Internal mammary artery injury during percutaneous coronary intervention: a case report
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Percutaneous coronary intervention (PCI) is widely used to treat coronary artery disease (CAD). However, complications of PCI are inevitable. Internal mammary artery (IMA) injury is an infrequent but potentially lethal complication of PCI.
A 78-year-old man was diagnosed with multivessel lesions by coronary angiography. The IMA was injured during PCI, then cured by early identification and active rescue.
This is the first reported case, to our knowledge, of injury to the IMA during PCI. We we report this case to discuss how to treat this injury effectively and avoid this complication during clinical therapy.
KeywordsComplications, diagnostic catheterization Percutaneous coronary intervention (PCI) Vascular, closure Bleeding
Coronary artery disease
Internal mammary artery
Left anterior descending coronary artery
Left main anterior coronary artery
Percutaneous coronary intervention
Percutaneous coronary intervention (PCI) can improve coronary flow and relieve the symptoms of myocardial ischemia, and is therefore widely used to treat coronary artery disease (CAD) . However, it is an invasive treatment, and complications are inevitable. Common complications include coronary dissection, ano-reflow of coronary artery, stent thrombosis, perforation and cardiac tamponade, thrombus, puncture site hematoma, pseudoaneurysm, arteriovenous fistula, ventricular fibrillation, and contrast-induced nephropathy . Immediate recognition of complications and prompt treatment is vital. Here, we report a case of injury to the internal mammary artery (IMA)—an infrequent but potentially lethal complication during PCI—that was repaired using a general vascular closure device.
Discussion and conclusions
This case report describes a rare but potentially lethal complication of PCI.
The IMA arises from the first segment of the subclavian artery and descends upon the parietal pleura in the upper intercostal spaces . The artery is often injured in patients who suffer sternal fracture or penetrating parasternal injury. IMA injury is an uncommon complication of central venous catheter placement [4, 5]. Rarely, it can be a life-threatening complication of PCI and other endovascular procedures. The complication can be avoided by ensuring correct placement of the guidewire before delivering the guiding catheter. Furthermore, the left anterior oblique view and right anterior oblique view are not the most appropriate for judging the position of the guidewire as there is some overlap of the IMA and the aorta in these views; an anteroposterior projection displays the position more reliably and may help avoid this complication.
Flow rates in the IMA average 150 mL/min, and massive hemorrhage can result from injury to the artery . The possibility of iatrogenic injury to the IMA should be considered in any catastrophic situation during PCI. Emergency blood transfusion and fluid infusion can maintain the patient’s vital signs, and prompt chest tube drainage can help re-expand the lung. Selective arterial embolization is an option for emergency treatment of IMA injury. The choices for embolization material are microcoil , spongel  and covered stent grafts . However, IMA embolization would result in loss of the ideal bypass conduit for coronary artery bypass grafting, and the decision must therefore be made after careful consideration of the pros and cons .
IMA injury is a very rare complication of PCI, which may cause hemothorax, severe shock, or even death. Before delivering the guiding catheter, the position of the guidewire should be confirmed to avoid this complication. Prompt diagnosis, effective embolotherapy, adequate drainage, and aggressive resuscitation are recommended for patients with IMA injury during PCI.
1. National Natural Science Foundation of China (81500359): Dr. Yaqin Chen.
2. Technological Innovation Foundation of Shenzhen (JCYJ20170306152620264): Dr. Zhicong Zeng.
Availability of data and materials
All available information is contained within the present manuscript.
ZZ and FL wrote the manuscript. ZZ and YChen conducted the percutaneous coronary intervention and embolization with coils. ZS and FL conducted the clinical diagnosis and data collection. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and the accompanying images. A copy of the written consent form is available for review by the editor of this journal.
The authors declare that they have no competing interests.
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