A 57-year-old man visited due to chest discomfort and right shoulder pain, 2 weeks ago. A health checkup a week ago revealed no abnormal finding. He had a history of anterior wall STEMI 18 months ago. He underwent coronary stenting at the proximal left anterior descending artery and received intra-aortic balloon pump therapy for cardiogenic shock. Antiplatelet agent (aspirin 100 mg daily, ticagrelor 90 mg twice daily) and statin (rosuvastatin 20 mg daily) were taken, and smoking was currently maintained. For the coronary anatomy evaluation, CAG was performed under fluoroscopic guidance, using the right radial artery, a 4 French (F) sheath, a 0.035″ × 180 cm, angled, J-type Radifocus hydrophilic guidewire (Terumo, Tokyo, Japan), and a 4 F Tiger II Outlook 100-cm coronary catheter (Terumo). CAG showed no significant in-stent restenosis at the proximal left anterior descending artery but significant stenosis at the distal right coronary artery (RCA). For PCI of the distal RCA, a 4 F sheath was replaced with a 6 F sheath, and RCA was engaged under fluoroscopic guidance, using a 0.014″ × 195 mm ATW steerable coronary guidewire (Cordis, MI) and a 6 F Vista Brite Tip Judkins right 4.0 coronary catheter (Cordis). Immediately after the ATW coronary guidewire was passed through the distal RCA, the patient began coughing vigorously in several consecutive episodes and exhibited facial redness. PCI was reserved until he was stabilized. Unexpectedly, however, the voice changed, dyspnea occurred within a few minutes, and lip cyanosis and stridor were observed. Initially, a dye-induced anaphylactic reaction was suspected. Corticosteroid and antihistamine (Pheniramine) were injected intravenously, and endotracheal intubation was successfully performed by the anesthesiologist. After endotracheal intubation, 100% oxygen saturation was recovered, vital signs stabilized, and alert mentation was observed. Balloon angioplasty and coronary stenting were performed using a 2.5 mm × 15 mm balloon catheter (Lacrosse NSE, Goodman Medical, Ireland) and 3.25 mm × 18 mm Xience Sierra stent (Abbott, Santa Clara, CA), respectively. PCI was terminated successfully after high-pressure balloon angioplasty using a 3.25 mm × 8 mm non-compliant balloon (Powered Lacrosse 2, Goodman Medical). The intubated patient was moved to the intensive care unit, for ventilator support and close hemodynamic monitoring. Because spontaneous respiration, obey command and 100% oxygen saturation were maintained, he was extubated 30 minutes after PCI. At 1-hour post-extubation, the oxygen saturation was maintained above 97%. However, his blood pressure suddenly decreased to 70/50 mmHg and recovered to 100/70 mmHg by intravenous fluid hydration and dopamine infusion. Despite the normal ranges of blood pressure and oxygen saturation, he was agitated and complained of chest discomfort. Transthoracic echocardiography, electrocardiography, chest X-ray, and blood test were performed. On the transthoracic echocardiography and electrocardiography, there was no significant interval change from previous findings, but a markedly widened superior mediastinum was newly noted on chest X-ray, and blood hemoglobin was reduced from 15.2 to 13.0 g/dL, suggesting a mediastinal hemorrhage (Fig. A and B). As the contrast-enhanced chest computed tomography (CT) scan performed immediately also showed contrast extravasation surrounding the brachiocephalic artery, and a mediastinal hematoma compressing the trachea and hemothorax, hemorrhagic shock by brachiocephalic vessel rupture was strongly suspected (Fig. A–C). First, for the perforating vessel closure, brachiocephalic angiography was performed using the right femoral artery. The innominate, subclavian, and vertebral arteries were intact, whereas contrast extravasation was noted in the terminal portion of the inferior thyroidal artery of the thyrocervical trunk (Fig. A and B). Endovascular embolization therapy was performed successfully using a 3 × 2 mm Tornado embolization microcoil (Cook Medical, Bloomington, IN), Gelfoam gelatin sponge (Medical Impact, Bucheon, Korea), and Histoacryl glue (B/Braun, Barcelona, Spain), which extinguished the extravasation blood (Fig. C–E).\nThe next day (hospitalization day 2), the mediastinal hemorrhage was drained by mediastinoscopy, to relieve the trachea compression and fibrosis due to extravasated blood. In total, 1.5 L of blood was drained from the mediastinum and hemothorax. The endotracheal intubation and ventilator care were maintained for 2 days, due to severe tracheal compression by the mediastinum hematoma. After 6 units of packed red blood cells were transfused, hemoglobin was maintained at 9.6 g/dL, and vital signs and oxygen saturation were stabilized. The antithrombotic agent ticagrelor was maintained at 60 mg twice daily, to prevent stent thrombosis. Additionally, antibiotics were used for infection control.\nOn day 4, airway patency was improved, and extubation was performed. As hemoglobin was maintained at 9.7 g/dL, aspirin (100 mg daily) plus ticagrelor (60 mg twice daily) was administered. The follow-up chest CT on day 7 showed the mediastinum hematoma had decreased in size (Fig. A and B). On day 9, the mediastinal drainage had decreased to below 50 mL, and the drainage tube was removed. Meanwhile, antiplatelet therapy, as measured by the Multiplate Analyzer (Roche Diagnostics, Mannheim, Germany), showed a high on-treatment platelet reactivity (56; normal range; 1–38) and also thrombocytosis (platelet count; 799,000/μL), so the daily ticagrelor dose increased from 60 mg twice to 90 mg twice. On day 10, the patient was discharged with medication, including antiplatelet agents and rosuvastatin.\nTwo weeks post-discharge, high on-treatment platelet reactivity had disappeared, and the follow-up chest imaging showed the normalized mediastinal structure, except for embolization remnants (Fig. A–C). At 14 months post-discharge, the patient remains healthy.
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.