Fatal vascular complications during transradial percutaneous coronary intervention

Abstract

Rationale: Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. However, vessels along the tract of the wire or catheter can be injured at any point, causing various types of bleeding complications. Patient concerns: A 57-year-old man visited due to chest discomfort. Coronary angiography showed significant stenosis at the distal right coronary artery (RCA). Immediately after the coronary guidewire was passed through the distal RCA, he started a vigorous cough. The voice changed, dyspnea occurred within minutes, and lip cyanosis and stridor were observed. After endotracheal intubation, successful stenting of the distal RCA was achieved. He was extubated at 30 minutes after coronary stenting, but 1-hour post-extubation, his blood pressure suddenly decreased to 70/50 mmHg. Diagnosis: Mediastinal widening was newly noted on chest X-ray, and blood hemoglobin was decreased. Contrast-enhanced chest computed tomography showed mediastinal hematoma, tracheal compression, and hemothorax. Contrast extravasation was noted in the terminal branches of the inferior thyroid artery on brachiocephalic angiography. Interventions: Successful hemostasis was achieved with endovascular embolization therapy using a Tornado embolization microcoil, Gelfoam gelatin sponge, and Histoacryl glue. The next day, the mediastinal hemorrhage was drained by mediastinoscopy. The endotracheal intubation and ventilator care were maintained for 2 days, and 6 units of packed red blood cells were transfused. Antithrombotics were used to prevent stent thrombosis, and antibiotics to control infection, respectively. Outcomes: After successful hemostasis, thrombocytosis and high on-treatment platelet reactivity that disappeared at 2 weeks post-discharge were noted. Follow-up chest imaging showed the normalized mediastinal widening. At 14 months post-discharge, the patient remains healthy. Lessons: As life-threating vascular complications, such as brachiocephalic, subclavian vessel dissection, and vessel perforation in the internal mammary, costocervical, and thyrocervical arteries, can occur anytime during transradial PCI, the intervention cardiologist should be well aware of it and have the appropriate countermeasures implemented in the routine procedure.

Profile and outcomes of patients with mediastinal hematoma after cardiac catheterization: A retrospective analysis

“…The management of mediastinal hematoma mainly includes supportive treatments, analgesic therapy, appropriate fluid infusion, blood transfusion if necessary, and keeping the airway unobstructed. 11 Mediastinal hematoma after cardiac catheterization is usually benign and has a favorable prognosis. In our study, all 10 patients received conservative management, and their conditions during the hospital stay and after discharge were all stable.…”

“…The management of mediastinal hematoma mainly includes supportive treatments, analgesic therapy, appropriate fluid infusion, blood transfusion if necessary, and keeping the airway unobstructed 11 . Mediastinal hematoma after cardiac catheterization is usually benign and has a favorable prognosis.…”

“…However, if there are signs of active bleeding, physicians should suspend dual antiplatelet therapy or continue to administer only one kind of antiplatelet agent. Active and timely blood transfusion and operations should be implemented for patients with severe bleeding 11,13,14 . Additionally, reinitiation of dual antiplatelet therapy is advisable if it is certain that no active hemorrhage exists.…”

Life-threatening subclavian artery bleeding following percutaneous coronary intervention with stent implantation: A case report and review of literature

“…Percutaneous coronary intervention (PCI) is an extensively used medical therapy for acute and chronic coronary artery disease (CAD)[ 1 , 2 ]. Vascular complications of transradial PCI are rare and usually occur at the access site below the elbow[ 3 - 6 ]. A study population consisting of 1984998 PCI procedures performed at 1292 participating sites demonstrated that the median rate of bleeding at the access site was 0.2%-0.5%[ 7 ].…”