Left atrial inflow and outflow obstruction as a complication of retrograde approach for chronic total occlusion

Abstract

Retrograde recanalization of a chronic coronary total occlusion has become an increasingly utilized method to increase success from percutaneous coronary intervention (PCI). Retrograde wire passage using a septal collateral is the preferred route as the consequences of vessel perforation are more benign than epicardial collateral perforation which may produce cardiac tamponade. Tamponade risk is thought to be lessened by previous coronary bypass surgery due to adhesions preventing free flow of blood throughout the pericardial space. We report the first case of the retrograde approach producing epicardial collateral perforation resulting in a localized epicardial hematoma, which in turn, produced left atrial (LA) inflow and outflow obstruction, with the former producing localized pulmonary edema and pleural effusion. We review reported cases of LA hematoma as a consequence of the antegrade PCI approach and describe a unified explanation for the development of this phenomenon.

Pseudo‐Pericardial Tamponade From Right Ventricular Hematoma After Chronic Total Occlusion Percutaneous Coronary Intervention of the Right Coronary Artery

“…Tamponade in the post bypass patient is a particularly vexing problem because the ensuing shock occurs indolently and via different mechanisms. The mechanisms of shock in this setting are from hypovolemia due to the perforation producing bleeding into [1] the cardiac muscle itself with expansion into the cavity or outwardly into the subepicardial space and [2] bleeding within the adhered intrapericardial space and subsequent compression of the cardiac chambers [5].…”

The inherent catastrophic traps in retrograde CTO PCI

“…Epicardial channel perforation may look very minor but should always be dealt with (Fig. a), even if there is no pericardial effusion as atrial hematoma can occur . If there is any contrast extravasations suction or balloon tamponade should be used.…”