Unusual Vascular Complications Associated with Transradial Coronary Procedures Among 10,324 Patients: Case Based Experience and Treatment Options

Radial artery pseudoaneurysm a rare complication after coronary angiography: A case report and systematic review of the reported cases

This is a case of 83 years old male who had radial artery pseudoaneurysm after cardiac catheterization. The diagnosis was through Doppler ultrasound and the patient was treated with thrombin injection and reported good outcomes. The literature also included 41 cases of pseudoaneurysm after catheterization. The mean age of patients was 68.5 years with a male prevalence of 49%. Onset of pseudoaneurysm ranged from 0 days (directly after the catheterization) to 150 days with a median of 5 days. The treatment of patients was mainly surgical (19 cases) followed by compression (either manual or TR band) (12 cases), thrombin injection (four cases), compression then surgery (three cases), compression then thrombin injection (one case), percutaneous endovascular repair using a covered stent (one case) and not reported in one case. All cases recovered well.

Giant thoracic hematoma post-transradial coronary angiography: a case report and review of the literature

BACKGROUND

Although there are cardiac interventional procedures, certain transradial access complications might be life-threatening.

CASE PRESENTATION

A 67-year-old male was admitted for coronary angiography due to chest tightness and shortness of breath on exertion. Hours after the right transradial access angiography, the patients complained the right side of chest pain. Emergent chest X-ray revealed a giant mass in the right chest. The right radial artery was reaccessed and subsequent arteriograms confirmed that the presence of a rupture of the branch of right internal mammary artery. Simultaneously, a microcoil was implanted to seal the perforation. The perforation caused a thoracic hematoma measuring 13.8 cm × 6.7 cm, along with a decrease in hemoglobin concentration from 14.1 g/dL to a minimum of 7.8 g/dL. Additionally, the drainage of the hematoma and red blood cells transfusion were carried out. Further, the patient underwent ascending aortic replacement, aortic valve replacement, mitral valve replacement, and thoracic hematoma removal. Postoperative echocardiography showed that the prosthetic valves were properly positioned and functioning normally. The patient recovered well after the surgery and remained event-free during the latest 14moth follow-up period.

CONCLUSIONS

Vascular perforation and subsequent hematoma might occur due to guidewire maneuvering during transradial approach. Awareness of prevention, early recognition and management of access complications may help reduce the occurrence and severity of complications related to the transradial approach.

Ultrasound Assessment of Postprocedural Arterial Pseudoaneurysms: Techniques, Clinical Implications, and Emergency Department Integration

This narrative aims to evaluate the efficacy of point-of-care ultrasound (POCUS) in the early diagnosis and management of postprocedural arterial pseudoaneurysms in the emergency department (ED). We hypothesize that POCUS can be used as the first line of imaging to distinguish vascular from non-vascular causes and diagnose a pseudoaneurysm if present. A comprehensive review of cases involving postprocedural pseudoaneurysms was conducted. We focus on patients who underwent endovascular procedures, including transfemoral and transradial arterial access for cardiac interventions, or received laceration repair after blunt head trauma. We analyzed each case's clinical symptoms, POCUS findings, and subsequent management. POCUS demonstrated high efficacy in early diagnosis by detecting pseudoaneurysm sacs with characteristic bi-directional flows (yin-yang sign) and, in some cases, partial thrombosis. The early identification of potential arterial complications allowed for efficient planning of further imaging and expedited surgical consultation, leading to timely and definitive management. Our study emphasizes the significance of using POCUS as the primary imaging modality for early detection and diagnosis of postprocedural arterial pseudoaneurysms. Incorporating POCUS into the initial assessment of patients presenting with pain and swelling at the site of arterial access or laceration repair can streamline consultation and potentially reduce the need for additional imaging, optimizing patient care in the ED setting.

Distal versus conventional radial artery access for coronary catheterization: A systematic review and meta-analysis

BACKGROUND

The distal radial artery (DRA) access is an alternative to the conventional radial artery (CRA) access for coronary angiography and interventions and appears to be associated with reduced incidence of certain outcomes.

