Coronary artery perforation is a rare but potentially fatal complication of percutaneous coronary interventions.1,2 Most cases are recognized at the time of the procedure. While some are identified as a localized collection of contrast outside the arterial wall without clinical sequelae, others are characterized by free flow of contrast outside the coronary lumen into the pericardial space. This can result in pericardial tamponade with its attendant morbidity and mortality.3 We describe an unusual case of coronary perforation presenting late as a large coronary artery pseudoaneurysm. Case Report. A 57-year-old woman with a history of diabetes mellitus, hypertension, cigarette smoking and alcohol abuse first presented to our emergency department with a non-Q wave myocardial infarction complicated by pulmonary edema. Cardiac catheterization showed a totally occluded distal circumflex coronary artery, total occlusion of a small nondominant right coronary artery and mild disease of the left anterior descending coronary artery. Left ventricular injection showed inferior and inferobasal hypokinesis, and mild mitral insufficiency. She underwent balloon angioplasty to her circumflex coronary artery, resulting in dissection and requiring placement of multiple stents. There was a good final angiographic result with no residual dissection and TIMI 3 distal coronary flow. Eptifibatide was given during the procedure. The procedure was complicated by contrast-induced renal failure that ultimately necessitated hemodialysis. Seven months later, she returned to the emergency department complaining of dyspnea. Myocardial infarction was excluded and she was referred for diagnostic catheterization. This showed total occlusion of the circumflex coronary artery with a perforation in the proximal portion filling a large posterior pseudoaneurysm (Figure 1). The left anterior descending and right coronary arteries were unchanged from the previous catheterization. Left ventriculography showed inferior and inferobasal akinesis, and moderate mitral insufficiency. The angiograms were reviewed by a cardiothoracic surgeon (RJB) who felt that the proximal location of the pseudoaneurysm and its position behind the great vessels would make surgical repair difficult. We therefore planned to close the neck of the pseudoaneurysm using microcoils placed percutaneously through an end-hole catheter positioned in the neck of the pseudoaneurysm. Prior to the planned intervention, the patient experienced recurrent chest pain associated with a moderate increase in total serum creatinine kinase activity. The patient returned to the catheterization lab a few days later and angiography showed that the pseudoaneurysm had spontaneously closed (Figure 2). Her coronary anatomy was otherwise unchanged from the previous catheterization. Left ventriculography again showed inferior and inferobasal akinesis, and severe mitral insufficiency. She subsequently underwent successful mitral valve repair. During the surgery, the circumflex artery was inspected and appeared chronically occluded. A firm mass was palpated behind the pulmonary artery, consistent with the thrombosed pseudoaneurysm. The patient did well after surgery with no further episodes of heart failure. Discussion. Coronary perforation is a rare, life threatening complication of percutaneous coronary intervention occurring in = 1.5 times the diameter of the adjacent reference segment. True aneurysms occur at a rate of approximately 5% after percutaneous intervention and appear to have a good clinical outcome.11 There is no reported increase in the likelihood of myocardial infarction, death or repeat revascularization procedures. The patient in our report had a very large pseudoaneurysm identified 7 months after percutaneous intervention that spontaneously closed. It is unclear why this occurred, although there was clinical evidence of an acute ischemic event prior to her follow-up catheterization, which suggests that she may have had a hypercoagulable state or activation of her platelets. On the basis of this case, one might also speculate that pseudoaneurysms may occur at a higher frequency than is generally appreciated, but remain unrecognized due to spontaneous thrombosis.
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