A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure –] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [], scheduled for staged PCI. For the staged procedure, three weeks later, again via right radial access, check angiogram was done with Tiger II (5 Fr; Terumo Interventional Systems, Somerset, NJ, USA) showing patency of LAD stent [] and ECR 3.5 6F guide catheter was advanced over Terumo exchange 0.035” guidewire across right subclavian artery (RSCA) into the ascending aorta. During this manipulation, the guidewire transiently slipped out of ascending aorta into proximal RSCA. Despite a few attempts, the guidewire and catheter could not be negotiated across the vessel, and rather than injuring the vessel by repeated wire passages, access was changed and procedure was subsequently completed from right femoral route. Two overlapping EES were deployed with good angiographic result [].\nThroughout the procedure, the patient kept complaining of mild intensity back pain, without any hemodynamic compromise or oxygen desaturation. At the end of procedure, check aortogram was performed which ruled out any aortic or RSCA dissection/perforation [, , and Supplementary Material].\nFollowing transfer to the coronary care unit, within 30 minutes, the patient was noted to be hypotensive ((BP 85 mmHg systolic) and tachypneic (RR 22/min.), with resting room air saturation of 90%. Examination revealed bilateral neck swelling, hoarseness of voice, and stridor. Chest auscultation was significant for the absence of any basal crackles and decreased air entry on right side.\nElectrocardiogram revealed sinus tachycardia without fresh ST-T changes. An urgent bedside echocardiogram revealed no fresh regional wall motion abnormality with an extracardiac mass posterior to the left atrium (LA) []. There was no compromise of LA filling as evidenced by normal pulmonary venous and transmitral flow signals. A bedside chest X-ray (CXR) showed right superior mediastinal widening and homogenous opacity occupying the right upper lung zone without any mediastinal shift suggestive of a possible hematoma []. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [].\nA diagnosis of mediastinal hematoma secondary to injury to RSCA or its branches was entertained and an urgent contrast enhanced computed tomography (CT) of chest was scheduled. Vasopressors were started, along with 2 units of packed red blood cells (Hematocrit dropped from 33% to 20%). A compressive bandage was strapped on right infraclavicular area with sandbag weight compression to achieve whatever hemostasis was possible to prevent any ongoing bleed.\nThe CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [].\nInitially, elective endotracheal intubation was considered in view of stridor, but since the patient's condition stabilized over next 2 hours with improving hemodynamics, urine output and oxygen saturation, conservative management was continued.\nOver the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [ echo]. The hematoma gradually resorbed in the next 12 hours []. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure –]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma []. A CXR at 3 months follow-up showed complete resolution of hematoma [].
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.