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 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.