Commentary

I would like to compliment Dr. Wava Truscott for an excellent article on a very important topic. This outstanding article should cause medical staff and support staff members to reconsider certain practices in the cath lab. One example is the washing of sterile surgical gloves in the basins containing sterile aqueous solutions that are used to flush catheters, guide wires, and specialized percutaneous coronary intervention equipment. Lint may be floating on the surfaces of the sterile water in the open containers on cath trays, along with other forms of debris originating from catheters, guidewires, angioplasty balloons and stents, including contamination from the powder used in surgical gloves. I first became aware of this as a potential source of contamination in the late 1970’s, working at a large academic center in south Florida. Two interventional radiologists on staff at the time noticed how much lint and dust appeared in the sterile water solutions on the trays. They discussed concerns about what would happen if these particles were injected into the vascular system along with the water or contrast media, and as a result, began to use a closed flushing system on the sterile trays. I can also recall one particular case from the early 1980’s, involving a 43-year-old white female. She had a routine cardiac cath. Findings were normal coronaries with normal left ventricular function. About four hours post-procedure, she developed excruciating chest pain with ST changes in leads II, III, and aVF. We rushed her into the cath lab. During the emergent procedure, the proximal right coronary artery was occluded. A thrombolytic agent was used invasively, but flow was not established. The patient experienced a fatal event and resuscitative maneuvers were not successful. A post-mortem study was performed. A few days later, the pathologist came and asked both the cardiologist and I to come to pathology. He showed us the histopathological slides. What he described was very similar to the reports mentioned by Dr. Truscott. The cause of the patient’s thromboembolic event was a long strand of cotton thread from a sterile gauze. In her conclusion, Dr. Truscott mentions three important recommendations: 1) Understand the complications that can occur if any from of particulate matter is injected into the circulatory system; 2) try to reduce the risks of such contamination along with morbidity and mortality; and 3) select sterile surgical products that do not generate lint and other foreign body materials. I strongly advocate trying to keep all flushing solutions in a closed system, not washing hands in solutions in basins on sterile tray setups, and being careful what type of material is used for the sterile fields. I have always been a believer in pressurizing invasive medical suites, similar to the design and setup of OR suites. Filters in the air handling systems should be replaced every 30 days. Concerns remain about unintentional foreign body emboli in invasive cardiology procedures and should be considered in the diagnosis of myocardial ischemia or infarction following an invasive or interventional cardiac procedure. Histopathologic studies should be performed on thrombo-embolic material removed from occluded arteries which have been studied angiographically and/or where an interventional procedure has been performed.

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