Interact CardioVasc Thorac Surg 2009;9:543-544. doi:10.1510/icvts.2008.199471
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
Imaging modalities for retrieval of a migrated coil from the left ventricle, after pulmonary arterio-venous malformation embolisation
Amit Pawalea,*,
Gopal Chealikania,
Leslie Mitchellb and
Stephen Clarka
a Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK
b Department of Radiology, Freeman Hospital, Newcastle upon Tyne, UK
Received 16 January 2009;
received in revised form 15 April 2009;
accepted 16 April 2009
*Corresponding author. Tel.: +441912448443; fax: +441912231417.
E-mail address: amitpawale{at}doctors.org.uk (A. Pawale).
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Abstract
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We present a case of a 62-year-old lady who was a known case of hereditary haemorrhagic telangectasia (Rendu-Osler-Weber syndrome) and had pulmonary arteriovenous malformations (AVMs). She had multiple embolisations of pulmonary AVMs. During the last embolisation therapy, one of the coils migrated into the heart. This could not be located by transoesophageal echocardiography, however, was identified in the left ventricle by computerised tomogram scan. It was removed successfully using cardiopulmonary bypass.
Key Words: Arteriovenous malformation; Embolisation; Hereditary haemorrhagic telangectasia
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1. Case report
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A 62-year-old lady had a long-standing history of anaemia and required regular iron transfusions.
She had multiple pulmonary arteriovenous malformations (AVMs) which had been embolised on three separate occasions in the past.
She had multiple episodes of transient ischaemic attacks and left hemiparesis with residual weakness on the left side. Computed tomography (CT) of brain and magnetic resonance imaging of the head detected no abnormality of intracranial vasculature.
She had experienced increasing shortness of breath recently and on this admission underwent embolisation of two left lower lobar AVMs and one lingular AVMs. The AVMs being embolised shunted blood directly from pulmonary artery to pulmonary vein. However, during the embolisation of lingular AVM, one of the platinum embolisation coils measuring 3 mm in diameter and 6 mm in length migrated through the AVM and resided in cardiac area on X-ray (Fig. 1).
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Fig. 1. Single coil migrated in the cardiac area at the centre with previous successfully embolised coils in pulmonary AVMs in surrounding.
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The patient was anaesthetised for the transesophageal echocardiography (TOE) and retrieval of the coil. However, the coil could not be seen on the TOE with very good views of all the chambers and in spite of a good search. We performed a CT-scan of the chest with intravenous contrast and the coil was found residing in the left ventricle behind the posterior mitral leaflet (Fig. 2). She underwent median sternotomy, bicaval cannulation and cardiopulmonary bypass. The heart was cardiopleged after aortic cross-clamping of the aorta. The coil was then removed through the left atrium which was caught in the chordae of posterior mitral leaflet. A patent foramen ovale was closed. The patient was extubated after 12 h, stayed in the intensive care unit for 4 days for continuous positive airway pressure and went home after 2 weeks.
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Fig. 2. The coil located behind the posterior mitral leaflet in the left ventricle with the IV contrast CT-scan.
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2. Discussion
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Hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber disease) is a genetic disorder with autosomal dominance and variable penetrance. Diagnosis is based on clinical criteria including epistaxis, telangiectasia, visceral manifestations, and familial occurrence. Pulmonary AVMs, present in 15–33% of patients, are its primary visceral complication. The disease may be revealed by infections and ischaemic neurological manifestations due to paradoxical embolism [1]. Pulmonary AVMs are effectively and safely treated by transcatheter embolotherapy. Coil embolisation is an effective and well-tolerated method for treatment of pulmonary AVMs. Improvements in pulmonary gas exchange and lung function and decrease in right to left shunting is proven after the treatment. The procedure has a low complication rate [2, 3]. There are a very few reported cases of inadverant coil migration in the literature [4, 5]. In those in whom coil migration into the heart occurs, surgery is required to remove the foreign body to avoid serious embolic sequelae. While X-ray successfully demonstrates the general location of the coil, further imaging before surgery may be required to accurately locate it. The important lesson from this case is the inadequacy of TOE (despite excellent image quality and thorough examination) to locate the coil. CT-scan, however, accurately located the coil and allowed easy surgical extraction. In future, we would advocate CT with intravenous contrast as the imaging modality of the choice in such cases. It is more reliable, accurate and time-saving as delay in retrieval can lead to further embolisation into the systemic circulation.
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References
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- Blanchet AS, Cottin V, Cordier JF. Pulmonary vascular manifestations in hereditary hemorrhagic telangiectasia. Presse Med 2005;34:1487–1495.[CrossRef][Medline]
- Dutton JAE, Jackson JE, Hughes JMB, Whyte MKB, Peters AM, Ussov W, Allison DJ. Pulmonary arteriovenous malformations: results of treatment with coil embolisation in 53 patients. Am J Roentgenol 1995;165:1119–1125.[Abstract/Free Full Text]
- Pugash RA. Pulmonary arteriovenous malformations: overview and trans-catheter embolotherapy. Can Assoc Radiol J 2001;52:92–102.[Medline]
- Haitjema T, ten Berg JM, Overtoom TT, Ernst JM, Westermann CJ. Unusual complication after embolisation of pulmonary arteriovenous malformation. Chest 1996;109:1401–1404.[CrossRef][Medline]
- Adachi T, Osama K, Kuwata H, Isaka T, Kikkawa T, Murasugai M, Onuki T. Inadvertent coil migration that required urgent thoracotomy during embolization for the treatment of pulmonary arteriovenous fistula. Kyobu Geka 2004;57:867–870.[Medline]
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Abstract
1. Case report