METHODS

A systematic review was performed to evaluate differences between DRA versus CRA access for coronary angiography and/or interventions. Following preferred reporting items for systematic review and meta-analysis-protocols guidelines, two reviewers independently selected studies published in the electronic databases (MEDLINE, EMBASE, SCOPUS, CENTRAL) from inception to October 10, 2022, followed by data extraction, meta-analysis, and quality assessment.

RESULTS

The final review included 28 studies with (total: 9151 patients [DRA: 4474; CRA: 4677]). Compared with CRA, DRA access was found to be associated with a shorter time to achieve hemostasis (mean difference, MD: -32.49 [95% confidence interval, CI: -65.53, -2.46], p < 0.00001), and reduced incidence of radial artery occlusion (RAO) (risk ratio, RR: 0.38 [95% CI: 0.25, 0.57], p < 0.00001), any bleeding (RR: 0.44 [95% CI: 0.22, 0.86], p = 0.02), and pseudoaneurysm (RR: 0.41 [95% CI: 0.18, 0.99], p = 0.05). However, DRA access has increased access time (MD: 0.31 [95% CI: -0.09, 0.71], p < 0.00001) and crossover rates (RR: 2.75 [95% CI: 1.70, 4.44], p < 0.00001). There were no statistically significant differences in other technical aspects and complications.

CONCLUSION

DRA access is a safe and feasible approach for coronary angiography and interventions. Compared to CRA, DRA provides a shorter hemostasis time, lower incidence of RAO, any bleeding, and pseudoaneurysm, and is associated with increased access time and crossover rates.

Complications of catheter ablation for ventricular tachycardia

With the increasing literature demonstrating benefits of catheter ablation for ventricular tachycardia (VT), the number of patients undergoing VT ablation has increased dramatically. As VT ablation is being performed more routinely, operators must be aware of potential complications of VT ablation. This review delves deeper into the practice of VT ablation with a focus on periprocedural complications.

A Concurrent Pseudoaneurysm and an Arteriovenous Fistula Following Percutaneous Radial Artery Access

The incidence of radial artery cannulation resulting in the concurrent development of a pseudoaneurysm and an arteriovenous fistula is not well defined. Here, we present the case of a 42-year-old man who developed an iatrogenic pseudoaneurysm (PSA) and a concurrent arteriovenous fistula (AVF) following multiple right radial artery cannulations. Access was obtained for a preoperative diagnostic cardiac catheterization and again for hemodynamic monitoring intraoperatively during a surgical aortic valve replacement. A palpable thrill over the right radial artery developed and persisted for nine months, leading to anxiety and mental fixation on the thrill. There were no other symptoms. Given a failed resolution with conservative care for the same duration, the patient elected to proceed with surgical resection. Following resection, the patient reported resolution of his symptoms and decreased anxiety. A follow-up targeted arterial ultrasound demonstrated no residual PSA or AVF.

Open resection for a large iatrogenic radial artery pseudoaneurysm. Case report

INTRODUCTION AND IMPORTANCE

We present the case in which a large symptomatic pseudoaneurysm (PSA), 6 × 5 cm, with one year of evolution on the path of the right radial artery (RRA) appeared after its punction and cannulation for performing cardiac catheterism in an atrial fibrillation (AF) indefinite anticoagulated patient. Diagnosis and surgical planning were consolidated only by using color duplex ultrasound (CDU), contrasted images were not indicated. The open surgical management was performed during a short-time supraclavicular blockade of peripheral nerves without stopping nor bridging anticoagulant therapy. Complete excision of the deforming mass with no blood loss, decompression of the adjacent structures and direct closure of the arterial defect without compromising of its lumen and path were also achieved.

CASE PRESENTATION

A 74-year-old, Hispanic male patient and former smoker underwent coronary catheterization for thoracic typical pain. One year after, he is admitted for move restrictive pain in distal right forearm and hand paresthesia related to a rapidly growing right radial artery PSA of 6 cm in diameter where the indefinite anticoagulation, indicated for chronic AF, confers a risk of major bleeding. After clinic and exclusive CDU assessing, the patient granted us written authorization for performing an open surgery. One year follow up showed an asymptomatic patient with no RRA residual lesions.

