Guidewire Perforation during PTCA with Subsequent Off-Pump Bypass Surgery

A 58-year-old man presented with a 6-month history of symptomatic ischemic heart disease. Cardiac catheterization showed single-vessel disease with a long chronic total occlusion in the mid-segment of the left anterior descending (LAD) artery and grade III collateral vessels supplied by the nondominant right coronary artery (Fig. 1). The left ventricular ejection fraction was normal.

Fig. 1 Simultaneous left and right coronary angiography in the right anterior oblique projection shows the excellent reconstitution of the left anterior descending artery, beyond the long occlusion; the collateral vessels are provided by the right coronary artery. The guidewire has partly crossed the lesion: its tip (arrow) is situated just proximal to the junction of the main left anterior descending coronary artery and the diagonal branch (arrowhead).

During percutaneous transluminal coronary balloon angioplasty (PTCA), the occlusion was crossed, after much difficulty, with a 0.014-inch floppy-tip guidewire, which was then anchored in what was thought to be the diagonal branch (Fig. 2). Subsequent contrast injection, however, showed extravasation of contrast medium into the pericardial space (Fig. 3). Multiple attempts at sealing off the guidewire perforation point with sustained proximal balloon inflations were unsuccessful; nor could the bleeding be stopped by reversal of heparin with intravenous protamine sulfate. The patient remained free of ischemia and was stable hemodynamically throughout the procedure. Subsequently, he was taken to surgery with the guidewire left in place and with the PTCA balloon inflated in the proximal segment of the LAD. Intraoperatively, about 30 mL of blood was found in the pericardial sac, and the guidewire was observed to have entered the pericardial space at the junction of the LAD and the diagonal branch (Fig. 4). During off-pump bypass surgery, the target cardiac area was immobilized with a Medtronic Octopus® 2 stabilization system (Medtronic, Inc.; Minneapolis, Minn), the perforation was sutured, the LAD was revascularized with a left internal mammary artery graft, and the pericardium was closed with interrupted sutures. The postoperative course was uncomplicated, and the patient was discharged 4 days later. He remained well when seen in the outpatient suite 6 days after discharge and again 6 months later.

Fig. 2 Right coronary angiogram in the right anterior oblique view shows the collateral vessels that supply the left anterior descending coronary artery and the guidewire (arrowhead) across the occlusion, anchored in what was thought to be the diagonal branch.

Fig. 3 Contrast staining in the pericardial sac (arrow), after contrast medium has been injected into the left anterior descending coronary artery, with the guidewire left in place across the occluded lesion.

Fig. 4 Intraoperative view of the beating heart shows the left anterior descending coronary artery (LAD) (open arrow) and the guidewire (small arrow) as it emerges from the junction of the LAD and the diagonal branch (hidden from view), into the exposed pericardial sac. Note the attachment of the Octopus® 2 across the LAD to immobilize it in preparation for graft anastomosis.