Computerized tomography angiography in diagnosing an obtuse marginal branch perforation after pericardiocentesis: a case report

Abstract

Background: Pericardiocentesis is both therapeutic and diagnostic invasive procedure, guided by echocardiography and/or angiography. It can be done using subcostal or apical approach. One of the major complications of pericardiocentesis is coronary artery laceration with an incidence of less than 1%. Diagnosis of such lacerations is often made by invasive coronary angiography or urgent thoracotomy. Computed tomography angiography is used to determine the extent of bleeding and hemopericardium, but its potential for detailed evaluation of bleeding site is somewhat underestimated.

Case presentation: We present a rare case of distal obtuse marginal (OM) artery perforation resulting from apical pericardiocentesis that was diagnosed with CT angiography (CTA) further treated with coronary guidewire particle embolization. A 49-year-old male patient who had undergone ascending aorta and aortic arch reconstruction after an aortic dissection Type A was evaluated with echocardiography before being discharged from our hospital. A loculated pericardial effusion was identified, necessitating pericardiocentesis. The clinical course was further complicated by hemopericardium due to coronary laceration. The hemorrhage was managed with coronary guidewire segment embolization which led to immediate improvement in hemodynamic status. The patient was discharged seven days after intervention.

Conclusion: Coronary artery perforation is a rare, albeit life-threatening complication of pericardiocentesis that requires urgent surgical or percutaneous intervention. CTA can provide important diagnostic information on perforation location and help in deciding whether embolization or open-heart surgery is needed to address ongoing bleeding.

Keywords: aortic dissection; computed tomography angiography; coronary laceration; obtuse marginal; pericardiocentesis.

Figure 1

Cross section cardiac CT image before pericardocentesis demonstrating circumferential low attenuating pericardial effusion, thickest behind lateral wall of the left ventricle.

Figure 2

(a) Cross sectional thickened maximal intensity projections (MIP) image of cardiac CT after pericardiocentesis, in early arterial phase. Blue arrow shows the course of OM branch. Black arrow points to the contrast extravasation, at distal part of the OM branch. Note the proximity of the pericardial catheter (marked with *) to the site of hemorrhage. (b) Axial cross section CT image showing heterogeneous pericardial effusion in portovenous phase. Black arrow points to hypodense (ischemic) anterolateral papillary muscle, irrigated by OM branch, further suggesting its lesion. (c) Volume rendering (VR) reconstruction showing—blue arrows pointing to distal OM and site of contrast extravasation.

Figure 3

(a) Contrast extravasation seen on invasive coronary angiography, left coronary artery in right anterior oblique (RAO) cranial view, blue arrow pointing to extravasation site. (b) Left coronary artery in RAO caudal projections (blue arrow pointing to extravasation site).

Figure 4

Coronary angiography—final result after placing guide wire tips in lacerated artery. No further contrast extravasation is seen. Small pool of contrast remains trapped in pericardium at the previous bleeding site.