Successful Coil Embolization of Pericardiacophrenic Artery Perforation Occurring During Transradial Cardiac Catheterization Via Right Radial Artery

Abstract: The transradial approach for percutaneous coronary intervention (PCI) has gained increasing popularity as an alternative site for coronary angiography and intervention. The transradial approach has safely been used in patients with contraindications to the transfemoral approach. Despite its overall lower complication rates compared with the transfemoral approach, the transradial approach has its own inherent complications. The risk of arterial perforation with the transradial approach is less than 1%, primarily involving the radial artery with the incidence of compartment syndrome at approximately 0.004%. In addition, the risk of significant bleeding requiring transfusion with transradial approach is extremely rare, occurring in about 1/1000 patients. In this report, we present a case of pericardiacophrenic artery perforation occurring during wire advancement into the aorta via right radial artery approach, which was treated with coil embolization for treatment of significant hemorrhage. This case emphasizes the importance of recognizing this artery in order to prevent similar complications in the future. This artery can be confused with the aorta, since it has a similar course paralleling the aortic arch, and as such it can be inadvertently mistaken for the ascending aorta during wire advancement. 

J INVASIVE CARDIOL 2012;24(12):671-674

Key words: transradial, complications, coil, perforation, radial artery, angiography, acute stent thrombosis, free-wall rupture, transfusion, NSTEMI

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The transradial approach for percutaneous coronary intervention (PCI) has gained increasing popularity since its advent as an alternative site for coronary angiography and intervention,^1,2 although the transfemoral approach continues to remain the preferred access site in most United States centers, possibly related to its higher overall success rate.^3,4 The transradial approach has safely been used in patients with contraindication to the transfemoral approach due to significant peripheral vascular disease or morbid obesity.⁵ The transradial approach is more cost effective,⁶ has fewer access-site bleeding complications,^4,7 and is associated with a shorter hospital stay when compared with the transfemoral approach.⁸ Furthermore, the  door-to-balloon times are similar between the transradial and transfemoral approach in patients presenting with ST-elevation myocardial infarction (MI), although the transradial approach has significantly fewer access-site related complications.⁹ Despite its overall lower complication rates compared to the transfemoral approach, the transradial approach has its own inherent complications, which include radial artery occlusion, thrombosis, non-occlusive radial artery injury, catheter entrapment, resistant vasospasm, perforation, compartment syndrome, pseudoaneurysm, and arteriovenous fistula.^10-13The risk of arterial perforation with the transradial approach is less than 1%, primarily involving the radial artery,¹³ with the incidence of compartment syndrome being approximately 0.004%.¹⁴ In addition, the risk of significant bleeding requiring transfusion with transradial approach is extremely rare, occurring in about 1/1000 patients.¹³ In this report, we present a case of pericardiacophrenic artery perforation occurring during wire advancement into the aorta via the right radial artery leading to significant bleeding, which was successfully treated with coil embolization. 

Case Description

A 76-year-old male with past medical history significant for chronic obstructive pulmonary disease and multiple prior percutaneous coronary interventions (PCI) in the past presented with non-ST-elevation myocardial infarction. He had undergone cardiac catheterization two weeks earlier after presenting with unstable angina, at which time he underwent stenting of a high grade stenosis in the first obtuse marginal branch using a 2.5 mm x 9 mm Integrity bare-metal stent (Medtronic Corp.) with difficulty in fully deploying the stent due to severe calcification. In the emergency room, he had been started on unfractionated heparin, nitroglycerin, and eptifibatide and was also continued on his aspirin, clopidogrel, metoprolol, and simvastatin. Based on his ongoing symptoms, elevated cardiac biomarkers, and recent coronary intervention, the decision was made to proceed with cardiac catheterization. The patient was mildly dyspneic and had difficulty lying supine; therefore we decided to proceed with a transradial approach. 

