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Patient initials or identifier number
Relevant clinical history and physical exam
A 76-year-old male was hospitalized for sever months' chest discomfort on exertion and 12 hours unstable angina. He was a heavy smoker for 50 years and had risk factor of hypertension and dyslipidemia. The patient’s symptom was released after treatment of dual antiplatelet therapy andlow molecular weight heparin.
Relevant test results prior to catheterization
Lab tests for cardiac troponin were negative. Electrocardiography indicated T wave depression in V3 to V6 leads. Transthoracic echocardiography showed reduced ejection fraction as 42% and hypokinesis of left ventricular apex and inferior ventricular septum.
Relevant catheterization findings
Coronary angiography revealed a dominant right coronary artery with diffuse calcification and severe stenosis in the proximal and distal portion. The left anterior descending (LAD) artery showed significantly calcification with subtotal occlusion in the middle segment. The circumflex artery indicated moderate atherosclerosis and no obvious stenosis.
By using the Rotablator (Boston Scientific), a 1.25mm burr can pass through the lesion with maximal rate of 150,000 rpm and maximal rotation time for 29 seconds. Coronary dissection was indicated by first cine after the ablation. For the ease of stent passing through the vessel, balloon inflation was deployed from the distal to middle segment of LAD (balloon size 2.0mm× 20mm and 2.5mm× 15mm) The following cine showed middle LAD perforation with contrast agent leakage to the ventricular septum and formation of pseudoaneurysm. A 2.25mm× 30mm drug eluting stent (Resolute, Medtronic) and 3.0× 33mm drug eluting stent (Firebird2, Microport) were deployed continuously and a non-compliance balloon (balloon size 3.0mm× 15mm) was inflated for post dilation and specifically for the lesion of perforation. The final angiography showed no obvious residual stenosis on target lesion of LAD and active bleeding to pericardium. Although instant transthoracic echocardiography did not find pericardial effusion, the patient developed cardiac temponade after transferred to the ward. He was successfully rescued by pericardial drainage and protamine sulfate. Coronary computed tomography (CT) scan was prescribed for re-evaluation 2 weeks after the procedure. It indicated no stenosis or stent thrombosis in LAD lesion with the persist pseudoaneurysm. The patient was suggested for low dose of aspirin and clopidogrel.
Although coronary artery pseudoaneurysm is a quite rare complication of rotational atherectomy, the severe consequence could be cardiac temponade and even fatal. It is not clear the benefit of invasive strategy compared with the conservative therapy and the effect of traumatic pseudoaneurysm to the duration and intensity of dual antiplatelet therapy.