An Urgent CABG Complicated by Coronary Artery Intramural Hematoma from Percutaneous Intervention
with Corresponding Electrocardiogram and Echocardiogram Changes in the Setting of Renal Transplantation
Yusef Shibly, BS1; Vincent Bargnes, MD2; Henry Tannous, MD3; Igor Izrailtyan, MD, FACC2

Renaissance School of Medicine, Stony Brook University 1 Department of Anesthesiology, Stony Brook Medicine 2 Department of Surgery, Stony Brook Medicine 3

Introduction

• Coronary artery bypass grafting is the most commonly performed cardiac
surgery in adults
• The complexity of these procedures can vary by vessel involvement,
preexisting valvular disease, and other cardiac considerations
• A coronary artery intramural hematoma is a rare complication of percutaneous
coronary intervention which involves rupturing the coronary vasorum or
tearing the tunica intima layer of the coronary artery potentially as a result of
plaque compression

Case Description

78-year-old male with a history of hypertension, hyperlipidemia, and end-stage
renal disease status-post renal transplant presented to the emergency room with
diaphoresis and abdominal pain with electrocardiogram and biomarker
evidence of acute coronary syndrome

• Cardiac catheterization revealed significant left main and right posterior
descending (PDA) coronary artery stenosis
• Angioplasty was performed on the PDA with subsequent concern for PDA
intramural hematoma with inferior ST-segment changes and anticoagulation
with heparin and cangrelor was initaited
• Cardiothoracic surgery was consulted and proceeded with coronary artery
bypass grafting (CABG)
• ASA Classification: 4 with increased risk of major hemodynamic shifts
intraoperatively
• Intraoperative transesophageal echocardiogram demonstrated hypokinetic
inferior and inferoseptal segments at the basal level with dilated atria and right
ventricle
• Following sternotomy, a small serosanguinous pericardial effusion and a distal
PDA hematoma were noted
• Vigilant hemodynamic monitoring and intervention with thoughtful vasopressor
use due to renal history
• Patient had a successful operation - extubated POD1 and discharged POD5

Discussion

• There are currently no published treatment guidelines
for coronary artery intramural hematomas
• Management options include medical therapy and
further coronary intervention to avoid sequelae
including hematoma progression, dissection
development, and vasospasm
• Potential sequelae require special anesthetic
consideration, including worsening of ischemia,
cardiopulmonary bypass separation difficulties, and
changes to the surgical approach
• Cardiac surgery is associated with AKI in a reported
20% to 30% of cases. Various approaches to
minimizing the risk of AKI and protecting renal
function in patients undergoing cardiac surgery have
been suggested, including functional hemodynamic
monitoring and goal-directed perfusion