From the Department of Cardiology, Western Infirmary, Glasgow, G11 6NT, United Kingdom. The authors report no conflicts of interest regarding the content herein. Manuscript submitted December 16, 2008, provisional acceptance given February 6, 2009, and final version accepted February 20, 2009. Address for correspondence: Jonathan R. Dalzell, MRCP, Department of Cardiology, Western Infirmary, Dumbarton Road, Glasgow, G11 6NT, United Kingdom. E-mail: firstname.lastname@example.org
_______________________________________________ ABSTRACT: We report the first case of extensive cellulitis and staphylococcal bacteremia with the subsequent development of a remote mycotic pseudoaneurysm in the ipsilateral brachial artery following right transradial coronary angiography in a diabetic patient with previous right axillary node clearance. The potential for serious complication should be borne in mind when deciding on the site of vascular access in such patients.
J INVASIVE CARDIOL 2009;21:E91–E92 An increased risk of cellulitis of the upper limb is a rare but recognized consequence of axillary node clearance for breast carcinoma which can occur seemingly spontaneously or secondary to recognizable traumatic breaks in the skin.1–4 It has never previously been reported following a sterile clinical procedure. Pseudoaneurysm formation at the site of arterial puncture is a well-recognized complication of coronary angiography. To the best of our knowledge the development of a mycotic pseudoaneurysm remote to the site of arterial puncture has never previously been reported. Case Report. A 73-year old female with diabetes, hypertension and coronary artery disease was admitted for outpatient coronary angiography to investigate recurrent chest pain. She had undergone percutaneous coronary intervention 4 years previously, with the implantation of a bare-metal stent to her right coronary artery. Other relevant past medical history included right-sided breast carcinoma requiring wide local excision with axillary node clearance and adjuvant radiotherapy 8 years previously. She had no history of lymphedema. Uncomplicated coronary angiography was performed via the right radial artery using a 5 Fr sheath and 5 Fr Judkins diagnostic catheters, which revealed modest coronary artery disease. She was commenced on appropriate secondary prevention and discharged home later the same day. She represented as an emergency 48 hours later with pyrexia, extensive erythema of her right hand and forearm and an extremely tender right middle finger. Surgical exploration revealed extensive infection involving the flexor tendon sheath with multiple abscesses along the ulnar border and lateral aspect of the right middle phalynx. A surgical washout of the affected area was performed and she was treated initially with 7 days of intravenous flucloxacillin and benzylpenicillin followed by oral flucloxacillin and penicillin V. Wound swabs were negative, but Staphylococcus aureus (methicillin-sensitive) was detected in multiple blood cultures. She made an uncomplicated recovery and was discharged home after 7 days. On attending the cardiology clinic 3 months later, she complained of swelling and discomfort in her right arm. Examination revealed a pulsatile mass in her right antecubital fossa and signs consistent with median nerve compression. An ultrasound confirmed a 2.2 x 1.6 cm wide-mouthed brachial pseudoaneurysm and she was referred to vascular surgery. Surgical exploration revealed a long defect in the brachial artery and a large false aneurysm sac compressing the median nerve (Figure 1). This defect required a vein graft patch to close (Figure 2). She recovered uneventfully, and 1 year later continues to do well. Discussion. Cellulitis in patients with previous axillary node clearance is more common in those with coexistent lymphedema and can occur spontaneously or following recognized traumatic breaks in the skin.1–4 As far as we are aware, there are no published reports of cellulitis following a sterile medical procedure in a territory without lymphatic drainage. In this case, the impairment of local immune surveillance was compounded by the coexistence of diabetes, resulting in the development of an extraordinarily aggressive and extensive infection involving deep-seated structures as well as the overlying skin. Arterial pseudoaneursym formation is a recognized complication of angiography at the arterial puncture site, but in this case, the pseudoaneurysm developed remotely in the brachial artery. There was no suggestion of trauma to the brachial artery during angiography, and there was no visible swelling or hematoma of the arm following the procedure. Staphlycoccus and salmonella are the pathogens most commonly associated with mycotic aneurysm formation, and late representation with a mycotic pseudoaneurysm has previously been reported in an apparently nontraumatized adjacent artery in the context of regional sepsis.5–8 Thus, the likeliest explanation in this case is a mycotic pseudoaneursym resulting from weakening of the arterial wall by the earlier staphylococcal bacteremia. Conclusion. There are currently no official recommendations regarding the approach to percutaneous procedures in patients with axillary node clearance. While breast surgeons strongly advise avoidance of any percutaneous intervention to a limb in which the lymphatic surveillance has been compromised, there is a lack of awareness of this concern in nonsurgical specialties. Given the increasing popularity of the transradial approach to coronary angiography, this case highlights an extremely important consideration when preparing to perform angiography in female patients. This patient experienced considerable morbidity and two surgical procedures requiring general anesthesia as a result of her angiogram. As such, we recommend that the potential for significant complications should be borne in mind when considering the optimal site for vascular access in patients such as this undergoing cardiac catheterization. Acknowledgement. We would like to thank Mr. D. Kingsmore, FRCS, vascular surgeon for supplying the images.
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