Eur J Cardiothorac Surg 2002;22:470-471
© 2002 Elsevier Science NL
Spontaneous rupture of coronary artery
Naotaka Motoyoshia*,
Tsunehiro Komatsua,
Yoshimasa Moizumia,
Kohichi Tabayashib
a Department of Thoracic and Cardiovascular Surgery, Sendai City Medical Center, 22-1, Tsurugaya 5-choume, Miyagino-ward, Sendai 983-0824, Japan
b Department of Cardiovascular Surgery, Tohoku University Hospital, Sendai, Japan
Received 20 December 2001;
received in revised form 7 April 2002;
accepted 24 April 2002.
* Corresponding author. Tel.: +81-22-252-1111; fax: +81-22-252-9431
e-mail: naotaka5{at}hotmail.com
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Abstract
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We report a case of spontaneous coronary artery rupture (SCAR) 3 months after descending aortic replacement. Cardiac tamponade was confirmed at first by using echocardiography following emergency pericardial centesis. The patient was denied aortic dissection by computed tomography, thereafter diagnosed as SCAR with selective angiography, which revealed a leakage from the left circumflex branch. The patient underwent successful rupture site isolation by bilateral ligation and distal revascularization with aortocoronary bypass with saphenous vein graft.
Key Words: Spontaneous rupture • Coronary artery
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1. Introduction
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Spontaneous coronary artery rupture (SCAR) is a rare occurrence, and in less than ten cases have treatments been reported to have a successful outcome [1–3]. Various causes for SCAR have been suggested such as trauma, anomaly, localized infection and so on. SCAR often presents along with cardiogenic shock in the early period, and is confirmed by cardiac tamponade using echocardiography following emergency pericardial centesis, and is denied aortic dissection by computed tomography (CT), thereafter diagnosed as SCAR with selective angiography. Some patients have recovered through emergency surgical operations or catheter interventions. After such treatment, most patients recover without complication.
A 69-year-old patient had undergone descending aortic replacement using a left heart bypass due to an atherosclerotic aneurysm in June 2000. Preoperative coronary angiography (CAG) had revealed no abnormal finding (Fig. 1A)
. The operation was uneventful, and the postoperative CT revealed nothing abnormal in the heart. He was discharged without complication. On 24 September 2000, he suddenly complained of epigastralgia, and turned pale. Soon after, he was transferred to our hospital. The physical examination revealed cardiogenic shock and no cardiac murmur. Among the physical findings and laboratory data, blood pressure was found to be 80/38 mmHg and hematocrit was 36%. Serum creatine kinase (CK) and CK-MB were 843 IU/l (-250) and 75 IU/l (-15). Electrocardiography revealed a normal sinus rhythm and no myocardial ischemic change. Chest roentgenography demonstrated slight cardiomegaly. Echocardiography confirmed cardiac tamponade with pericardial effusion of 11 mm anteriorly and 18 mm posteriorly. Emergency pericardiocentesis was initiated and the circulation adjusted to acceptable levels. The content was uncoagulated blood. CT revealed no dissection or aneurysm on the ascending aorta and no pseudoaneurysm around the previous anastomosis. CAG suggested bleeding from around the LCx (Fig. 1B). SCAR was highly suspected, and a rescue perfusion catheter was used for hemostasis prior to surgical intervention. Emergency sternotomy revealed pericardial bloody effusion and continuous bleeding around the LCx (Fig. 2)
. We decided to perform an operation under cardiac arrest. Cardiopulmonary bypass was established with the cannulation of ascending aorta, superior and inferior caval vein. The ascending aorta was clamped before cardiac arrest using antegrade cardioplegia. Small amounts of bleeding could be easily detected by intermittent antegrade injection of cardioplegic solution. Isolation of the bleeding portion using the bilateral ligation and coronary-aorta bypass grafting for segment 14 were performed using a saphenous vein graft. Total perfusion time and aortic cross-clamping time were 98 and 43 min. The patient was transferred to the intensive care unit (ICU) in a satisfactory condition. He left the ICU on the day after the operation and recovered without complication. Laboratory data revealed that serum CK-MB levels had normalized within 3 days. No ischemic change was detected on the ECG. Postoperative CAG showed a LCx occlusion at segment 11 where it had been ligated, a patent graft and good distal run-off. Hospital discharge was 20 days after the operation.
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Fig. 1. A previously performed coronary arteriogram had revealed no abnormal finding (A), however the rupture of the left circumflex branch was detected 3 months after (B).
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2. Comment
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SCAR is rarely observed whereas incidences of secondary occurrences due to selective radiological intervention have been increasing recently. Various origins of SCAR, such as trauma, anomaly, localized infection, and sarcoma, have been reported [1–3]. Traumatic injury, like iatrogenic centesis, might have initiated the disease in our patient during the earlier surgical operation. However, CT performed 3 months before, soon after the previous descending aortic replacement surgery, revealed no pericardial effusion or hematoma. Nor had the patient ever suffered from other traumatic injuries. Preoperative CAG showed no anomalous vessel formation. Intraoperative findings indicated no localized infection.
As the incidence of secondary coronary artery rupture has increased, a covered stent using an allograft vein or PTFE (polytetrafluoroethylene) has become the popular intervention [4]. However, surgical operation is still performed. We had no opportunity to prepare a covered stent. Therefore, emergency surgical intervention was required. Distal revascularization with an isolation for the diseased portion is appropriate, and requires only conventional remedies if bleeding is confirmed and localized in appearance. If the origin of bleeding is unknown, matters are different. Meticulous efforts to identify the root source prior to surgical operation are essential. Kihara et al. reported a successful case of repaired secondary coronary artery rupture on LAD by patch angioplasty using an allograft vein during off-pump surgery [5]. However, for rupture of the other coronary vessels such as LCx and the right coronary artery, such an elaborate technique would be difficult. More practical and simple techniques were recommended in our case. Isolation that enables elimination of the diseased portion, and distal revascularization, were reasonable for these kinds of localized coronary artery disease [6]. The emergent nature of the case and the advanced age of the patient also encouraged us to perform saphenous vein grafting.
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References
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- Evans R.H., Fraser A.G. Spontaneous coronary artery rupture and cardiac tamponade. Ehlers-Danlos syndrome type IV. Int J Cardiol 1996;54:283-286.[Medline]
- Fan C.C., Andersen B.R., Sahgal S. Isolated myocardial abscess coronary artery rupture with fatal hemopericardium. Arch Pathol Lab Med 1994;118:1023-1025.[Medline]
- Nageh T., Thomas M.R. Coronary-artery rupture treated with a polytetrafluoroethylene coated stent. N Engl J Med 2000;342:1922-1924.[Free Full Text]
- Kihara S., Shimakura T., Tanaka S.A. Surgical angioplasty of ruptured left anterior descending coronary artery without cardiopulmonary bypass. Jpn J Thorac Cardiovasc Surg 2000;48:326-328.[Medline]
- Cengiz T., Iihan G., Nursel S., Mehmet K., Omer B. Surgical management of an atherosclerotic aneurysm of the left main coronary artery. J Thorac Cardiovasc Surg 2001;122:626-627.[Free Full Text]
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Abstract
1. Introduction
