Letter to the Editor

Vascular Perforation Occurring During Transradial Cardiac Catheterization is More Common Than Thought and Could Be Fatal

Dear Editors:

In a recently published article in the clinical images section of the Journal of Invasive Cardiology entitled, “A Hydrophilic-Wire Induced Vascular Perforation Causing Mediastinal Hematoma During Transradial Coronary Intervention,”1   the authors describe a case of small artery perforation occurring during transradial cardiac catheterization requiring embolization. They mentioned it as the first case report of its kind. However, this is not a true fact. We have previously published a similar case that required emergent embolization to prevent death due to severe bleeding in the Journal of Invasive Cardiology.2 In our report, we presented a case of pericardiacophrenic artery perforation occurring during wire advancement into the aorta while performing right radial cardiac catheterization, which was treated emergently with coil embolization. These cases emphasize the importance of recognizing this type of complication in the future. The pericardiacophrenic artery can be confused with the aorta, as it has a similar course paralleling the aortic arch and therefore can be inadvertently mistaken for the ascending aorta during wire advancement while performing transradial cardiac catheterization.

Sincerely,

Mohammad Reza Movahed, MD, PhD, FACP, FACC, FSCAI

Clinical Professor of Medicine, University of Arizona Sarver Heart Center; CareMore Regional Cardiology Director, 7091 E. Speedway Blvd., Tucson, AZ 85710. Email: rmova@aol.com

References

1. Guo J, Song J. A hydrophilic-wire induced vascular perforation causing mediastinal hematoma during transradial coronary intervention. J Invasive Cardiol. 2019;31:E96.

2. Arsanjani R, Echeverri J, Movahed MR. Successful coil embolization of pericardiacophrenic artery perforation occurring during transradial cardiac catheterization via right radial artery. J Invasive Cardiol. 2012;24:671-674.


Authors’ Response:

We appreciate the comments by Dr Movahed on our recent publication.1 In our article, we demonstrated a hydrophilic-wire induced perforation of a small branch of the right subclavian artery, resulting in mediastinal hematoma and treated by gel-foam embolization.

  Dr Movahed pointed out a similar previously published article showing pericardiacophrenic artery perforation via right radial artery approach and treated with coil embolization successfully.2 In this article, three types of wires (J-wire, standard Terumo glidewire, and Amplatz super-stiff wire) and catheters (JR5 diagnostic catheter, JL 3.5 diagnostic catheter, and EBU 3.0 guide catheter) were advanced into the right subclavian brachiocephalic junction, and resistance was encountered in advancing the J-wire, JL 3.5 diagnostic catheter, and EBU 3.0 guide catheter at this point; the exact reason behind the perforation (which wires or catheters caused the problem) is still unknown. In fact, Habib et al first described a possible wire-related subclavian artery perforation managed with coated stent in 2012.3

In our study, the first case report indicates there is certainly a strong association between hydrophilic wire traveling into a small branch with perforation located at the corresponding site, demonstrated by cardiac x-ray, CT, and angiographic images and video, which were not provided in the previous report.

In addition, we agree with Dr Movahed and colleagues that a hydrophilic wire can inadvertently enter the small arterial branches, leading to perforation. Operators should be alert for this potential complication.

Sincerely,

Jincheng Guo, MD and Jiahui Song, MD

Department of Cardiology, Beijing Luhe Hospital, Capital Medical University, Beijing, China. Email: guojcmd@126.com

References

1. Guo J, Song J. A hydrophilic-wire induced vascular perforation causing mediastinal hematoma during transradial coronary intervention. J Invasive Cardiol. 2019;31:E96.

2. Arsanjani R, Echeverri J, Movahed MR. Successful coil embolization of pericardiacophrenic artery perforation occurring during transradial cardiac catheterization via right radial artery. J Invasive Cardiol. 2012;24:671-674.

3. Habib N, Jerzewski A, Koomen EM. Subclavian artery perforation complicating coronary angiography. Neth Heart J. 2012;20:288-290.

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