V entricular pseudoaneurysm is a contained rupture of the ventricular wall that may occur after myocardial infarction, trauma, infection, transcatheter valve replacement, or cardiac surgery (1-4). It usually occurs in the left ventricle, with very few reports of right ventricular (RV) pseudoaneurysm (3). Left untreated, this serious complication is associated with a 40% incidence of rupture at 1 year (1). Surgical repair is generally considered the standard treatment, but is associated with high morbidity and mortality (2). Percutaneous pseudoaneurysm closure has emerged as a new alternative for high-risk surgical patients. This technique has been described in small case series of patients with left ventricular pseudoaneurysm (1,3,4). We describe a case of an acquired RV pseudoaneurysm following pericardiocentesis, which was successfully treated with percutaneous closure. A 71-year-old man with hypertension, diabetes, atrial fibrillation, morbid obesity, and oxygendependent obstructive pulmonary disease presented with worsening dyspnea and was found to have a large pericardial tamponade. Pericardiocentesis was attempted via the apical route under ultrasound guidance, but images were very limited by body habitus. The attempt was complicated with RV puncture, severe tamponade and shock requiring intubation, and emergent pericardial window. Two days later, an abdominal computed tomography was done after an episode of hematemesis and incidentally revealed an RV pseudoaneurysm. This was further confirmed on transthoracic echocardiogram (Online Video 1). He was at an excessive risk for open repair, and was therefore referred for a percutaneous closure of the pseudoaneurysm. A planning cardiac computed tomography revealed a pseudoaneurysm sac size of 3.6 Â 3.2 cm, and a tortuous neck that measured 15.3 Â 7.9 mm in diameter and 5.1 to 7.2 mm in length (Figures 1 and 2, Online Videos 1, 2). Right ventriculography was performed revealing the RV pseudoaneurysm (Figure 3A, Online Videos 3, 4).FIGURE 1 3D CT Long-Axis View of RV Pseudoaneurysm Cardiac computed tomography (CT) 3-dimensional (3D) reconstruction showing the right ventricular (RV) pseudoaneurysm in long-axis view (arrow). See Online Videos 1 and 2. F ¼ foot; L ¼ left; LA ¼ left atrium; LV ¼ left ventricle; P ¼ posterior; R ¼ right; RV ¼ right ventricle.
Distal embolization due to atherothrombotic debris during subclavian artery interventions is extremely rare and can usually be managed conservatively. Herein, we describe a case of acute hand ischemia due to massive distal embolization during balloon angioplasty and stenting of a left subclavian artery chronic total occlusion. This limb-threatening complication was effectively treated with rescue surgical thrombectomy.
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