Coronary Embolization of an Avulsed Radial Arterial Wall Fragment During Transradial PCI

Transradial access is the preferred approach for coronary interventions, but vascular complications may rarely lead to unexpected coronary events.

A 50-year-old woman with cardiovascular risk factors presented with exertional symptoms and a positive stress echocardiography result in the anterior territory. Coronary angiography via right radial access revealed a significant mid-left anterior descending coronary artery lesion. During ad hoc percutaneous coronary intervention (PCI), difficult catheter advancement due to radial resistance and spasm required escalation to a long guide sheath. After guidewire placement, angiography revealed a new hazy filling defect at the proximal left anterior descending coronary artery-left circumflex coronary artery bifurcation, associated with chest pain and ST-segment elevation. Thromboaspiration restored coronary flow, retrieving a 3-cm vascular fragment. Histopathology confirmed an avulsed radial arterial wall fragment containing the 3 layers of the vascular wall. Upper limb imaging showed preserved radial flow.

This case illustrates coronary embolization secondary to radial arterial wall injury during transradial PCI.

Difficult catheter advancement during transradial PCI may cause radial arterial wall avulsion with subsequent coronary embolization. Unexpected angiographic filling defects should prompt consideration of nonthrombotic embolic mechanisms and rapid bailout strategies.