An accidental sheath insertion into the internal thoracic artery during the subclavian vein puncture: bailed out by the sandwich coiling strategy

摘要

A 60-year-old man was admitted to undergo pulmonary vein isolation. After the subclavian puncture using the anatomic landmark approach, since the guidewire appeared to go through the superior vena cava (SVC) and right atrium (RA) into inferior vena cava (IVC) on fluoroscopy, a 7 Fr sheath was placed at the puncture site. However, an electrode catheter could not advance towards the coronary sinus. The angiography from the sheath depicted a right internal thoracic artery (ITA) (Panels A and B and Video 1). Heparin had not been administered yet and we decided to embolize the ITA before the sheath removal. Because the puncture site was just after the ITA ostium, detachable coils were placed at the ostial ITA, being not detached, from the guiding catheter inserted via the femoral sheath (Panel C). On the other hand, a total of five detachable coils were delivered through the misinserted sheath to embolize the distal ITA (Panel D). The sheath was pulled out of ITA, after 17%NBCA-lipiodol was delivered through it. Then the proximal coils were detached, and subclavian venous angiography demonstrated a total ITA occlusion (Panel E and Video 2). Several reports demonstrated the risk of ITA injury during subclavian puncture, but no report has described the direct wire insertion to the ITA, which could, not only allow for the weak arterial backflow at the puncture site but also make the guidewire route confusing on the fluoroscopic anterior-posterior view. In subclavian puncture, it is important to carefully observe how the guidewire tip advance and confirm another fluoroscopic direction as needed. The sandwich coiling to the ITA artery was effective as a bailout strategy.