CLINICAL DISCUSSION

Although contrasted are the preferred diagnosis methods when arterial issues are suspected especially angiography since, when indicated, the endovascular treatment may be performed immediately after diagnosis. The CDU performed with a high-sensitivity transducer is the image of choice for an immediate differential diagnosis (Meola et al., 2021 [1]). In addition, it allowed us to see both, the particular PSA inside structure and the patency of ipsilateral ulnar artery, necessary details to propose the successful open surgical treatment finally conducted.

CONCLUSION

Vascular and trauma surgeons should be trained to ensure the correct diagnosis based on preexisting medical conditions, clinical findings and those provided by CDU in order to offer an appropriate and definitive management to peripheral vascular iatrogenic lesions with potential bleeding risk, especially in anticoagulated patients. Since large limb deforming PSAs are recommended to be excided through open access, they should also be trained to perform it without additional risks nor sequelae. Since the number of AF patients is increasing worldwide, main aspects on anticoagulation therapy have to be taught to every surgical team.

Radial arteriovenous fistula complicated with ischemic steal syndrome after transradial cardiac catheterization: a case report and literature review

Background

The radial arteriovenous fistula (AVF) is a rare complication occurring after transradial cardiac catheterization. Patients with AVF typically present with signs of venous dilation, such as swelling or palpable thrills. However, neurological complications secondary to radial AVFs are rare. This paper reported a rare case of ischemic steal syndrome that occurred 11 months after the transradial cardiac catheterization, most likely as a consequence of radial arteriovenous fistula.

Case presentation

This paper described a case of a 73-year-old female, who complained of right forearm swelling and radial 1–3 fingers numbness for several months after the catheterized stent surgery through radial approach. Upon Clinical examination, this patient presented with a slight bump and palpable thrill at the distal third of right forearm, and the sensory of radial 1–3 fingers and pinch force was compromised. The Ultrasonography and computed tomography angiography (CTA) of the upper extremity revealed AVF between the right radial artery and the adjacent vein. Microsurgery was performed successfully to ligate the fistula and reconstruct the radial artery. The numbness has gradually improved about 1 week after the surgery, with no recurred swelling. The two-point pinch force and digital sensitivity recovered at the 20-month follow-up. What’s more, due to the scarcity of cases, the optimal therapy for iatrogenic radial AVF is controversial. Accordingly, we provided a literature review of previous reports of catheter-related radial AVFs and proposed an algorithm to manage them.

Conclusions

We believe that once an AVF is diagnosed, early treatment options such as compression or surgery are necessary to relieve symptoms and prevent further complications. Otherwise, serious complications can occur, including the ischemic steal syndrome.

Minimizing Guidewire Unwilling Passage and Related Perforation During Transradial Procedures: Prevention Is Better Than Cure

Background

Current guidewires for transradial coronary angiography had defects of passage difficulty or branch injury. This study sought to investigate the safety and efficiency of a novel method of active knuckle-angle 0.035-inch hydrophilic guidewire in transradial coronary angiography.

Methods

Patients undergoing a transradial coronary procedure in our team from August 2015 to June 2020 were retrospectively investigated. We compared the demographic and interventional characteristics of 1,457 patients receiving advancement of unmodified guidewires (Traditional group) and 1,322 patients receiving advancement of the knuckle guidewire (Knuckle group). Afterwards we included 239 patients and randomized them according to a random number table to either the unmodified or the knuckle guidewire to further confirm the efficiency and safety of knuckle guidewire advancement.

Results

In the retrospective analysis, unwilling passage of guidewire into branches occurred more in the Traditional group than in the Knuckle group (9.5 vs. 0.08%, p < 0.001). Two patients in the Traditional group experienced guidewire-associated perforation. One patient was treated with covered stent for internal mammarian artery perforation, while the other was managed with compression for brachial branch perforation. In the randomized controlled study, unwilling passage of guidewire also occurred more in the Traditional group (10.8 vs. 1%, p < 0.001). Median duration of guidewire advancement from the sheath to aortic root significantly decreased from 33 seconds in the Traditional group to 21 seconds in the Knuckle group.

Conclusion

Active knuckle angle guidewire represented a novel method to prevent unwilling passage and associated perforation with efficiency improvement and a reduction in radiation exposure.

