A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.
A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.