A 63-year-old female patient presented 15 years after coronary artery bypass graft surgery (CABG) with severe angina pectoris. Invasive coronary angiography revealed occluded bypass grafts, occluded left anterior descending, and right coronary artery (RCA) with a patent left circumflex artery as a last remaining vessel. After non-invasive documentation of large inferior ischaemia by SPECT, percutaneous revascularization (PCI) of the chronic total occlusion of the RCA was attempted using a retrograde route via septal collaterals and the reverse controlled antegrade and retrograde subintimal tracking technique. After successful recanalization, a distal wire perforation (Ellis class III) of the first right posterolateral branch (PLA) was observed (Panel A, Supplementary Data) and immediately sealed by implantation of three Axium™ coils (3 mm/6 cm) (ev3 Endovascular, Inc., Plymouth, MA, USA) (Panel B, Supplementary Data). Despite successful sealing, the patient remained hypotensive over the following hours, and required a short period of catecholamines. A drop in haemoglobin concentration from 14.6 to 9.8 g/dL was observed. A transthoracic echocardiography ruled out pericardial effusion and showed a collapsed inferior vena cava. A CT scan to rule out retroperitoneal haematoma revealed left haemothorax with partial compression atelectasis of the left lower lobe (Panel C). After successful thoracoscopic evacuation (Panel D) of 1–1.5 L of haematoma followed by pleural drainage for 2 days and transfusion of two units of packed red blood cells, the patient recovered quickly and was discharged in good condition on the 7th day post-admission. Prior CABG without pericardial repair may protect against pericardial tamponade. However, the present case should alert clinicians to consider haemothorax as a source of protracted hypotension after coronary perforation.
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Frangieh et al. (2014) studied this question.