부산대학교 도서관

Introduction:There are a few case reports of Intercostal artery injury after pleural tap and trauma but none after a PCI.Case:A 61-year-old Caucasian male with PMH of T2DM, Hypertension, Hyperlipidemia, former tobacco chewing, family history of premature CAD presented to ED with midsternal chest pressure of 2 hours and three weeks of dyspnea on exertion. He was seen earlier in the outpatient office where an ECHO showed an EF of 55%, and a Nuclear stress test showed moderate inferior ischemia. CT coronary Angiogram showed complex plaques in Mid RCA and mid LAD. Troponin and EKG were normal. A diagnosis of unstable angina was suspected, and he was loaded with clopidogrel and heparin drip. He underwent emergency cardiac catheterization via a trans-radial approach. The standard J wire was switched to an angled-tip stiff Terumo guidewire due to difficulty traversing the aortic arch. The guidewire briefly went down the descending thoracic aorta. There was complex, eccentric stenosis of 99% in mid LAD and mid-RCA, which were stented with DES. The patient developed right chest pain radiating to his back. He became hypotensive, and Hemoglobin dropped from 13 to 8g/dl. CT scan showed a large right-sided hemothorax, and a chest tube was placed. He was resuscitated, and Angiogram showed three pseudoaneurysms and rupture of the right 8thintercostal artery with active contrast extravasation. The right 9thintercostal artery had one pseudoaneurysm. Both the vessels were embolized by an interventional radiologist.Discussion:Intercostal arteries arise from descending thoracic aorta. It is likely the catheter advanced into the descending aorta and the intercostal artery resulting in injury. Proper guidewire advancement under fluoroscopy and confirming the position of guidewire before advancing the guiding catheter may prevent this complication. Prompt recognition and emergency treatment with a chest tube and IR-guided embolization should be done.