Vascular complications from transradial percutaneous coronary intervention (PCI) are rare. We report an unusual case of stridor after PCI due to brachiocephalic artery perforation, pseudoaneurysm formation, and development of a large mediastinal hematoma with tracheal compression. Endovascular repair of the brachiocephalic artery was achieved with covered stent placement at the neck of the pseudoaneurysm. This case highlights the importance of careful guide catheter placement from the right radial approach. Ultimately, rapid diagnosis of vascular perforation, appropriate airway management, and prompt endovascular repair of the injured vessel is critical to the successful management of this life-threatening condition.
Percutaneous coronary intervention (PCI) via the radial artery is an effective approach to treat patients with coronary artery disease. In large randomized trials of transradial versus transfemoral arterial access, patients who underwent transradial catheterization had fewer major adverse cardiovascular events, fewer access site bleeding events, and lower mortality than those who underwent transfemoral coronary intervention [
A 69-year-old man with a history of hypertension, dyslipidemia, and type 2 diabetes mellitus presented with lifestyle-limiting angina. He underwent diagnostic coronary angiography that revealed stenoses of the left anterior descending (LAD) coronary artery, ramus intermedius coronary artery, and the distal right coronary artery (RCA). Coronary artery bypass grafting was recommended, but the patient refused surgery and elected for percutaneous coronary intervention (PCI) instead. Initially, transradial PCI of the LAD and ramus coronary arteries was performed with placement of drug-eluting stents in each vessel. The patient was discharged on aspirin and ticagrelor with a plan for staged coronary intervention of the distal RCA at a later date.
Three months after the initial coronary intervention, the patient returned for planned PCI of the distal RCA stenosis. Access was again obtained in the right radial artery with a short 6 French slender sheath. After routine diagnostic coronary angiography confirmed a severe stenosis in the distal RCA (Figure
Coronary angiography of the right coronary artery in the left anterior oblique view before (a) and after (b) percutaneous coronary intervention and drug-eluting stent placement.
Chest radiography (AP orientation) demonstrating a widened superior mediastinum.
Based on the findings on chest radiography, transesophageal echocardiography (TEE) was urgently performed. Echocardiography revealed no evidence of aortic dissection, but vague echodensities were noted anterior to the right heart suggestive of a hematoma. Thus, computed tomography (CT) of the chest without intravenous contrast was performed to obtain cross-sectional imaging of the mediastinum. The chest CT revealed a large hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma, resulting in severe airway compression (Figure
Computed tomography (CT) of the chest without intravenous contrast demonstrating a hyperdense region surrounding the trachea suggestive of an anterior mediastinal hematoma (a). Computed tomography (CT) of the chest with intravenous contrast demonstrating a small pseudoaneurysm arising from the inferior aspect of the brachiocephalic artery (b).
After consultation with cardiothoracic and vascular surgery, the decision was made to pursue endovascular repair of the brachiocephalic artery pseudoaneurysm and presumed site of vascular perforation. Access was obtained in the left common femoral artery, and angiography of the brachiocephalic artery was performed, which confirmed the presence of a brachiocephalic artery pseudoaneurysm (Figure
Angiography of the brachiocephalic artery demonstrating a small pseudoaneurysm (a). There was an excellent angiographic result after deployment of a covered stent (b).
Due to persistent tracheal compression after endovascular repair of the brachiocephalic artery, a Tracheobronxane Dumon silicone tracheal stent (Novatech, La Ciotat, France) was inserted by interventional pulmonology to maintain airway patency while the mediastinal hematoma resorbed. Over the ensuring days, serial imaging demonstrated no further enlargement of the mediastinal hematoma, and dual antiplatelet agents were resumed. The tracheal stent was retrieved and removed after 12 days. The patient was ultimately discharged to inpatient rehabilitation on hospital day 19.
Vascular perforation associated with delivery of a 6 French guide catheter in the subclavian and brachiocephalic arteries is rare, with few cases reported in the literature [
This report also illustrates the importance of maintaining a broad differential diagnosis when respiratory distress occurs after PCI. In this case, an allergic reaction to iodinated contrast was initially suspected when stridor and wheezing developed after completion of the procedure. Reactions to contrast media affect approximately 1 in every 500 patients undergoing coronary angiography in the cardiac catheterization laboratory, and the clinical presentation can range from urticaria to laryngeal edema and bronchospasm to cardiovascular shock and respiratory arrest [
In conclusion, vascular perforations due to guide catheter advancement from the right radial artery are rare. In this case, a 6 French AL 0.75 guide catheter led to brachiocephalic artery perforation, pseudoaneurysm formation, and a large mediastinal hematoma with tracheal compression. Prompt recognition, appropriate airway management, and endovascular repair of the injured vessel is critical to the successful management of this potentially life-threatening condition.
Dr. Muhamed Saric serves on a speaker bureau for Philips and Medtronic and an advisory board for Siemens. Dr. Michael J. Attubato is a consultant to Boston Scientific. The remaining authors have no relevant conflicts of interest to disclose.