A 61-year-old male patient with a history of coronary stent implantation, pacemaker implantation, and previous radiofrequency ablation for atrial flutter, visited the hospital due to intermittent hemoptysis that had been occurring for more than 4 months. Initially, the patient did not seek medical treatment, but recently the frequency of hemoptysis increased, leading him to seek treatment at the hospital. Computed tomography angiography (CTA) revealed occlusion of the left pulmonary vein, which prompted the decision to admit the patient for pulmonary vein stent implantation. During the procedure, the right femoral vein was punctured and the pulmonary artery pressure was measured to be 55/20/33mmHg. To establish a track, the interatrial septum was punctured using SWARTZ (Braided 8.5F Transseptal Guiding Introducer). However, due to the patient's relatively hard atrial septum resulting from a previous puncture, excessive force caused the puncture needle to penetrate into the pulmonary artery and the outer sheath of SWARTZ to penetrate the left atrial wall and enter the pericardium. Considering the extent of the atrial breach, the decision was made not to insert the SWARTZ outer sheath tube into the pericardium. As a result, the patient experienced chest tightness and the contrast agent remained in the pericardium. Immediate pericardiocentesis was performed, draining approximately 200 ml of hemorrhagic fluid and relieving the patient's symptoms.Then we performed another pulmonary artery angiography and found that no contrast agent was found in the pulmonary artery. The overflow indicated that the pulmonary artery was intact. Then we introduced a 5F catheter into the SWARTZ, sent the 0.018-300cm and 0.035-260cm guidewires to the distal end of the pericardial cavity, and quickly introduced the occluder interventional delivery device along the 0.035-260cm guidewire exchange. A 0.018-300cm indwelling occluder was inserted on the outside of the delivery device, and then the shape memory ventricular septal occluder (SQFDQ-II i06) was released. The patient had no obvious discomfort. The operation was completed. The CTA was reviewed 4 days after the operation and a breach was found. It is located at the upper edge of the interatrial septum and is in a good position(Figure 1).
Therefore, we performed pulmonary vein stent implantation again on the 5th day. Through the right femoral vein approach, we successfully punctured the interatrial septum and inserted a microguidewire into the distal pulmonary vein. We used a balloon dilation catheter to gradually dilate the stenotic outlet of the left lower pulmonary vein, while aiming to preserve the integrity of the pulmonary vein branches. We chose a 10*19mm stent (Abbott vascular, Omnilink Elite) for this purpose. However, during the release process of the stent, it was accidentally displaced into the atrium. We then inserted another stent (9*19mm) into the branch and successfully released it. To address the detached stent, we punctured the right femoral artery and inserted a 6F vascular sheath. We introduced a 0.035-260cm exchange guidewire from the left atrium along the blood flow direction, leaving it in the descending aorta. Using a catcher, we captured the exchange from the right femoral artery, with the guide wire left outside the body. To strengthen the support of the guide wire, we introduced a JR4.0 catheter along the artery end. Finally, we used the JR4.0 catheter to push the stent from the left atrium along the guide wire. The stent smoothly followed the guide wire during the systole of the left ventricle, descending to the iliac artery (Figure 2). The postoperative cardiac color ultrasound examination revealed no abnormalities in each heart valve, and the patient was discharged from the hospital on the 7th day.