A right radial access was obtained using a micro-puncture kit (Cook Medical), and a 6 Fr sheath (Cordis) was placed in the right radial artery without difficulty. A-cocktail of unfractionated heparin (5000 units), verapamil (500 mcg), and nitroglycerin (400 mcg) was administered following the sheath insertion. There was some difficulty advancing the J-wire into the aorta, therefore we switched to a standard Terumo glidewire (Terumo Medical) which was eventually advanced into the aortic root after initial difficulties due to the aortic tortuosity. The entire wire manipulation occurred under direct fluoroscopic guidance and careful manipulation of wires and catheters; and the patient remained asymptomatic at this time. Right coronary angiography was then performed using a 6 Fr JR5 diagnostic catheter (Medtronic). This catheter was then exchanged for a 6 Fr JL 3.5 diagnostic catheter, however we again had some difficulty advancing the catheter over the J-wire past the right subclavian-brachiocephalic junction. We were also unsuccessful at advancing an EBU 3.0 guide catheter (Medtronic) past the right subclavian-brachiocephalic junction, but were finally able to advance it upon exchanging the J-wire for an Amplatz super-stiff wire (Vascular Solutions). The left coronary angiography demonstrated stent thrombosis of OM1. He was also found to have a high-grade lesion in the large first diagonal branch. Due to severe calcification of OM1, we were unable to advance the wire across the occluded stent; therefore, the decision was made to intervene on the diagonal lesion (due to persistent post MI angina). At this point, the patient was on heparin and eptifibatide for anticoagulation, and the diagonal lesion was successfully crossed with a Cougar XT wire (Medtronic) with a balloon inflation using 2.5 mm x 15 mm Sprinter NC (Medtronic) at 16 atm with marginal success due to calcification. During the procedure, the patient became more restless and began to complain of chest and back pain. He also developed worsening tachycardia and progressively worsening hypotension and hypoxia. Intravenous nitroglycerin was discontinued and the patient received a 250 mL bolus of intravenous normal saline. Due to persistent hypoxia, the patient then underwent successful endotracheal intubation. 

An arterial blood gas (ABG) showed significant hypoxia and worsening anemia, with the hemoglobin reading 9.8 gm/dL, which was slightly lower than his baseline reading of 11 gm/dL. Based on his vitals and ABG reading, bleeding was suspected as the likely etiology. Blood products were ordered and the right common femoral artery was accessed. An intra-aortic balloon pump (IABP) was then placed. Despite IABP with aggressive fluid resuscitation while waiting for blood products, the patient continued to develop progressively worsening hypotension, which subsequently deteriorated into pulseless electrical activity (PEA) cardiac arrest. Advanced cardiac life support (ACLS) was immediately initiated and spontaneous circulation was restored within 2 minutes on high doses of epinephrine, norepinephrine, vasopressin, and phenylephrine. All anticoagulants had been immediately stopped and protamine had been administrated for heparin reversal. A repeat ABG confirmed ongoing bleeding and showed hemoglobin of 5 gm/dL. A bedside transesophageal echocardiogram showed a small right ventricle and hyperdynamic left ventricular function with no evidence of pericardial effusion. A right subclavian angiogram demonstrated contrast dye extravasation from the right pericardiacophrenic artery, confirming a perforation as well as a small right subclavian dissection (Figure 1). Balloon tamponade was successfully performed to achieve hemostasis and cardiothoracic surgery was immediately consulted. The patient subsequently received a total of 80 mg of intravenous protamine, 6 units of packed red blood cells (PRBC), 4 units of fresh frozen plasma, and 2 units of platelets. He was also aggressively fluid resuscitated with 8 liters of normal saline. Based on discussion with the cardiothoracic surgeon and interventional radiologist, we decided to proceed with coil embolization as the patient was deemed to be at high risk for surgical intervention. 

Initial attempts at engaging the pericardiacophrenic artery using a 6 Fr IMA catheter (Medtronic) were unsuccessful. Eventually, we were able to gain access using a 5 Fr Kumpe catheter (Cook) and a 0.035˝ Glidewire (Terumo). A 2.8 Fr Renegade microcatheter (Boston Scientific) was coaxially advanced over a 0.016˝ Headliner (Terumo) wire into the pericardiacophrenic artery. Contrast injection revealed extravasation into the mediastinum (Figure 2). The Renegade microcatheter was then advanced beyond the site of extravasation. Ten 4 x 20 and one 5 x 20 Complex Helical – 18 Fibered Platinum Coils (Boston Scientific) were then deployed using the sandwich technique (beyond, across, and proximal to the extravasation site). Following successful coil embolization, a repeat angiogram demonstrated no further active bleeding and successful hemostasis (Figure 2). The patient’s hemodynamics improved following coil embolization and he was successfully weaned off the vasopressors. Unfortunately, the patient had also developed bilateral pneumothoraces following intubation, likely related to his underlying significant COPD, which were successfully treated with chest tube insertion. A CT scan of the chest revealed a streak artifact from the embolization coils within the pericardiacophrenic artery territory with small amounts of contrast extravasation into the right posterolateral aspect of the mediastinum consistent with mediastinal hemorrhage leading to mediastinal enlargement (Figure 3). 

