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.
A 59-year-old female with a past medical history of tobacco abuse, hypertension, and coronary artery disease and prior percutaneous coronary intervention presented with complaints of angina and subsequently underwent coronary angiography. The procedure was performed via the right radial artery approach. A 5 French Jacky catheter was used to engage the left coronary artery system, and a 6 French Judkins Right 4 catheter was used to engage the right coronary artery system. The procedure was completed without difficulty from the operator, and the patient was transferred to the postoperative holding area in stable condition.\nHowever, immediately after the procedure, the patient began to experience chest pain and odynophagia. Stat electrocardiogram and bedside echocardiogram were unremarkable, and a CT scan demonstrated an ill-defined fluid collection present in the superior mediastinum ().\nWhile a hematoma and a mass were both considered to be in the differential diagnosis, the CT scan also made note of an aberrant right subclavian artery (ARSA) coursing posterior to the trachea and esophagus (). Esophageal anomalies were otherwise ruled out with an esophagram, and the differential diagnosis was narrowed down to a mediastinal hematoma.\nConsequently, the patient was admitted to the cardiac care unit but continued to complain of midsternal chest pain and odynophagia. The patient remained hemodynamically stable and without any airway compromise. The patient was managed expectantly with analgesia. A repeat CT scan a day later again demonstrated the ill-defined collection which had now extended into the inferior right paravertebral aspect near the gastroesophageal junction. This was deemed to be an extension of the same fluid collection with the size of the hematoma remaining stable. The patient was monitored closely and improved clinically over the course of four days and was subsequently discharged home in good condition. On outpatient follow-up, the patient reported her symptoms had completely resolved.