経網膜経皮的冠動脈インターベンションにおける致命的な血管合併症。症例報告

Fatal vascular complications during transradial percutaneous coronary intervention: A case report.

• SeongIl Choi
• Joon Hee Joh
• Ju Won Choe

抄録

ラショナル:

経皮経皮的冠動脈インターベンション（PCI）の血管合併症はまれであり、通常は肘下のアクセス部位で起こる。しかし、ワイヤーやカテーテルの管路に沿った血管はどの部位でも損傷を受け、様々なタイプの出血性合併症を引き起こす可能性がある。

RATIONALE: Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. However, vessels along the tract of the wire or catheter can be injured at any point, causing various types of bleeding complications.

患者の悩み:

57歳の男性が胸部不快感のため受診した。冠動脈造影では右冠動脈遠位部に有意な狭窄が認められた。冠動脈ガイドワイヤーをRCA遠位部に通した直後に激しい咳嗽を開始した。声の変化、数分以内に呼吸困難が生じ、口唇チアノーゼ、喘鳴が認められた。気管挿管後、RCA遠位部のステント留置に成功した。冠動脈ステント留置後30"Zs_200A"分で抜管したが、抜管1時間後に血圧が70/50mmHgまで急低下した。

PATIENT CONCERNS: A 57-year-old man visited due to chest discomfort. Coronary angiography showed significant stenosis at the distal right coronary artery (RCA). Immediately after the coronary guidewire was passed through the distal RCA, he started a vigorous cough. The voice changed, dyspnea occurred within minutes, and lip cyanosis and stridor were observed. After endotracheal intubation, successful stenting of the distal RCA was achieved. He was extubated at 30 minutes after coronary stenting, but 1-hour post-extubation, his blood pressure suddenly decreased to 70/50 mmHg.

診断:

胸部X線検査で縦隔拡大が新たに認められ，血中ヘモグロビンは低下していた．胸部造影CTでは縦隔血腫，気管圧迫，血胸を認めた．上腕骨血管造影では甲状腺下動脈末梢に造影剤の滲出が認められた。

DIAGNOSIS: Mediastinal widening was newly noted on chest X-ray, and blood hemoglobin was decreased. Contrast-enhanced chest computed tomography showed mediastinal hematoma, tracheal compression, and hemothorax. Contrast extravasation was noted in the terminal branches of the inferior thyroid artery on brachiocephalic angiography.

介入:

Tornado塞栓マイクロコイル、Gelfoamゼラチンスポンジ、Histoacryl接着剤を用いた血管内塞栓療法で止血に成功した。翌日、縦隔内視鏡検査で縦隔内出血をドレナージした。気管内挿管と人工呼吸器ケアを2日間維持し、パック赤血球6単位を輸血した。ステント血栓予防のために抗血栓薬を、感染症のコントロールのために抗生物質をそれぞれ使用した。

INTERVENTIONS: Successful hemostasis was achieved with endovascular embolization therapy using a Tornado embolization microcoil, Gelfoam gelatin sponge, and Histoacryl glue. The next day, the mediastinal hemorrhage was drained by mediastinoscopy. The endotracheal intubation and ventilator care were maintained for 2 days, and 6 units of packed red blood cells were transfused. Antithrombotics were used to prevent stent thrombosis, and antibiotics to control infection, respectively.

OUTCOMES:

止血成功後、退院後2週間で消失した血小板症と治療中の高い血小板反応性が認められた。フォローアップの胸部画像検査で縦隔拡大は正常化していた。退院後14ヵ月目には患者は健康であった。

OUTCOMES: After successful hemostasis, thrombocytosis and high on-treatment platelet reactivity that disappeared at 2 weeks post-discharge were noted. Follow-up chest imaging showed the normalized mediastinal widening. At 14 months post-discharge, the patient remains healthy.

レッスン:

上腕骨動脈、鎖骨下血管解離、乳腺内動脈、肋骨頸部動脈、胸部頸部動脈の血管穿孔など、生命を脅かす血管合併症は経網膜的PCI中にいつでも起こりうるため、インターベンション循環器専門医はそのことを十分に認識し、ルーチンの手技で適切な対策を講じておくべきである。

LESSONS: As life-threating vascular complications, such as brachiocephalic, subclavian vessel dissection, and vessel perforation in the internal mammary, costocervical, and thyrocervical arteries, can occur anytime during transradial PCI, the intervention cardiologist should be well aware of it and have the appropriate countermeasures implemented in the routine procedure.