Pseudoaneurysm of the thyrocervical trunk after coronary intervention from the right radial approach
A 70-year-old male patient was referred to the emergency service with signs and symptoms of acute coronary syndrome. Targeted medical history showed a previous ischemic cerebrovascular event with no residual neurological deficit and well-controlled hypertension. He was transferred to the catheterization laboratory after administration of dual antiplatelet drug loading doses (i.e. ticagrelor 180 mg and aspirin 300 mg). Diagnostic coronary angiography through the right radial artery route indicated normal right and left anterior descending coronary arteries, and a culprit lesion in the left circumflex artery. Subsequently, the left main ostium was engaged with a 6 F Judkins-4 guiding catheter (Cordis corporation, Miami Lakes, Florida, USA). A 0.014 inch floppy guidewire was advanced distally in the LCx and an everolimus-coated stent 2.5×16 mm in size was implanted successfully. A swelling was noticed at the right supraclavicular region immediately after removal of the radial sheath (Fig. 1a). Urgent duplex ultrasonography examination of the neck showed a pulsatile pseudoaneurysm (PsA) with an unclear origin. Contrast-enhanced computed tomography angiography showed a 30×25×28 mm aneurysmal sac that was connected to the right thyrocervical trunk (Fig. 1b and c). The ultrasound-guided repair of the neck of the PsA was performed with 20 min of intermittent compression cycles until the cessation of the flow through the aneurysm neck. After the fourth compression, the flow through the neck of the PsA disappeared and the sac was totally thrombosed (Fig. 1d). The patient was discharged uneventfully and did well at the 2-week follow-up.
The PsA of the thyrocervical trunk is a rare complication after radial access for a percutaneous coronary intervention. The ultrasound and computed tomography are imaging methods of choice for accurate diagnosis. Once recognized, it can be readily repaired with ultrasound-guided compression, with surgery remaining as a last resort for failed cases.