A 75-year-old white female presented with recurrent atypical chest pain radiating to her left arm. She was on optimal medical therapy with persistent symptoms. A stress test was non-diagnostic. Therefore, she underwent a coronary angiogram using the right radial approach. Coronary angiogram revealed mid-left anterior descending artery moderate stenosis and a 3.0-millimeter drug-eluting stent was placed post-dilation with a 3.5-millimeter non-compliant balloon over a Wholey wire (Medtronic, Dublin, Ireland), which was chosen due to tortuosity encountered in the brachial artery. One brief episode of hypotension occurred and was treated with a one-time dose of intravenous phenylephrine. The patient left the cardiac catheterization lab with no immediate complications.\nThirty minutes later, the patient became hypotensive with a blood pressure (BP) of 80/60 mmHg. A fluid bolus was administered but hypotension continued to worsen, with BP dropping to 70 mmHg systolic and a heart rate of 55 beats per minute. A stat electrocardiogram showed normal sinus rhythm with a rate of approximately 55 beats per minute and low voltage as compared to baseline. Approximately 0.5 milligrams atropine and 100 micrograms of phenylephrine were administered with a brief improvement in BP. The patient then started experiencing excruciating chest pain. A bedside transthoracic echocardiography was completed with limited windows. A contrast-enhanced CT of the chest was ordered revealing a subclavian artery perforation resulting in hemomediastinum (Figures , ).\nInterventional radiology was consulted, and a 8.5-French pigtail drainage catheter was placed in the mediastinum using an anterior approach to prevent cardiac tamponade, taking care to avoid the internal mammary artery (Figure ). The patient was then brought back to the catheterization lab for emergent percutaneous management. The brachial artery measured small on ultrasound; therefore, the right common femoral artery was accessed with an eight-French sheath, six-French JR4 guide.\nThe right subclavian artery measured 9.0 millimeters on CT, and the site of the bleed was noted to be in close proximity to the origin of the right vertebral artery. A 10-millimeter balloon inflatable covered stent was advanced using a long sheath. The stent migrated off the balloon. Smaller balloons were used to reposition the stent, and a new 10-millimeter balloon was placed through the stent. The stent was placed with regard to the close proximity of the vertebral artery (Figure ). The patient complained of back pain and was receiving norepinephrine 20 mcg/kg/min and dopamine 20 mcg/kg/min during the procedure. The patient received a total of four units of packed red blood cells, and the norepinephrine and dopamine infusions were stopped after six hours.\nTen hours after stenting, the patient started complaining of back pain and began vomiting. A chest radiograph was immediately obtained, revealing an apical cap sign with a density at the apex of the pleura (Figure ).\nOn repeat CT angiography of the chest, active extravasation from the subclavian artery had ceased but an extrapleural hematoma was found. The extrapleural hematoma was drained using a pigtail drainage catheter under CT guidance (Figure ). The patient was stable afterward and discharged home after one week.
A 73-year-old man underwent percutaneous angioplasty due to unstable angina CCS III-IV. He had a history of mild chest pain for the last 20 years with a crescendo pattern in the early past. No pathological findings were detectable in electrocardiography. His cardiovascular risk factors included history of nicotine abuse, hypertension, as well as hyperlipidemia. Due to the severity of the angina an elective catheterization via the right radial artery was planned. Mecain 1% injection solution was used as a local anesthetic and verapamil was administered as an intra-arterial vasodilatory agent. For anticoagulation 5.000 IE heparin and 150 mg clopidogrel were applied.\nThe process of advancing the guide wire toward the ascending aorta has been described as difficult due to a kinking of the brachiocephalic trunk. As in the first case, the procedure was performed by an experienced cardiologist with a large number of transradial catheterizations performed. During the procedure the wire was not forced and a polymer-jacketed guidewire was used.\nHis coronary angiography revealed the presence of a chronic collateralized stenosis in the proximal third of the right coronary artery, diffuse sclerosis, and calcifications with high degree stenoses of the ramus circumflexus and the proximal left anterior descending coronary artery. After an extensive interdisciplinary discussion of the diagnostic findings it was decided to perform interventional treatment. During the switch to a guide catheter (Braun; Serpia; XB 3,5; 6 French) advancing the guide wire into the ascending aorta again appeared to be difficult and ultimately frustrating. The subsequent angiography demonstrated a strong suspicion of a dissection of the brachiocephalic trunk. A subsequent CT angiography confirmed a dissection of both the brachiocephalic trunk as well as the aortic arch (). The patient was referred to the Department of Cardiac Surgery for further conservative treatment and coronary artery bypass grafting. No repair of the ascending aorta was required, as the false lumen of the dissection spontaneously thrombosed and the dissection was treated conservatively.