冠動脈穿孔に起因した心停止の1救命例

A Case of Successful Recovery from Cardiac Arrest Resulting from Coronary Perforation

要旨　患者は83歳男性．近医で慢性腎不全，高血圧で加療されていた．2011年6月に左前下行枝(LAD)近位部と中間部の高度狭窄病変に対して冠動脈ステントが留置された．2011年12月に労作時の胸痛が出現したために侵襲的冠動脈造影検査を施行した．LAD中間部のステント留置中枢側にステント内再狭窄を認めたため，同部に経皮的冠動脈形成術を施行した．ステント内をバルーンにて高圧で拡張後に冠動脈ステントを留置したが，その直後に冠動脈穿孔が生じた．バルーンカテーテルにて長時間圧迫するも止血に成功せず，手技中に心室頻拍から心停止を来し，蘇生処置をしながら経皮的心肺補助装置を導入した．経胸壁心エコー検査で多量の心囊液貯留を認め，心囊ドレナージを施行した．その直後に心拍は再開した．冠動脈穿孔部にPTFEカバードステントを留置し，造影上は造影剤の漏出の所見はなかったが，心囊ドレーンより血液が100ml/時で流出した．手術適応と判断し，他院心臓血管外科に転院のうえ緊急手術が施行された．胸骨正中切開下に心膜を切開したところ，LAD穿孔部からの動脈性出血によりステント留置部は膨隆していた．大伏在静脈グラフトをLAD末梢側に吻合し，ステント留置部位の近位側でLADを結紮止血した．術後経過は良好で独歩退院した．

　An 83-year-old man with a history of chronic kidney disease and hypertension underwent stent implantation in 90% stenotic lesions of proximal segment and middle segment of left anterior descending artery, in June 2011. In December 2011, chest pain on exertion emerged, so coronary angiography was performed. Coronary angiography(CAG)showed restenosis in the proximal portion of stent implanted in the middle segment of left anterior descending artery and percutaneous coronary intervention was performed. After insertion of a balloon catheter into the re-stenotic lesion, we inflated the balloon at high pressure. Immediately after implantation of a stent to the lesion, coronary perforation occurred. In spite of long inflation of a balloon catheter, the extravasation of contrast medium from the perforated coronary artery could not be stopped. During procedure, he developed incessant ventricular tachycardia and cardiac arrest. Cardiopulmonary resuscitation was initiated and percutaneous cardiopulmonary support system was used. Since transthoracic echocardiography showed massive pericardial effusion, continuous drainage was performed. Soon after that, spontaneous circulation restored. A polytetrafluoroethylen(PTFE)-covered stent was implanted to the perforated coronary artery and CAG showed no retension of contrast medium. Since 100ml per an hour of serosanguineous fluid was drained, operation was thought to be indicated. He was transferred to another hospital and emergent operation was performed. Epicardial bleeding made buldge on the implanted stent. After saphenous vein graft was anastomosed to the distal of left anterior descending artery, left anterior descending artery was ligated proximal to the implanted stent. He was discharged on foot without any complications.