Life-threatening subclavian artery bleeding following percutaneous coronary intervention with stent implantation: A case report and review of literature

BACKGROUND

Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. Life-threatening vascular complications during transradial PCI therapy, such as vessel perforation and dissection in the brachiocephalic, subclavian, internal mammary, and thyrocervical arteries, are rarely reported. Subclavian artery bleeding is a potentially serious complication of vascular interventional procedures leading to tracheal obstruction, hemothorax, respiratory failure, hemorrhagic shock, and death if not diagnosed early and treated promptly.

CASE SUMMARY

A male patient with typical angina pectoris underwent coronary angiography and stent implantation. During the procedure, the patient felt pharyngeal pain and tightness, which we mistook for myocardial ischemia. After PCI, swelling in the right neck and supraclavicular area was observed. The patient experienced dyspnea, emergency endotracheal intubation was performed, and then a sudden drop in blood pressure was observed. Ultrasound and contrast-enhanced computed tomography scans demonstrated a cervical hematoma severely compressing the trachea due to subclavian artery bleeding. Brachiocephalic angiography revealed a vascular injury site at the root of the right subclavian artery at the intersection of the right common carotid artery. A covered stent was deployed to the right subclavian artery with successful sealing of the perforation, and a bare stent was implanted in the junction of the right common carotid and brachiocephalic arteries to prevent obstruction of blood flow to the brain.

CONCLUSION

Subclavian artery bleeding is a lifethreatening complication of PCI. Early prevention, rapid recognition, and prompt treatment may improve the prognosis.

Profile and outcomes of patients with mediastinal hematoma after cardiac catheterization: A retrospective analysis

OBJECTIVE

To provide a comprehensive introduction of mediastinal hematoma.

BACKGROUND

Mediastinal hematoma is a rare complication that is usually not considered in the differential diagnosis of chest pain after cardiac catheterization.

METHODS

From January 1, 2006, to December 31, 2013, at Fuwai Hospital, 126,265 patients underwent coronary angiography (CAG); 121,215 of them underwent CAG via the radial artery. Ultimately, 10 patients with mediastinal hematoma due to cardiac catheterization were included. Patients' clinical characteristics, diagnosis, treatment, and prognosis were retrospectively analyzed.

RESULTS

The incidences of mediastinal hematoma in cardiac catheterization and transradial cardiac catheterization were 0.79‱ and 0.74‱, respectively. A super slide hydrophilic guidewire was used in all 10 patients with mediastinal hematoma. These patients felt chest pain and dyspnea during/after the procedure, and computed tomography (CT) was used to diagnose mediastinal hematoma. Among them, two patients had a neck hematoma. The post-procedural hemoglobin level decreased substantially in all patients. Antiplatelet therapy was discontinued for 8-20 days in three patients without stents implanted, and then only oral aspirin was prescribed. Aspirin was transiently discontinued for 2 days in one patient undergoing percutaneous coronary intervention. The others continued taking dual antiplatelet drugs. Two patients received blood transfusion. There was no case of stent thrombosis, and surgery was not indicated for any patient. No complication was observed after discharge during the 9.0 ± 2.5-year follow-up.

CONCLUSION

CT should be performed as early as possible in patients with suspected mediastinal hematoma. The prognosis of mediastinal hematoma is usually good with early diagnosis and suitable therapy.

Pseudoaneurysm and Arteriovenous Fistula in the Radial Artery after Cardiac Catheterization: A Case Report

We report the case of a 71-year-old man who was experiencing a gradually worsening, dull pain and a cold sensation in his right hand. Three months earlier, he underwent a percutaneous coronary intervention for angina pectoris using a transradial approach in his right wrist and developed an arteriovenous fistula (AVF), a complication of percutaneous coronary intervention. Ultrasonography and computed tomography revealed a pseudoaneurysm and an AVF that were reducing the blood flow in his right hand. We observed that the pseudoaneurysm and the AVF were close to the bifurcation of the superficial palmar artery (SPA) and that the superficial palmar arch had radial artery superiority. Because we thought it was important to maintain the blood flow of the SPA branch, we excised the pseudoaneurysm, sutured the artery directly via microsurgery, and ligated the arteriovenous shunt. After the operation, the patient's symptoms were alleviated. Computed tomography showed that the blood flow in his right hand was improved and that his right SPA branch from the radial artery was directly fed to the index finger. Because the blood circulation in the hand is dual dominant but with many anatomical variations, we believe that it is important to preserve the blood flow of the SPA in postcatheterization pseudoaneurysm and AVF repair.

