Massive Myocardial Staining and Thebesian Venous Opacification during Complicated Coronary Angiography

Abstract

Myocardial staining is a complication of coronary angiography or intervention procedures and consists of extravasations of contrast material into the myocardium. The powerful injection of contrast (myocardial staining) is caused by the improper positioning of the angiography or guiding catheter and can lead to refractory ventricular tachyarrhythmias and occasionally cardiac death. It results in small puffs of dye extravasating into pericoronary space. Indeed, the coronary arteries have two distinct anatomical relationships with reference to epicardium and pericardial space. Half of the circumference of the coronary artery is represented by the myocardium and the remaining is related directly to the pericardial aspect. Case ReportA 69-year-old male patient underwent angiography for investigation of chest pain via the left radial approach.The left coronary angiogram revealed normal coronary arteries. However, repeated attempts at cannulating the right coronary artery were unsuccessful and failed to visualize the ostium because of preferential cannulation of separate origin of a conus branch. Moreover, there was also pressure dampening before the right coronary artery injection. Then, we considered to perform a "hit and run" technique; but unfortunately, massive myocardial staining of right ventricular outflow tract (RVOT) developed (►Fig. 1 and ►Video 1) and then immediately the catheter was pulled back. Visualization of the thebesian vein (black arrows), coronary vein, and sinus was also seen (Video 1). Emergency bedside hand-carried echocardiography showed no pericardial effusion. The patient remained asymptomatic without hemodynamic or arrhythmic compromise, though the myocardial staining appearance persisted on fluoroscopy. Then, we performed an aortic root angiogram after about 10 minutes of coronary angiogram to exclude possible iatrogenic aortic dissection, which showed no dissection flap but persistent RVOT myocardial staining (►Video 2). The course of our patient was uneventful, then he underwent a follow-up at coronary care unit approximately for 12 hours withelectrocardiography (ECG).The continued ECG monitoring showed no changes. The next day, control fluoroscopy revealed the complete resolution of myocardial staining. He was discharged from hospital 2 days after the procedure. At present, this patient is being followed at the outpatient clinic. Keywords► myocardial staining ► coronary angiography ► complication AbstractMyocardial staining is a complication of coronary angiography or intervention procedures and consists of extravasations of contrast material into the myocardium. The powerful injection of contrast (myocardial staining) is caused by the improper positioning of the angiography or guiding catheter and can lead to refractory ventricular tachyarrhythmias and occasionally cardiac death. It results in small puffs of dye extravasating into pericoronary space (epicardial or myocardial).We presented an interesting image of a massive myocardial staining and dense coronary and thebesian venous opac...