At the time of transfer to the ICU, the patient was off all vasopressors and his augmented pressure on the IABP was >130 mm Hg. He was hemodynamically stable over the next 24 hours with removal of his IABP next day. His sedation was weaned over the next 24 hours, and he was alert and able to follow commands without evidence of gross neurological deficit. A transthoracic echocardiogram (TTE) performed the day after the event showed preserved left ventricular function with no pericardial effusion. Five days after the event, he had been placed on a spontaneous breathing trial in anticipation of extubation, when he suddenly suffered a PEA cardiac arrest that could not be reversed despite CPR. A bedside TTE during CPR demonstrated an enlarging hemopericardium with suspected free wall rupture, which was confirmed by autopsy showing a 6 mm lateral wall free rupture secondary to his recent myocardial infarction.

Discussion

In this report, we highlight multiple challenging issues facing current-day cardiologists. Our patient had presented with acute stent thrombosis two weeks following PCI with bare-metal stent. The transradial approach has been shown to be a safe alternative to the transfemoral approach in STEMI patients with overall lower rates of access-site complication.⁹ Arterial perforation is a rare complication of transradial approach, occurring less than 1% of the time, which depending on the location, can occasionally be managed conservatively.¹⁴ Significant vascular injury is often treated surgically, although endovascular techniques have gained popularity over the last two decades.¹⁵ Coil embolization is a popular endovascular technique used for treatment of vascular injury,¹⁵ although its use in coronary perforations is rare.¹⁶ Endovascular techniques have significantly lower mortality rate when compared to open surgery for treatment of thoracic arterial injury.¹⁷ Successful subclavian coil embolization for treatment of subclavian artery injury following inadvertent injury has previously been described.^18,19 To our knowledge, this is the first reported case of inadvertent pericardiacophrenic artery perforation during cardiac catheterization using transradial approach, which was successfully treated with coil embolization. Based on a similar parallel course of pericardiacophrenic artery to the aortic arch (Figure 4), the guidewires must have inadvertently entered this artery at some point during repeated wire manipulation, leading to perforation. We would like to use this case as an example to alert other operators about this artery and other subclavian branches which they may encounter during transradial catheterization, in order to prevent similar complications in the future. Unfortunately, our patient passed away from a free wall rupture secondary to MI. Free wall rupture is a relatively rare complication of acute MI in the angioplasty era, and despite significant improvement in overall patient care, it continues to remain a fatal complication. Free wall rupture is more likely to occur in older patients, those with hypertension, Q-wave MI, chronic kidney disease, and those with an increased Killip class.²⁰ In addition, the risk of free wall rupture is increased in patients who are on oral anticoagulants, as well as those who received thrombolytic therapy.²⁰ 

Conclusion

Recognition of pericardiacophrenic artery during transradial cardiac catheterization is very important in order to avoid wire- or catheter-induced trauma or perforation to this artery, which may lead to major life-threatening hemorrhage similar to our case. Based on its anatomical course parallel to the aortic arch, this artery can at times be confused with the aorta and therefore result in inadvertent wire advancement and vascular complication. This complication should be recognized immediately upon occurrence and as demonstrated it can be successfully treated with coil embolization. 

Acknowledgments. We would like to thank Drs Mehrnoosh Hashemzadeh, Caroline Kilian, and Arpine Oganyan for proofreading the text.

