Great Cardiac Vein Injury after Circumflex Artery Intervention: a case report

Case Presentation

• Present history: male patient, 80 years old, presented with unstable anginal pain
• Past history: known coronary artery disease with RIM-DES and atrial fibrillation 
• CVRF: Hyperlipoproteinemia and arterial hypertension
• ECG: SR, HF 50 BPM, incomplete right bundle branch block Echocardiography: low normal LV-EF, ca. 50%

Coronary angiography

• LCX:  proximal to medial 85% stenosis  
• RIM: good result after RIM-DES
• RCA: distal 80% stenosis 

• LCX-PCI: DES (3,0 x 20 and 2,75 x 24 mm)

One hour post PCI dyspnoea NYHA IV and cardiogenic shock Echocardiography showed 15 mm pericardial effusion

• Angiography: no coronary artery, right and left ventricle or aortic perforation. 
• Three times pericardial drainage of 600 ml of venous haemorrhagic punctate (ABG: Hb 11g/dl, So2 45%)
• Three-U PRBCs were given 

Differential diagnosis of venous pericardial effusion directly after PCI

• Spontaneous pericardial effusion under Dabigatran, Aspirin and Clopidogrel therapy 
• Post LCX-PCI great cardiac vein injury with a large myocardial hematoma
• RV injury during pericardiocentesis 
• Hepatic or intraabdominal vessel injury during pericardiocentesis 
• Intramyocardial or arterial injury and perforation with hematoma during intervention (but in this case, it was a venous blood and not an arterial one!).

Pericardial hematome causing „dry tamponade

CT-Thorax (A 1 and 2): haemorrhagic pericardial effusion and delineation of a contrast in the area of the Cx that exceeds the myocardial contour

• Explorative surgical pericardiotomy a large myocardial hematoma And GCV injury
• Hematoma evacuation and vein repair

Explanation

Great cardiac vein crossing LAD and Cx arteries, forming a triangle. 

• The relations of the vein and these arteries are highly variable. 
• The anterior interventricular vein (arrows) courses superficial to the arteries in 60%– 70% of the population (A) and passes underboth arteries in 20% of the population (B) (1).

 

(1) Saremi F et al., Radiographics 2012.
Mechanism of great cardiac vein injury after circumflex PCI and possible bailout intervention 



(a)    Course and 

(b)   Mechanism of great cardiac vein injury after Cx-PCI

(a)    Severely calcific Cx lesion 

(b)   Cx PCI lead to protrusion of calcific plaque outside the Cx and injured the great cardiac vein. 

(c)    Possible Cx Stenting and prolonged balloon inflation as bailout interventional technique. 

(a)    Great cardiac vein drainage into coronary sinus

(b)   Possible bailout intervention technique of GCV through coronary sinus with prolonged balloon inflation



Summary and key points
Patient with ACS Post Cx- PCI cardiac shock, pericardial hematoma and effusion due to GCV injury A great cardiac vein injury during PCI is a very rare complication and It is not enough discussed in the literature. It is a diagnosis of exclusion if you have:  - a venous pericardial effusion (ABG), directly after PCI, no injury of the RV and a hematoma in PCI region, especially LCX then suspect great coronary vein injury  Consider CT-Thorax as hematoma can deteriorate the haemodynamic without pericardial effusion ”dry tamponade”. Therapy according to symptoms and hemodynamic could be conservative, pericardiocentesis, bailout intervention or even explorative pericardiotomy.