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.
A 73-year-old woman presented with angina CCS class I. Her past medical history included hypertension, obesity, and an apoplectic event. Electrocardiography did not show any repolarization disturbances, whereas stress echocardiography demonstrated a significant area of inducible myocardial ischemia. Due to these findings and typical symptoms, a diagnostic heart catheterization was performed via the radial artery. A standard dose of 5.000 IE heparin was given. During the procedure the insertion of the polymer-jacketed guidewire was technically difficult probably due to the narrowness of the chosen vessel. The patient complained of back pain. A computed tomography (CT) scan demonstrated a perforation of the right subclavian artery with a mediastinal hematoma (), and the patient was referred to the Department of Vascular Surgery for further treatment. Initially, it was decided to treat the finding with a stent. However, during the vascular interventional procedure the leak could not be detected and the procedure was aborted. In a subsequent CT scan the leak was no longer verifiable. Finally, after further conservative treatment the patient was returned to the referring hospital where she was successfully stented via transfemoral PCI. One year later, a follow-up CT scan did not show any abnormalities.