References

1. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn. 1989;16(1):3-7. 
2. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn. 1993;30(2):173-178. 
3. Rao SV, Ou F-S, Wang TY, Roe MT, Brindis R, Rumsfeld JS, Peterson ED. Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention: A Report From the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008;1(4):379-386. 
4. Agostoni P, Biondi-Zoccai GGL, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;21:44(2):349-356. 
5. Hildick-Smith DJR, Walsh JT, Lowe MD, Shapiro LM, Petch MC. Transradial coronary angiography in patients with contraindications to the femoral approach: an analysis of 500 cases. Catheter Cardiovasc Interv. 2004;61(1):60-66. 
6. Roussanov O, Wilson SJ, Henley K, et al. Cost-effectiveness of the radial versus femoral artery approach to diagnostic cardiac catheterization. J Invasive Cardiol. 2007;19(8):349-353. 
7. Brueck M, Bandorski D, Kramer W, Wieczorek M, Höltgen R, Tillmanns H. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv. 2009;2(11):1047-1054. 
8. Small A, Klinke P, Della Siega A, et al. Day procedure intervention is safe and complication free in higher risk patients undergoing transradial angioplasty and stenting. The discharge study. Catheter Cardiovasc Interv. 2007;70(7):907-912. 
9. Pancholy S, Patel T, Sanghvi K, Thomas M, Patel T. Comparison of door-to-balloon times for primary PCI using transradial versus transfemoral approach. Catheter Cardiovasc Interv. 2010;75(7):991-995. 
10. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty. Cathet Cardiovasc Diagn. 1997;40(2):156-158. 
11. Edmundson A, Mann T. Nonocclusive radial artery injury resulting from transradial coronary interventions: radial artery IVUS. J Invasive Cardiol. 2005;17(10):528-531. 
12. Zankl AR, Andrassy M, Volz C, Ivandic B, Krumsdorf U, Katus HA, Blessing E. Radial artery thrombosis following transradial coronary angiography: incidence and rationale for treatment of symptomatic patients with low-molecular-weight heparins. Clin Res Cardiol. 2010;99(12):841-847. 
13. Kanei Y, Kwan T, Nakra NC, Liou M, Huang Y, Vales LL, Fox JT, Chen JP, Saito S. Transradial cardiac catheterization: A review of access site complications. Catheter Cardiovasc Interv 2011;78(6):840-846.
14. Tizón-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a large series of transradial approach for coronary procedures. J Interv Cardiol. 2008;21(5):380-384. 
15. Kalish J. Selective use of endovascular techniques in the management of vascular trauma. Semin Vasc Surg. 2010;23(4):243-248. 

16. Al-Lamee R, Ielasi A, Latib A, et al. Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation. JACC Cardiovasc Interv. 2011;4(1):87-95. 
17. Reuben BC, Whitten MG, Sarfati M, Kraiss LW. Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg. 2007;46(6):1222-1226. 
18. Tokue H, Tsushima Y, Morita H, Endo K. Successful interventional management for subclavian artery injury secondary to internal jugular catheterization: a report of two cases. Cardiovasc Intervent Radiol. 2009;32(6):1268-1271. 
19. Jahnke T, Schaefer PJ, Heller M, Mueller-Huelsbeck S. Interventional management of massive hemothorax due to inadvertent puncture of an aberrant right subclavian artery. Cardiovasc Intervent Radiol. 2008;31(Suppl 2):S124-127. 
20. Shamshad F, Kenchaiah S, Finn PV, et al. Fatal myocardial rupture after acute myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: the VALsartan In Acute myocardial iNfarcTion Trial (VALIANT). Am Heart J. 2010;160(1):145-151. 

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From the ¹Department of Medicine, Division of Cardiology, University of Arizona Sarver Heart Center, Tucson, Arizona; ²Department of Medicine, Division of Cardiology; ³Department of Radiology, The Southern Arizona VA Health Care system, Tucson, Arizona; and ⁴ CareMore Arizona.

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.

Manuscript submitted April 9, 2012, provisional acceptance given May 4, 2012, final version accepted May 30, 2012.

Address for correspondence: Mohammad Reza Movahed, MD,  PhD,  FACP,  FACC,  FSCAI,  FCCP, CareMore Regional Cardiology Director Arizona, Professor of Medicine, University of Arizona, 7091 E Speedway Blvd, Tucson, AZ 85710. Email: mohammad.movahed@caremore.com or rmova@aol.com