Salvage therapy for subclavian artery perforation resulting in mediastinal hematoma during percutaneous coronary intervention

Abstract

Rationale: Transradial access (TRA) is a widely used technique during percutaneous coronary intervention (PCI). However, mediastinal and cervical hematomas, the rare and severe complications of transradial approach, have extremely high mortality rates. To the best of our knowledge, there were no medical literatures about the successful anticoagulation reversal procedure of mediastinal hematoma in PCI till now. Patient concerns: We here present a 54-year-old male Han patient who underwent PCI. Immediately after PCI, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. Emergency chest computed tomography (CT) revealed a perforation of the subclavian artery resulting in a large mediastinal hematoma with potentially lethal tracheal compression. Diagnosis: A diagnosis of the large mediastinal hematoma was made based on the enhanced computed tomography. Interventions: The patient was successfully managed with palliative therapy of anticoagulation reversal instead of a covered stent graft and surgical operation. Outcomes: Angiography confirmed the absence of leakage after anticoagulation reversal. The patient had an apparent remission of clinical dyspnea. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge. Lessons: The current case highlights the importance of anticoagulation reversal as well as careful guidewire and guide catheter manipulation by the radial approach. Early evaluation, prompt identification, appropriate treatment, and close monitoring are all essential for invasive cardiology.

Fatal vascular complications during transradial percutaneous coronary intervention

“…Previously, the use of a hydrophilic wire, rough catheter manipulation, and extravasated bleeding during transradial PCI in patients with severe vessel tortuosity have been reported, but no case was ever reported in a routine process performed without difficulty as scheduled. [ 3 , 4 , 8 ] In our case, several severe coughs occurred just before the event, which was also observed in Smilowitz's case. [ 4 ] However, it is unclear whether extravascular bleeding or mediastinal hemorrhage was ascribed to those severe coughs alone.…”

“…Our case of inferior thyroid arterial bleeding, which resulted in a mediastinal hemorrhage complicating tracheal compression and respiratory failure during transradial PCI, was successfully treated with endovascular embolization and mediastinotomy drainage. To our knowledge, this is the third case report of inferior thyroidal arterial bleeding (including thyrocervical truck) during transradial PCI, [ 11 , 12 ] the twelfth report of mediastinal hemorrhage or hematoma, [ 3 – 6 , 8 – 14 ] and the fifth description of tracheal compression requiring endotracheal intubation [ 4 , 10 – 12 ] Moreover, it is the first case report of inferior thyroid bleeding during transradial PCI using an angled J-type hydrophilic wire, and succeeding in bleeding control using a microcoil, gel sponge, and glue.…”

Iatrogenic Arterial Perforation During Endovascular Interventions

“…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 ]. These complications are extremely rare and lethal, occurring in 0.008% of cases [ 11 ].…”

Multidisciplinary Management of Subclavian Artery Perforation and Complications

“…Disadvantages of the radial approach include radial artery injury with bleeding, pseudoaneurysm, spasm, and arteriovenous fistula formation. Rare and sometimes lethal complications of this approach include mediastinal and cervical hematomas, which occur in about 0.008% of the procedures [2]. Mediastinal hematoma after radial access cardiac catheterization has scarcely been reported in the literature, and the exact location of the bleed was rarely identified if this entity was suspected.…”

“…Utilization of a straight-tipped wire when encountering vascular tortuosity should be handled with delicate care to prevent vascular dissection and perforation. These hematomas tend to occur due to the perforation of small vessels originating in close proximity to the aortic arch [2]. These proximal hematomas are particularly difficult to manage due to the inability to provide pressure hemostasis.…”