Author + information
- Ryo Nishinarita1
Patient initials or identifier number
Relevant clinical history and physical exam
A 80-year-old male with chronic atrial fibrillation (Warfarin 3.5 mg) hospitalized at our hospital complaining at persistent chest pain and cold sweat. He showed sinus bradycardia (HR 52 /min), but not cardiogenic shock on admission.
Relevant test results prior to catheterization
Electrocardiogram revealed ST elevation in II,III,aVf and transthoracic echocardiogram is almost normal. Troponin T elevated slightly (0.03 ng/ml),but CK and CKMB did not elevate in laboratory findings.
Relevant catheterization findings
We performed Cardioangiography (CAG) in an emergency, which revealed Right Coronary Artery(RCA) segment 1 severe stenosis.
We diagnosed acute inferior myocardial infarction and performed Percutaneous Coronary Intervention (PCI) after administering dual antiplatelet therapy (aspirin 100 mg, prasugrel 20 mg). Next day, we had a slight breeding at the redial artery after the compression free and added to compression for two hours. After arresting bleeding, we resumed Warfarin 3 mg (PT-INR 2-2.5). However, radial artery puncture region gradually swelled and changed for skin hematoma (36 mm ×36 mm) with the ulcer three days later. Echocardiogram showed shunt flow for hematoma and we diagnosed radial artery pseudoaneurysms. We stopped prasugrel and started antibiotics, application of ointment and re-pressed to the shunt blood vessels. Shunt flow disappeared two days later in echocardiography and hematoma reduced. After compression free in 17 days, we applied ulcer treatment cream and protected with gaze and pressure bandage. He discharged from our hospital without re-bleeding and hematoma enlargement. This is high risk case of bleeding and triple antithrombotic therapy and insufficient compression for wound made radial artery pseudoaneurysms with refractory ulcer.
Surgical procedure could be considered the patient with big size pseudoaneurysms, high risk of rupture and insufficient compression case, however, we experienced the case showing that pressure bandage and hemostatic device as initial treatment was effective for radial artery pseudoaneurysms. Transradial coronary procedures is lower rate than other approach procedure in terms of complication, however, it is necessary to manage medication and assess the risk of bleeding in each case on triple antithrombotic therapy.