Great cardiac vein injury after circumflex artery intervention: a case report

Abstract

Background: Injury of the great cardiac vein (GCV) during circumflex coronary artery intervention is not discussed enough in the literature. In addition, relationship between the GCV and circumflex artery is highly variable and practically unpredictable in 30% of cases. This report describes a rare case of GCV injury during circumflex artery intervention.

Case summary: An 80-year-old man with known ischaemic heart disease was admitted with unstable anginal pain for urgent coronary angiography. Circumflex (Cx) percutaneous coronary intervention (PCI) of proximal-to-medial high-grade calcified stenosis was performed. Two hours later, the patient developed pericardial tamponade. Pericardiocentesis revealed a venous bloody effusion. Due to continuous bleeding, an urgent exploratory thoracotomy was performed. Intraoperatively, a large pericardial haematoma in the Cx region was evacuated. The perforation site was sought and identified as a tear at the GCV. Further hospitalization was uneventful, and the patient was discharged after one week. Clinical and echocardiographic outcomes were favourable at the 3-month follow-up.

Discussion: A GCV injury during PCI is a diagnosis of exclusion if there is a venous pericardial effusion directly after PCI and no injury of the right ventricle or surrounding structures, and thoracic computed tomography demonstrates a pericardial haematoma in the PCI region, especially the Cx region. A haematoma can deteriorate the haemodynamic status without effusion 'dry tamponade'. Treatment should be addressed according to haemodynamics. A conservative therapy, pericardiocentesis, catheter-based bailout intervention or even an explorative pericardiotomy could be imperative to evacuate the haematoma and seal the injured vein.

Keywords: Calcific lesion; Case report; Circumflex artery; Great cardiac vein; Pericardial effusion.

Figure 1

(A and B) Imaging of the cardiac venous system (CVS) by computed tomographic (CT) mapping of the coronary veins and its relations to coronary artery. Great cardiac vein crossing the left anterior descending (LAD) and left circumflex (LCx) arteries, forming a triangle. The relations of the vein and these arteries are highly variable. The anterior interventricular vein (arrows) courses superficial to the arteries in 60–70% of the population (A) and passes under both arteries in 20% of the population (B).

Figure 2

(A and B) Thoracic computed tomography revealed haemorrhagic pericardial effusion with delineation of a contrast medium in the area of the left circumflex (LCx) that exceeds the myocardial contour (haematoma).

Figure 3

Mechanism of great cardiac vein injury after circumflex artery intervention. (A) Severely calcific Circumflex (Cx) lesion. (B) Cx percutaneous coronary intervention lead to protrusion of calcific plaque outside the Cx artery and injured the great cardiac vein. (C) Possible Cx stenting and prolonged balloon inflation as bailout interventional technique.

Figure 4

(A) Course and (B) mechanism of great cardiac vein injury after circumflex artery intervention.

Figure 5

(A) Illustration of great cardiac vein drainage into coronary sinus and (B) possible bailout intervention technique of great cardiac vein injury through coronary sinus with prolonged balloon inflation.