Right Ventricular Wall Hematoma Following Angioplasty to RCA Occlusion

J INVASIVE CARDIOL 2019;31(4):E66.

Key words: angiography, cardiac imaging, chronic total occlusion, complications

A 65-year-old male was undergoing right coronary artery (RCA) chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with dual-arterial access of the right radial and right femoral arteries. An initial antegrade approach using wire escalation was unsuccessful, with wire exit distally. A retrograde approach through a septal collateral with a microcatheter was undertaken with difficulty advancing the microcatheter and evidence of perforation of the septal collateral (Figure 1A), with the patient complaining of chest pain and ST-segment elevation on electrocardiogram. The septal branch had to be coiled to achieve hemostasis.

Echocardiogram showed a 3 x 7 cm mass in the right ventricle (RV) wall (Figures 1C and 1D). There was a trivial rim of pericardial fluid. Subsequent computed tomography (CT) scan demonstrated a 4 x 7 cm hematoma within the anteroinferior portion of the RV (Figure 1B). Pericardial fluid tracked up into the mediastinum to the level of the aortopulmonary window and the pretracheal region. The patient remained stable and was managed conservatively and was discharged home 3 days later. Repeat echocardiogram 4 weeks later showed the hematoma remained at the same size; echocardiogram and cardiac CT are planned in 6 months to assess the resolution of the hematoma.

RV intramural hematoma is a rare complication of RCA-PCI. It may be self-limiting with minimal clinical consequences, or may result in rapid hemodynamic compromise through pseudo or dry tamponade physiology, necessitating emergency surgical hematoma evacuation. With the increased uptake and prevalence of complex CTO-PCIs, unusual complications will continue. Sharing these complications raises awareness and is, therefore, of paramount importance.

From ¹the Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom; and the ²Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Egred reports CTO proctorship honoraria/speakers’ fees from Boston Scientific, Abbott Vascular, and Vascular Perspectives. Dr Ghobrial reports no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 31, 2018.

Address for correspondence: Mohaned Egred, BSc (Hons), MB ChB, MD, FRCP, FESC, Cardiac Department, Freeman Hospital, Newcastle-upon-Tyne, NE7 7DN, United Kingdom. Email: m.egred@nuth.nhs.uk