Radial Artery Pseudoaneurysm Following Cardiac Catheterization: A Case Report

The transradial approach is the most preferred method for cardiac catheterization. The radial route approach has many advantages, including fewer puncture site-related complications and early mobility and discharge. The vascular complications include radial artery spasms, occlusions, dissections, perforations, and compartment syndrome. Although pseudoaneurysms are a well-known complication of femoral access (0.2%-3%), pseudoaneurysms are very infrequent (0.05%) after radial artery access. Very few cases of radial pseudoaneurysms have been reported to date. We present a rare case of an 82-year-old man on dual antiplatelet and anticoagulant therapy who underwent coronary angiography via the radial route. The patient developed a pseudoaneurysm requiring surgical intervention.

Percutaneous endovascular exclusion of radial artery pseudoaneurysm

BACKGROUND

Coronary angiography and intervention through transradial approach is becoming default approach because of infrequent local site complications. Although pseudoaneurysm is a well described complication for femoral access, it is extremely rare in transradial access.

CASE REPORT

Our patient was 68-year old female who had presented with pulsatile, painful, and gradually increasing swelling over lower part of right forearm near wrist joint for past 8-weeks following coronary angiography through right radial route. Swelling did not resolve following manual compression. It was diagnosed as pseudoaneurysm arising from right radial artery by duplex ultrasound. It was successfully excluded by deploying 3.5x18mm Graftmaster covered stent (Abott Vascular, USA) through right transbrachial route. Ultrasonography next day revealed partially thrombosed and completely excluded pseudoaneurysm with swelling completely disappearing at 6 weeks with patency maintained at one year.

CONCLUSION

With increasing use of transradial access, more cases of radial pseudoaneurysm are likely to surface which can be prevented following a proper haemostatic protocol. To best of our knowledge, it is first ever report of percutaneous endovascular exclusion using covered stent of radial pseudoaneurysm through transbrachial approach.

Mycotic aneurysm of the distal radial artery after cardiac catheterisation

A mycotic aneurysm of the distal radial artery following access for cardiac catheterisation is a rare complication that has not been described in the literature. We present the case of an 84-year-old man who developed bacteraemia and cellulitis over his left first dorsal webspace 2 days after undergoing cardiac catheterisation through the distal radial artery at the anatomic snuffbox. Ultrasound scanning and CT imaging were concerning for a possible pseudoaneurysm at that location. Once we confirmed that the patient had adequate flow through his hand with angiography and an Allen's test, we explored his left hand and found a mycotic aneurysm of the distal radial artery with surrounding frank purulence. We resected the aneurysm and ligated the artery. Pathology confirmed that this was a mycotic aneurysm. The patient quickly recovered from his infection after this definitive treatment.

Development of a nursing outcome for a percutaneous procedure

OBJECTIVES

To develop a nursing outcome, consistent with the standardized format of outcomes within the nursing Outcomes Classification (NOC). This outcome will include an outcome label, an outcome definition, and clinical indicators. The proposed use for this outcome is to evaluate the access site of a percutaneous procedure.

METHODS

Concept analysis with a scoping review. Initially, content experts were recruited to validate the indicators of the proposed outcome in order to complete a consensus validation. After consensus validation, a review of the proposed outcome and its indicators was completed by two of the editors of the NOC team to confirm that the outcome label, definition, and indicators were consistent with the NOC taxonomy. During this review, edits were made on the label name and definition.

FINDINGS

After a series of reviews, the initial outcome of Vascular Status: Percutaneous Procedure Access was changed to Tissue Injury Severity: Percutaneous Procedure. In addition, the original definition of the condition of an access site for percutaneous procedure by venous or arterial puncture and health of surrounding tissues was edited to: Severity of complications from a needle-puncture access through the skin and into deeper tissues. The outcome has 11 indicators to be used to formulate a target rating for use in the clinical setting. The indicators were not edited over the course of the reviews.

