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 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.