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 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.