Coronary angioplasty can be associated with serious complications that may be life-threatening for patients, such as tamponade from coronary perforation. Coronary perforations have an incidence ranging from 0.19 to 0.59%. They are classified into 5 types and are most often caused by the use of hydrophilic guidewires, with several risk factors, including complex lesions or advanced age. We report a case of tamponade complicating angioplasty of the distal Left Main Coronary Artery in the cardiology department of Mother-Child Luxembourg University Hospital in Bamako. Urgent management combining cardiopulmonary resuscitation, pericardiocentesis, and surgical drainage resulted in a favorable outcome.

Percutaneous coronary angioplasty is a procedure that is increasingly performed nowadays. Despite good mastery of the techniques, it can be associated with serious complications that may threaten the patient's life, such as tamponade. The occurrence of a pericardial effusion following a percutaneous coronary intervention has already been reported in the literature and is a rare complication [1–5]. We report a case of tamponade complicating a coronary angioplasty. The aim of our clinical case is to highlight certain rare but serious complications of coronary angioplasty.

Mr. MMS, 54 years old, hypertensive, active smoker with 45 pack-years, was admitted to the cardiology department of CHU Mother-Child Luxembourg in Bamako for NYHA class II-III dyspnea, with a history of constrictive retrosternal chest pain at rest four months earlier, treated for a peptic ulcer disease (PUD). Clinically, hemodynamics was stable with blood pressure at 125/70 mm Hg, heart rate at 67 bpm, regular heart sounds without murmurs, no signs of heart failure, peripheral pulses were palpable and symmetrical. The admission ECG (Figure.1) showed a regular sinus rhythm at 75 beats per minute and an antero-septal necrosis. On echocardiography, LVEF was 40-45% with hypokinesis of the anterior, lateral, and apical walls. Diagnostic coronary angiography (Figure.2-3) revealed a proximal LAD occlusion, a severe stenosis of the diagonal branch, and a chronic occlusion of the circumflex artery. A coronary angioplasty (Figure.4-5) of the distal left main, LAD, and diagonal branch was indicated and successfully performed using the T and small Protrusion strategy (TAP).

One hour after angioplasty, the patient exhibited agitation, profuse sweating, and then cardiopulmonary arrest (CPA). Cardiopulmonary resuscitation was immediately initiated, resulting in the recovery of a sinus rhythm on the monitor, but without peripheral pulses and without blood pressure. His post-CPA ECG (Figure.6) was identical to that before the angioplasty. Post-CPA transthoracic echocardiography (TTE) (Figure.7) revealed a circumferential pericardial effusion of 26 mm adjacent to the right cavities, compressing them. An emergency pericardiocentesis of 40 cc of hemorrhagic fluid was performed, and the patient was taken to the operating room for drainage, which yielded 300 cc of hemorrhagic fluid (Figure.8), and was subsequently transferred to the intensive care unit where he received 4 units of blood.

The progress was favorable, with the drain removed on the 6th day and discharge home on the 8th day under BASIC, with only a small pericardial detachment on the discharge echocardiogram  (figure 9)

                                                                                                                                   Figure 1: ECG d’admission

                                                                                                                                  Figure 2: Coronarography                                                                   

                                                                                                                                              Figure 3: Coronarography

                                                                                                                                       Figure 4: Result of angioplasty   

                                                                                                                     Figure 5: Result of angioplasty

                                                                                                                          Figure 6: ECG post CPA

                                                                                                                              Figure 7: TTE post CPA

                                                                                                            Figure 8: Pericardial drainage liquid

According to the literature, tamponade following angioplasty is due to coronary perforations, with an incidence ranging from 0.19 to 0.59% [4–11]. These perforations are most often caused by complete penetration of the arterial wall by a guidewire, balloon, or stent, and can expose the patient to a risk of tamponade [12]. Among the risk factors for coronary perforation are advanced age, female sex, renal insufficiency, NSTEMI, complex or calcified lesions, chronic occlusions, and the use of hydrophilic guides or atherectomy devices, which are considered aggressive materials [6–14]. Ellis et al. classified coronary perforations according to their anatomical severity: type I corresponds to an extraluminal crater without contrast leakage, type II to a pericardial or myocardial stain without frank extravasation, type III to a complete perforation with contrast medium diffusion through a breach ≥ 1 mm, and type IV or type III-CS corresponds to a communication between the coronary artery and an anatomical cavity such as the coronary sinus.[13]. In addition to these four types, Muller et al. described a type V, which refers to distal perforations caused by guides, often hydrophilic or rigid, and which account for more than half of the cases. [9,11,15,16]. The treatment depends on the type and is detailed in the management algorithm (Figure. 10). [16].

                                                                                                                    Figure 9: Output TTE 

                                                                                                   Figure 10: Management algorithm for coronary

 In our case, the tamponade is due to a coronary perforation, the mechanism of which is likely related to the guidewire in a patient with risk factors such as complex lesions and the use of a stiff guidewire. The absence of signs of acute rupture during the initial procedure and the occurrence of tamponade one hour later support this hypothesis. This allows us to classify our case as a type V coronary perforation according to Muller [16]. Urgent management, combining CPR, a pericardiocentesis of 40cc, and surgical drainage, led to a favorable outcome.

The occurrence of cardiac tamponade following angioplasty, even when technically successful, is rare but possible. It results from the perforation of a coronary artery by the guidewire. Rapid management and good multidisciplinary collaboration are key to a favorable prognosis.

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