A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.
A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.\nThree months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (), bivalirudin was administered. A 6 French AL 0.75 guide catheter (Medtronic, Minneapolis, MN, USA) was advanced over an exchange length 0.035″ J-wire, but could not be delivered to the ascending aorta due to resistance in the brachiocephalic artery. The guide was removed and exchanged for a 6 French JR 4 guide catheter (Medtronic, Minneapolis, MN, USA), which was easily advanced into the ascending aorta and used to engage the ostium of the RCA without complication. Next, a standard 0.014″ RunThrough coronary guidewire (Terumo, Tokyo, Japan) was placed in the distal RCA, and percutaneous coronary intervention was performed. The lesion was predilated with a 2.0 mm Maverick compliant balloon (Boston Scientific, Marlborough, MA, USA) inflated to 10 ATM, and a Xience Alpine 2.75 × 12 mm cobalt chromium everolimus drug-eluting stent (Abbot Vascular, Abbott Park, IL, USA) was delivered to the lesion and deployed at 16 ATM. There was a good angiographic result of the distal RCA with no residual stenosis (). Immediately following completion of the procedure, the patient reported an episode of chest discomfort, a new cough, bilateral expiratory wheezes, and respiratory stridor. A transient episode of hypotension was noted but resolved without intervention. The patient was rapidly administered IV methylprednisolone, famotidine, diphenhydramine, and inhaled racemic epinephrine for presumed allergic reaction to iodinated contrast. Although his symptoms largely improved, stridor persisted. Urgent otolaryngology consultation was obtained for the evaluation of possible laryngeal edema, but flexible fiber-optic laryngoscopy was unremarkable. Next, chest radiography was promptly obtained, which revealed a markedly widened superior mediastinum ().\nBased on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (). Due to the severity of tracheal compression, the decision was made to perform endotracheal intubation and mechanical ventilation and transfer to the intensive care unit. After intubation, a repeat CT of the chest with administration of intravenous contrast was notable for a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery, as well as significant narrowing of the distal trachea below the endotracheal tube ().\nAfter consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (). Next, a SupraCore wire (Abbot Vascular, Abbott Park, IL, USA) was placed in the right subclavian artery and a 10 × 40 mm iCAST covered stent (Atrium Medical, Hudson, NH, USA) was deployed across the neck of the pseudoaneurysm. The covered stent was postdilated with a 12 × 20 mm Armada balloon (Abbot Vascular, Abbott Park, IL, USA). Following the intervention, there was an excellent angiographic result with preserved subclavian and carotid runoff (). Aspirin was continued; P2Y12 inhibitors were temporarily withheld.\nDue to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.