A Hydrophilic-Wire Induced Vascular Perforation Causing Mediastinal Hematoma During Transradial Coronary Intervention

J INVASIVE CARDIOL 2019;31(5):E96.

Key words: complications, computed tomography, hematoma

A 64-year-old man with hypertension presented with chest pain 1 month prior to admission. Electrocardiogram showed ST-segment depression in precordial leads. Chest radiography was unremarkable (Figure 1A). Right transradial coronary angiography was performed and percutaneous coronary intervention (PCI) was planned for the left anterior descending artery and right coronary artery. A hydrophilic wire glided transiently into a branch of the right subclavian artery during passage of the guiding catheter (Figure 1B; Video 1). The patient complained of mild back pain and subclavian artery angiography demonstrated a perforation, as shown by contrast extravasation (Figure 1C; Video 2). Protamine was intravenously administered to reverse heparin (Video 3). Repeat angiography showed no effusion 30 minutes later. An urgent computed tomography (CT) scan revealed superior massive mediastinal hematoma (Figure 1D). Repeated blood tests demonstrated a decreased hemoglobin from preprocedure value of 130 g/L to 68 g/L at 24 hours post procedure, and he was stabilized with fluid challenge and transfusion. Repeat CT scan demonstrated a high-density collection of the right hemithorax (Figure 1E; Video 4). This bleed was successfully treated by gel-foam embolization of the feeder artery after the trachea was intubated (Figures 1F, 1G, and 1H; Video 5). Two weeks after the procedure, he underwent surgical removal of the chest hematoma. Six weeks later, the left anterior descending and right coronary artery were successfully stented and he was discharged uneventfully.

This is the first reported case with evidence of the hydrophilic wire into a small branch and induced perforation; it highlights the need for fluoroscopically guided hydrophilic wire manipulation. Prompt treatment of such perforations is the best option.

Watch the Accompanying Video Series here.

From the Department of Cardiology, Luhe Hospital, Capital Medical University, Beijing, China.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted November 12, 2018.

Address for correspondence: Dr Jincheng Guo, Department of Cardiology, Luhe Hospital, Capital Medical University, Tongzhou District, Beijing, China 101149. Email: guojcmd@126.com