A 54-year-old male Han patient was referred to our hospital for a 6-day history of unstable angina on April 2, 2018. He complained of associated palpitation, diaphoresis, and pleuritic chest pain. The patient denied any history of trauma, cough, vomiting, or other constitutional symptoms. He had a 20-pack-year smoking history. His medical history was significant hypertension treated with amlodipine (5 mg/d). He received aspirin (Bayer, Leverkusen, Germany), clopidogrel (Sanofi, Paris, France), and other conventional treatments after admission. At the 3rd day, routine diagnostic coronary angiography revealed subtotal (99%) stenosis in the distal left anterior descending (LAD) coronary artery by the right radial artery approach. Heparin (70–100 U/kg) was administered during the intervention guided by the activated clotting time (ACT; target value of 280–350 seconds). A 6 French EBU3.5 guide catheter (Medtronic, Minneapolis, MN) was advanced over an exchange length 0.035″ hydrophilic J-wire without fluoroscopy, but could not be smoothly delivered to the ascending aorta due to resistance in the tortuous subclavian and the brachiocephalic artery. The distal guidewire was confirmed to be inside the lumen of the guide catheter by fluoroscopy. Therefore, the guidewire was again appropriately positioned in the ascending aorta under fluoroscopy. However, the guidewire's support was poor, and the guide catheter could not advance. Then, the dual-guidewire technique was successfully applied to advance the guide catheter to the left coronary artery (LCA). Finally, PCI was performed smoothly, during which the patient felt some discomfort on his right neck.\nImmediately after the procedure, the patient was transferred to the cardiac care unit (CCU). Five minutes later, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. However, sufficient peripheral artery oxygen saturation and normal blood pressure revealed stable hemodynamics. The patient was rapidly administered IV 10 mg furosemide (Jinling Pharmaceutical Co., Zhejiang, CN) for presumed acute left heart failure due to dyspnea, recurrent cough, and subtotal stenosis in LAD. However, the series of discomforts even worsened. Peripheral artery oxygen saturation declined to 90%–92% in room air and the heart rate significantly increased. Finally, careful physical examination showed a right-sided swelling at the base of the patient's neck and the absence of pulmonary rales. Chest fluoroscopy during PCI was promptly performed, which revealed a dramatically widened superior mediastinum (Fig. A).\nTo further clarify this problem, an emergency-enhanced computed tomography (CT) scan was performed, which showed a significant mass in the lower right neck and the anterior mediastinum (Fig. B, C). The mass surrounded the thoracic ascending aorta and the trachea, indicating an anterior mediastinal hematoma. The trachea was severely compressed by the mediastinal hematoma (Fig. C). Coronal CT scan of the chest revealed a small perforation of the subclavian artery (Fig. D). Urgent consultations with the anesthesiologist, and cardiothoracic and vascular surgeons were performed for the evaluation of possible anoxic events and unstable hemodynamics. Emergency endotracheal intubation was suggested, which was declined by the patient himself and his family members.\nDue to worsening dyspnea, the patient was taken to the catheter lab again. With the anesthetist on standby, angiography of the brachiocephalic artery was performed via the right radial route, which revealed a perforation of the proximal right subclavian artery (Fig. A). At the beginning, a suggestion was made to place a covered stent graft. However, the perforation site was extremely close to the carotid artery. It was possible to completely occlude the carotid artery by the covered stent graft, which may cause cerebral infarction and even death. Then, the jailed balloon technique was suggested to prevent carotid artery occlusion. To increase the success rate of the surgery, the femoral route was applied. Then, the patient's recorded ACT was 285 seconds and he was rapidly administered 50 mg IV protamine (First Biochemical Pharmaceutical Co., Shanghai, CN) to reverse the effect of heparin for presumed perforation and hematoma. Two minutes later, the ACT was 173 seconds, and angiography of the brachiocephalic artery was performed by the right femoral route, which revealed reduced extravasation of contrast from the site of vascular perforation. Five minutes later, another 10 mg protamine was provided, which reduced the ACT to 120 seconds. Angiography confirmed the presence of right subclavian artery pseudoaneurysm and the absence of leakage at this moment (Fig. B). The patient had an apparent remission of clinical dyspnea. The patient was transferred to the cardiac care unit (CCU) for close observation.\nThe next day after PCI, aspirin (75 mg/d) and clopidogrel (75 mg/d) were continued. Plain chest computed tomography (CT) was performed to confirm trachea compression alleviation (Fig. C). To avoid lung infection, cefazolin (2 g/d; Jiuxin Pharmaceutical Co., Shenzhen, CN) was prophylactically used for the next 48 hours. The patient was ultimately discharged 5 days later. The patient was advised to continue standard dual antiplatelet therapy for at least 12 months after discharge. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge on May 15, 2018 (Fig. D). The patient had no chest discomfort in the following 6 months as assessed during outpatient visits.
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.