Challenges of Coronary Access in Acute Coronary Syndrome With Severe Peripheral Arterial Disease: A Fatal Case

Timely coronary angiography (CAG) is pivotal for the management of acute coronary syndrome (ACS). However, in patients with severe peripheral arterial disease (PAD), conventional vascular access through the radial or femoral arteries may be impossible, resulting in critical treatment delays. In this case study, we report a 42-year-old woman who presented with ACS and acute pulmonary edema. Electrocardiography revealed ST-segment elevation in aVR with reciprocal changes, and echocardiography showed inferoposterior wall hypokinesia with reduced ejection fraction (40%). The patient was urgently transferred for CAG. Catheterization revealed complete occlusion of both axillary arteries and the distal abdominal aorta, precluding radial and femoral access. Carotid and superficial temporal artery access were briefly considered but deferred owing to the absence of prior vascular imaging and lack of surgical standby. Computed tomography angiography was planned to evaluate potential alternative routes; however, the patient developed rapid hemodynamic deterioration and died before imaging could be performed. This case highlights the catastrophic implications of unrecognized diffuse PAD in ACS, in which conventional vascular access may be entirely unavailable. In summary, these findings suggest that awareness and early assessment of PAD, particularly in high-risk patients, are essential for anticipating procedural challenges. In extreme cases, unconventional access routes, such as the carotid or superficial temporal arteries, may offer viable, life-saving alternatives if planned in advance with appropriate imaging and surgical support.