Hematoma of the Breast: A Rare Complication of Transradial Angiography and its Treatment With Handmade Stent Graft

ABSTRACT: Mediastinal hematoma is a very rare complication of coronary angiography. The catheters or guidewires passing through the lumen may lead to bleeding and hematoma formation at adjacent sites along the tract of the vessels. We present a 72-year-old female patient with a right internal mammary artery perforation following transradial coronary angiography, which was managed with implantation of a handmade stent graft.

J INVASIVE CARDIOL 2014;26(2):E24-E26

Key words: transradial angiography, hematoma, perforation, handmade stent graft

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Case Report. A 72-year-old female patient presenting with typical angina pectoris was admitted to the cardiac catheterization laboratory with evidence of inferior left ventricular wall ischemia detected by myocardial perfusion scintigraphy spect. A short, 5 Fr  sheath was inserted into the right radial artery and a 5 Fr radial diagnostic catheter (Optitorque; Terumo Corporation) and 0.035˝  (150 cm) angled Glidewire (Terumo Corporation) were used for diagnostic coronary angiography. While the guidewire was advanced to reach the ascending aorta, it inadvertently entered into the lumen of the right internal mammary artery (RIMA). The wire was withdrawn and then easily advanced to the ascending aorta. Coronary angiography showed patent left main and left descending coronary arteries, and non-critical plaques in the right and left circumflex coronary arteries. The patient was symptom free and the procedure was completed uneventfully.

 A few hours after the procedure, the patient complained of pain in the right anterior chest. Physical examination revealed a huge hematoma on the right breast (Figure 1). Ultrasonography and subsequent computed tomography of the breast and chest were performed, and indicated a high-density attenuation within the soft tissue of the right breast consistent with a huge hematoma. Control hemogram detected a fall in hemoglobin level from 11.6 g/dL to 9.6 g/dL post procedure. Intravenous saline infusion was initiated for volume replacement and the patient was taken to the catheterization laboratory again due to possible RIMA perforation.

A 6 Fr sheath was inserted into the right radial artery and a 6 Fr right Judkins guiding catheter was used to engage the RIMA ostium. Selective RIMA angiography displayed a perforated segment with massive contrast extravasation (Figure 2A). After crossing the perforated segment with a floppy guidewire, a 2.0 x 20 mm balloon was inflated for 15 minutes at 12 atm (Figure 2B). However, the perforation did not seal. Thereafter, a 2.5 x 16 mm Direct-Stent stent graft (InSitu Technologies, Inc) was implanted into the site of perforation at 14 atm, but this maneuver was unsuccessful because of the improper stent placement (Figure 2C).

Since we did not have another stent graft in the catheterization laboratory at that moment, we decided to produce a handmade stent graft. A 2.5 x 15 mm Simpass balloon was inflated at 4 atm and the proximal and distal tips of the balloon catheter were cut with a surgical blade and removed. The remaining middle shaft of the balloon was extracted as a thin sheet. Afterward, the outer surface of a 2.5 x 16 mm Gazelle stent (Biosensors International, Ltd) was covered with this extracted material and it was compressed between the thumb and index finger to ensure that the material did not peel off from the stent. The produced handmade stent was passed through the sheath of the used balloon catheter and demonstrated that it was moving forward without embolization (Figure 3). Afterward, we started to move to seal the perforation with this handmade stent graft and advanced the material into the radial artery. The perforated segment of the RIMA was sealed completely following implantation of the handmade stent graft at 16 atm. RIMA angiography showed complete sealing of the perforation and disappearance of contrast extravasation from RIMA to the soft tissue of the right breast (Figures 4A and 4B). The size of the hematoma was reduced within a few hours after the stent implantation. The patient was discharged after 72 hours with analgesic medication. 

Discussion. Vascular complications, such as bleeding, hematoma formation, pseudoaneurysm, arteriovenous fistula, and thromboembolism, are rare complications of cardiac catheterization.^1-3 Vascular complications can occur at any site of the vessel along the tract of the wires or catheters.³ The hydrophilic wire was advanced under fluoroscopic guidance in the patient presented. The wire went toward the RIMA unexpectedly as if it was passing through ascending aorta. The wire was withdrawn and then easily advanced to the ascending aorta. There was no resistance or difficulty encountered during the procedure. However, the hematoma was observed at the site of the right breast a few hours after the procedure. The perforation occurred as a result of the advancement of a 0.035˝ guidewire in a relatively small vessel, such as the RIMA. Therefore, extra caution and careful maneuvering of the hydrophilic guidewire are warranted during the transradial interventions. Only three reports have been published in the literature demonstrating mediastinal hematoma after cardiac catheterization via the transradial approach.^4-6 The reported patients were managed conservatively, unlike our patient. Our patient is different from the others because the case was treated with a handmade stent graft. Producing and using a handmade stent graft is a valuable option if the operator does not have a chance to use an original stent graft in cases of vascular perforation. It should be kept in mind that the balloon over the surface of the metal stent may be embolized as a result of elusion during the procedure. Also, the high risk of thrombosis of the handmade stent graft should not be forgotten.

Conclusion. Vascular perforation or injury can occur during transradial coronary procedures. The most common cause is traumatic injury due to guidewire maneuvering, which may cause mediastinal hematoma. Therefore, extra caution and careful maneuvering of the hydrophilic guidewire is warranted during the transradial interventions. This very rare complication is managed conservatively or interventionally.  Handmade graft stent production and usage should be kept in mind in cases of perforation if original graft stents are not available in your catheter laboratory.

References

1. Ricci MA, Trevisani GT, Pilcher DB. Vascular complications of cardiac catheterization. Am J Surg. 1994;167(4):375-378.
2. Babu SC, Piccorelli GO, Shah PM, Stein JH, Clauss RH. Incidence and results of arterial complications among 16,350 patients undergoing cardiac catheterization. J Vasc Surg. 1989;10(2):113-116.
3. Fransson SG, Nylander E. Vascular injury following cardiac catheterization, coronary angiography, and coronary angioplasty. Eur Heart J. 1994;15(2):232-235.
4. Jao YT, Chen Y, Fang CC, Wang SP. Mediastinal and neck hematoma after cardiac catheterization. Catheter Cardiovasc Interv. 2003;58(4):467-472.
5. Park KW, Chung JW, Shang SA, et al. Two cases of mediastinal hematoma after cardiac catheterization: a rare but real complication of the transradial approach. Int J Cardiol. 2008;130(3):e89-e92.
6. Parikh P, Staniloae C, Coppola J. Pain in the neck: a rare complication of transradial cardiac catheterization. J Invasive Cardiol. 2013;25(4):198-200.

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From the 1Department of Cardiology, Ada Tıp Hospital, Sakarya/Turkey, 2Department of Radiology, Sakarya University School of Medicine, Sakarya/Turkey, and 3Department of Cardiology, Acibadem University Hospital, Istanbul/Turkey.

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 July 8, 2013, provisional acceptance given July 22, 2013, final version accepted August 21, 2013.

Address for correspondence: Dr Ersan Tatli, Department of Cardiology, Ada Tıp Hospital, Sakarya/Turkey. Email: ersantatli@yahoo.com