CASE 25 Retroperitoneal Bleed

Case presentation

A healthy, active, nonsmoking 40-year-old man with a history of hypertension and dyslipidemia noted midsternal chest pain while dragging a heavy deer he had just hunted out of the woods and to his car. He stopped to rest, but the pain increased in severity and was associated with diaphoresis. He drove himself to a local hospital’s emergency department, where an electrocardiogram showed sinus tachycardia and ST elevation in the anterior precordial leads. Shortly after the electrocardiogram was obtained, he became unresponsive from ventricular fibrillation and required cardioversion. After administration of 325 mg of aspirin, 5 mg of intravenous metoprolol, an intravenous bolus of unfractionated heparin, and 4 mg of morphine sulfate, he was flown by helicopter to a tertiary care hospital 40 miles away for emergency coronary angiography.

Cardiac catheterization

Angiography confirmed proximal occlusion of the left anterior descending artery (Figure 25-1). The operator successfully restored normal flow in this vessel with balloon angioplasty (2.5 mm diameter by 20 mm long balloon) followed by insertion of a 3.5 mm diameter by 15 mm long bare-metal stent (Figure 25-2). Adjunctive pharmacology included an additional bolus of unfractionated heparin and a bolus and infusion of eptifibatide. The left circumflex and right coronary arteries were angiographically normal. At the end of the procedure, 600 mg of clopidogrel was administered orally. The activated clotting time measured 260 seconds. An angiogram of the right femoral artery performed through the arterial sheath is shown in Figure 25-3 and Video 25-1. The operator successfully achieved access site hemostasis using a closure device (Starclose, Abbott Medical). The patient left the cardiac catheterization laboratory feeling well, with a blood pressure of 110/70 mmHg.