Hypotension, Tachypnea, and Stridor Following Radial PCI: Solving the Conundrum.

The radial artery route is being increasingly used by interventional cardiologists as a default access site for both diagnostic and interventional coronary procedures, and although rare, serious complications can occur. We herein report a potentially catastrophic complication of radial percutaneous coronary intervention (PCI) in the form of a large mediastinal and retro-left-atrial hematoma from possible subclavian artery injury with tracheal compression and stridor in a 60-year-old female presenting with anteroseptal myocardial infarction having undergone PCI of the left anterior descending artery through right radial access and then planned for a second stage PCI of the right coronary artery. The patient was managed conservatively with close hemodynamic and echocardiographic monitoring, inotrope support, and blood transfusions. Transradial PCI, despite having a better safety profile in terms of bleeding compared to transfemoral PCI, is not without complications. Manipulation of hydrophilic guidewires as well as diagnostic catheters while performing radial procedures can cause injury to conduit vessels, potentially leading to intrathoracic, axillary, and arm hematomas may remain undetectable in the cath lab, presenting late and can pose a diagnostic and management challenge. Decision to proceed toward repeat interventional/surgical/"wait and watch" strategy should be guided by the patient's clinical status and noninvasive imaging. Copyright:

INTRODUCTION

Coronary diagnostic and intervention procedures through the radial artery route have been shown to be safe with fewer access site bleeding complications compared to the transfemoral route.[12] Although rare, major vascular complications of transradial arterial access are reported in approximately 0.2%–0.5% of coronary procedures.[3] Excessive/aggressive manipulation of hydrophilic guidewires and catheters in radial, brachial, subclavian, or brachiocephalic arteries can lead to trauma, shearing of the vessel wall, and resultant perforation.

We report an unusual complication of radial percutaneous coronary intervention (PCI) wherein the patient developed a large mediastinal retro-left-atrial hematoma and tracheal compression following elective radial PCI to RCA.

CASE PRESENTATION

A 60-year-old female underwent an uncomplicated PCI to LAD artery [Figure 1a–b] at our institute with two overlapping everolimus-eluting stents (EESs) for acute anteroseptal MI via transradial access with residual disease in RCA [Figure 1c], 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 [Figure 2a] 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 [Figure 2b].

Figure 1

(a) Diagnostic left coronary artery angiogram (right anterior oblique cranial) done through right radial access with Tiger catheter showing mid-segment severe stenosis. (b) Postpercutaneous coronary intervention of left anterior descending with good angiographic result. (c) Diagnostic right coronary artery angiogram (left anterior oblique) showing mid-segment critical stenosis

Figure 2

(a) Check left coronary artery angiogram done through right radial access with Tiger catheter. Left anterior descending stent is patent. (b) Final result of transfemoral right coronary artery percutaneous coronary intervention. (c) Check aortogram after percutaneous coronary intervention showing no major dissection or perforation

Throughout 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 [Figure 2c, Video 1, and Supplementary Material].

Following 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.

Electrocardiogram 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) [Figure 3a]. 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 [Figure 4a]. The hematoma progressed and a subsequent CXR revealed opacification of the entire right lung [Figure 4b].

Figure 3

(a) Transthoracic echo apical four-chamber view showing hematoma (arrowhead) compressing the left atrium (arrow). (b) Transthoracic echo showing resolution of hematoma (red arrow) behind the left atrium (green arrowhead)

Figure 4

(a) Chest X-ray showing upper mediastinal widening with rounded opacity in the right upper lung zone. (b) Progression of chest X-ray opacity involving the entire right lung field. (c) Repeat chest X-ray showing resolving hematoma (arrowhead). (d) Follow-up chest X-ray at 3 months showing complete resolution of hematoma

A 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.

The CT confirmed a large posterior mediastinal hematoma without active bleeding from any vessel [Figure 5a].

Figure 5

(a) Computed tomography thorax axial section showing posterior mediastinal hematoma (blue star) extending behind the left atrium (red asterisk). (b) Repeat computed tomography showing resolving hematoma in the posterior mediastinum (thick arrow) with no hematoma behind the left atrium (thin arrow)

Initially, 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.

Over the next 6 hours, the neck swelling and hoarseness gradually subsided and inotropes were tapered and finally stopped [Figure 3b echo]. The hematoma gradually resorbed in the next 12 hours [Figure 5b]. The patient made an uneventful recovery and was discharged. Repeat CXR showed a decrease in mediastinal widening and clearing of lung fields [Figure 4a–c]. Repeat CT chest after 4 weeks showed a decrease in size of hematoma [Figure 5b]. A CXR at 3 months follow-up showed complete resolution of hematoma [Figure 4d].

DISCUSSION

Although shearing of the arterial vessel wall in tortuous, small caliber segments of radial or brachial artery can occur by hydrophilic wires and aggressive catheter manipulation, vascular perforation of subclavian and brachiocephalic arteries is rare, with only a few cases reported.[4567] In our case, inadvertent manipulation of Terumo hydrophilic guidewire in one of the branches of RSCA probably caused vascular injury followed by formation of large mediastinal hematoma.

The appearance of a compressive extracardiac mass posterior to LA on echocardiography immediately after PCI as happened in our case is also rare. Compressive hematomas following PCI often encroach on to LA, possibly due to gravitation of blood posteriorly in supine patients.[8]

It is extremely important in such cases to do a careful echocardiogram and rule out obstruction of pulmonary venous inflow and/or inflow through mitral valve, which can potentially compromise cardiac output. Fortunately, in our case, there was no interference to LA filling at any point of time and posterior atrial hematoma resolved spontaneously.

To avoid such complications, it is important not to advance guidewires/catheters against resistance and always use fluoroscopy to confirm positions of distal guidewire or guide catheters. A low profile 0.035 compatible support catheter (e.g. pigtail) or a PTCA balloon, protruding through the lumen of guide catheter is also used occasionally. These help provide a u razor effect at the distal tip of the guide catheter to minimize vascular trauma.

While coil embolization of localized bleeders and emergency evacuation of compressive hematomas (surgically/percutaneously by pericardiocentesis) may be needed in such cases, conservative management with periodic hemodynamic monitoring and volume replenishment can also be effective in selected cases.[6910] In the present case, in absence of hemodynamic compromise due to localized hematoma resolving over time, conservative management was successful.

CONCLUSION

Although radial coronary procedures are safe, potentially serious vascular complications can occur. Interventional cardiologists need to be aware of such cases not only to prevent them but also to be able to timely manage them. Multimodality imaging, including CXR, echocardiography and CT are often needed to establish diagnosis. Although surgical management may be required, careful hemodynamic and echocardiographic monitoring of atrial filling along with blood transfusions, as needed, can also be effective, as in our case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.