CONCLUSION

The proposed outcome will assist nurses in evaluating the access site of percutaneous procedures and in identifying possible complications.

IMPLICATIONS FOR THE NURSING PRACTICE

This research contributes to the refinement of the NOC taxonomy by having a new outcome that meets clinical practice needs.

Hypotension, Tachypnea, and Stridor Following Radial PCI: Solving the Conundrum

The radial artery route is being increasingly used by interventional cardiologists as a default access site for both diagnostic and interventional coronary procedures, and although rare, serious complications can occur. We herein report a potentially catastrophic complication of radial percutaneous coronary intervention (PCI) in the form of a large mediastinal and retro-left-atrial hematoma from possible subclavian artery injury with tracheal compression and stridor in a 60-year-old female presenting with anteroseptal myocardial infarction having undergone PCI of the left anterior descending artery through right radial access and then planned for a second stage PCI of the right coronary artery. The patient was managed conservatively with close hemodynamic and echocardiographic monitoring, inotrope support, and blood transfusions. Transradial PCI, despite having a better safety profile in terms of bleeding compared to transfemoral PCI, is not without complications. Manipulation of hydrophilic guidewires as well as diagnostic catheters while performing radial procedures can cause injury to conduit vessels, potentially leading to intrathoracic, axillary, and arm hematomas may remain undetectable in the cath lab, presenting late and can pose a diagnostic and management challenge. Decision to proceed toward repeat interventional/surgical/"wait and watch" strategy should be guided by the patient's clinical status and noninvasive imaging.

Iatrogenic Radial Artery Injuries: Variable Injury Patterns, Treatment Times, and Outcomes

Background: The radial artery is commonly accessed for arterial blood sampling, invasive blood pressure monitoring, and vascular access for cardiac catheterization. Iatrogenic radial artery injury is a rare complication with potentially devastating outcomes. The purpose of our study was to identify the timing of these injuries and define a treatment algorithm. Methods: A retrospective chart review of all patients with iatrogenic radial artery injuries were identified between the years 2008 and 2018. Patient demographics, mechanism of injury, interventions, and outcomes were recorded. Results: A total of 18 patients were identified with iatrogenic radial artery injury over a 10-year period. Fifty percent of these resulted from arterial line cannulation, and 50% occurred after transradial cardiac catheterization. Thirty-three percent resulted in radial artery pseudoaneurysm (RAP), and 66% had acute radial artery thrombosis (RAT). Eleven of the 18 patients underwent operative intervention. Of the 12 patients with RAT, 4 were treated with systemic anticoagulation for 3 months. All patients with RAP who were surgically treated had resolution of symptoms on follow-up evaluation. Of the patients with RAT, 2 had persistent sensorimotor deficits after treatment, and 1 patient had multiple necrotic fingers requiring amputation. Conclusion: Radial artery injuries are an uncommon but potentially devastating complication of common invasive procedures resulting in thrombosis, pseudoaneurysm, or overt hand ischemia. The treatment options vary depending on presenting symptoms.

Fatal vascular complications during transradial percutaneous coronary intervention: A case report

RATIONALE

Vascular complications of transradial percutaneous coronary intervention (PCI) are rare and usually occur at the access site below the elbow. However, vessels along the tract of the wire or catheter can be injured at any point, causing various types of bleeding complications.

PATIENT CONCERNS

A 57-year-old man visited due to chest discomfort. Coronary angiography showed significant stenosis at the distal right coronary artery (RCA). Immediately after the coronary guidewire was passed through the distal RCA, he started a vigorous cough. The voice changed, dyspnea occurred within minutes, and lip cyanosis and stridor were observed. After endotracheal intubation, successful stenting of the distal RCA was achieved. He was extubated at 30 minutes after coronary stenting, but 1-hour post-extubation, his blood pressure suddenly decreased to 70/50 mmHg.

DIAGNOSIS

Mediastinal widening was newly noted on chest X-ray, and blood hemoglobin was decreased. Contrast-enhanced chest computed tomography showed mediastinal hematoma, tracheal compression, and hemothorax. Contrast extravasation was noted in the terminal branches of the inferior thyroid artery on brachiocephalic angiography.

