was discharged the following day. Repeat echocardiography and cardiac computed tomography performed 6 weeks later showed complete resolution of the hematoma (Figures 1E and 1F).

The retrograde approach is increasingly used for CTO-PCI, and septal collateral perforation and hematoma formation is a rare but potentially serious complication of this technique. While typically benign, there are case reports of hematomas resulting in biventricular cardiac obstructive shock, ventricular septal defect, cardiac tamponade (dry), and coronary-ventricular fistulas. Treatment options include conservative management if hemodynamically stable (as in our patient) or occlusion of the septal perforator either locally with coils or aspiration through a microcatheter, or at the ostium using a covered stent.

From the 1Cardiac Department, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom; and 2Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 25, 2018.

Address for correspondence: Mohaned Egred, BSc (Hons), MB ChB, MD, FRCP, FESC, Cardiac Department, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN, United Kingdom. Email: