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 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.