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Left internal mammary artery puncture as a complication of subxyphoid pericardiocentesis
1University Hospital Sestre Milosrdnice, Cardiac intensive care unit - Zagreb - Croatia
2University Hospital Sestre Milosrdnice, Radiology department - Zagreb - Croatia
3University Hospital Sestre Milosrdnice, Cardiology department - Zagreb - Croatia
Topic(s): Myocardial and pericardial diseases
European Heart Journal: Acute Cardiovascular Care
Pericardiocentesis is considered aggressive but relatively safe procedure, especially when performed under echocardiographic guidance. Unintentional left internal mammary artery (LIMA) puncture is known complication of anterior parasternal pericardiocentesis, while it is extremely rare in subxyphoid approach. The authors experienced the later and present such case. 59-years old female was presented to tertiary Clinic due to large pericardial effusion unresponsive to medical therapy. She complained of fatigue, exertional dyspnea, and pitting edema on extremities. Physical examination revealed alert, moderately obese female with picnic constitution. She was normotensive, but tachycardic, tachypnoic, with distended jugular veins, diminished lung sounds and pleural effusion bilaterally, moderate hepatomegaly, ascites and crural pitting edema. Echocardiography showed circumferential pericardial effusion with largest amount of effusion located inferoposteriorly (45 mm), while apically and parasternally effusion measured 10 mm, with signs of threatening tamponade. Due to poor cooperability, small amount of effusion anteriorly, and operator experience, a subxyphoid approach was chosen, however without success in obtaining effusion. One hour after procedure, arterial hypotension and swelling of left m. rectus abdominis (mRA) was observed. Hemoglobin level decreased from 136 to 84 g/L. Computed tomography revealed active blood extravasation from distal LIMA to mRA hematoma spreading through whole of the muscle. Endovascular treatment was chosen over surgery due to coagulopathy and hemodynamic instability. Through left radial approach LIMA was accessed, over the microcatheter ethylene vinyl alcohol copolymer Onyx (Covidien) was administered with successful embolization of LIMA proximal to the lesion. Postprocedural period was complicated with hemodynamic instability, paralytic ileus and acute renal failure. With cardiac surgeon in back-up, an echo-guided apical pericardiocentesis was performed with immediate evacuation of 500 ml of effusion. With corticosteroid and other supportive therapy patient recovered well, mRA hematoma regressed completely, Meigs-like syndrome seems to be the most probable etiology of effusions. Although rare in subxyphoid approach, LIMA puncture during pericardiocentesis is a possible complication, especially in picnic patients with ascites and hepatomegaly. Apical approach with echocardiographic guidance is recommended for avoiding it. Urgent diagnosis and treatment of such patients is needed.