Multidisciplinary Management of Subclavian Artery Perforation and Complications

Abstract

The radial approach to cardiac catheterization and percutaneous coronary interventions has increased in popularity due to the favorable side effect profile relative to the femoral approach. Mediastinal hematoma after radial access cardiac catheterization has scarcely been reported in the literature and, if present, the exact location of the bleed was rarely identified. In this case presentation, we describe an elective transradial coronary angiography resulting in subclavian artery perforation in close proximity to the vertebral artery, with subsequent mediastinal and cervical hematoma formation. This scenario was managed by immediate imaging of the chest after sudden deterioration raised suspicion of an adverse event during wire navigation. Formation of a mediastinal hematoma is the equivalent of retroperitoneal bleed from the femoral approach and requires rapid recognition, interdisciplinary collaboration, and endovascular management.

Iatrogenic Arterial Perforation During Endovascular Interventions

“…Subclavian artery perforation is one of the more frequent iatrogenic central artery perforation events reported in the literature. These events more commonly occur when utilizing transradial access [ 5 ]. Relative to the femoral artery, the radial artery has a smaller luminal caliber and is more prone to vascular tortuosity, requiring straight tipped wire navigation.…”

“…Straight tipped wires and stiff wires should be handled with delicate care to avoid trauma to the vessel wall. Perforations proximal to the aortic arch and near the origin of the vertebral artery are among implicated locations [ 5 , 9 ]. Perforation at the first segment of the subclavian artery, which is located anterior to the cervical pleura and communicates with the mediastinum proximally, can result in mediastinal and cervical hematoma formation [ 10 - 11 ].…”

“…Risk factors for vessel perforation include all comorbidities that promote medial artery calcification, such as hypertension, diabetes, and chronic renal failure, which lead to increased arterial stiffness [ 4 ]. Vascular anatomic variants and tortuosity, especially when utilizing a straight tipped wire, can predispose to vascular perforation [ 5 ]. During wire navigation, it is important that a catheter is advanced through vessels over a wire.…”

“…The two most common locations of arterial vascular access are at the radial artery and the femoral artery. In general, the radial approach is favored due to less access site bleeding, definitive hemostasis, and quicker patient mobilization [ 5 ]. Complications associated with arterial access include spasm, hematoma formation, pseudoaneurysms, dissection, arteriovenous fistula, and distal ischemia [ 6 ].…”

“…Complications associated with arterial access include spasm, hematoma formation, pseudoaneurysms, dissection, arteriovenous fistula, and distal ischemia [ 6 ]. Unlike the transradial approach, the femoral approach can lead to the extension of bleeding into the retroperitoneal space, which can be life-threatening [ 5 ]. Although the risk of major complications is significantly reduced via the transradial approach, large vessel perforation has still been reported in the literature for both approaches.…”