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 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.