A 52 y.o. male sp esophagectomy and gastric pull up for esophageal ca 10 years pta presents with chest pain.

A cath showed the circumflex was occluded and the RCA had a tight lesion. A stent was placed. A week later he returned with an occluded stent and a trop of 25. Laser atherectomy and thrombectomy was done with placement of new stents . The pt became febrile. His xrays are shown below.

What do you notice on the images?

Our patient had a gastro pericardial fistula as a complication of the cardiac cath. It had been very difficult to place a stent in the circumflex and the wire went through the vessel and through the pericardium causing a pneumopericardium. It went even further into the gastric pull-up which had been done for cancer. There was an immediate pneumopericardium after the cath but the fever began two days later when the CT was done showing an air fluid level in the pericardium.

air fluid level in the pericardium

While this is an unusual complication of cardiac catheterization; there are many complications which are more common.  There are 1,000,000 cardiac caths in the US in one year.  The most common complications are:

Local hematoma or retroperitoneal bleed .2%

Pseudoaneursym

AV fistula

Dissection of the femoral artery or aorta; femoral nerve compression

Emboli from plaques going distally to the retina or extremities or air emboli

Death  .05% which increases to 1% in those with critical Aortic stenosis

MI in .1% pulmonary edema ( those with class IV heart failure have a 20 times higher risk)

Stroke in .05%

Renal compromise About 7% of people have a bump in creatinine from the dye load.

A more common complication of cath is AV fistula

Eisen A, Kornowski R, Vaduganathan M, et al. Retroperitoneal bleeding after cardiac cath: a 7 year descriptive single center experience. 2013 Cardiology:125(4):217-22.

Werner N, Zahn R, Zeymer U 2012 Stroke in patients undergoing coronary angiography. Expert Rev Cardiovasc Ther Oct 10(10):1297-305.

Writing Group Members Mozaytarian D, et al.  AHA Statistics Committee, 2016 updte.  Circulation 2016 Jan 26 133(4) e38-360.

Noto TJ, Johnson LW, Drone R, et al. Cardiac catheterization 1990: A report of the Registry of the Society for Cardiac Angiography and Interventions. Cathet Cardiovasc diagn 1991;24:75

The fistula was repaired with a two layer closure of a 1 cm defect, it was covered with a muscle flap and a J tube was inserted. the pt was discharged