INTERVENTIONS

Successful hemostasis was achieved with endovascular embolization therapy using a Tornado embolization microcoil, Gelfoam gelatin sponge, and Histoacryl glue. The next day, the mediastinal hemorrhage was drained by mediastinoscopy. The endotracheal intubation and ventilator care were maintained for 2 days, and 6 units of packed red blood cells were transfused. Antithrombotics were used to prevent stent thrombosis, and antibiotics to control infection, respectively.

OUTCOMES

After successful hemostasis, thrombocytosis and high on-treatment platelet reactivity that disappeared at 2 weeks post-discharge were noted. Follow-up chest imaging showed the normalized mediastinal widening. At 14 months post-discharge, the patient remains healthy.

LESSONS

As life-threating vascular complications, such as brachiocephalic, subclavian vessel dissection, and vessel perforation in the internal mammary, costocervical, and thyrocervical arteries, can occur anytime during transradial PCI, the intervention cardiologist should be well aware of it and have the appropriate countermeasures implemented in the routine procedure.

Radial artery pseudoaneurysm as a rare very late complication of transradial cardiac catheterization

AIMS

Here, we report a case of very late (70+ days) development of pseudoaneurysm on the site of sheath insertion in a 60- year old woman.

METHODS

The patient underwent cardiac catheterization using transradial approach.

RESULTS

Despite the transradial approach, which is generally considered as a suitable prevention of this problem, and despite absence of any periprocedural complications, the patient developed a pseudoaneurysm after more than 70 days from the procedure.

CONCLUSIONS

In some cases, a pseudoaneurysm may develop extremely late after cardiac catheterization. Such an extremely late development of pseudoaneurysm has not been described in literature so far.

Update on complications and their management during transradial cardiac catheterization

Introduction: Transradial artery access (TRA) was introduced in 1989 and has been universally used as an alternative approach to the traditional transfemoral access (TFA). Complications of TRA include asymptomatic and less likely symptomatic radial artery occlusion, nonocclusive radial artery injury, radial artery spasm, radial arterial perforation, radial artery pseudoaneurysm, arteriovenous fistula, granuloma formation, access-site bleeding, nerve damage, complex regional pain syndrome along with other rare complications.Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 1 May 2019). Authors reviewed all articles related to transradial artery catheterization, its complications, as well as novel techniques for their management. The article provides insight on the incidence, risk factors, and prevention of such complications along with a description of usual and newer techniques to decrease morbidity.Expert opinion: With increasing experience, TRA complication rate is decreasing and new very uncommon complications are being described. A 'radial first' approach should be implemented in all catheterization laboratories and a physician's familiarity with minor and major complications is a must. Distal radial artery access through the snuff box might be the preferred site of accessing the radial artery and further studies will be needed to prove its superiority to the current access site.

Is trans-radial approach related to an increased risk of radiation exposure in patients who underwent diagnostic coronary angiography or percutaneous coronary intervention? (The SAKARYA study)

OBJECTIVE

It is still debatable whether diagnostic coronary angiography (CA) or percutaneous coronary interventions (PCIs) increase radiation exposure when performed via radial approach as compared to femoral approach. This question was investigated in this study by comparison of dose-area product (DAP), reference air kerma (RAK), and fluoroscopy time (FT) among radial and femoral approaches.

METHODS

All coronary procedures between November 2015 and November 2017 were assessed; and 4215 coronary procedures were enrolled in the study. Patients with bifurcation, chronic total occlusion, cardiogenic shock, or prior coronary artery bypass surgery were excluded. These 4215 procedures were evaluated for three different categories: diagnostic CA (Group I), PCI in patients with stable angina (Group II), and PCI in patients with ACS (Group III).

RESULTS

Age was significantly higher in the femoral arm of all groups. Among patients in the radial arm of Groups I and II, males were over-represented. Therefore, a multiple linear regression analysis with stepwise method was performed. After adjusting these clinical confounders, there was no significant difference with regard to DAP, RAK, and FT between femoral and radial access in Group I. In contrast, PCI via radial access was significantly associated with increased DAP, RAK, and FT in Groups II and III.

CONCLUSION

In spite of an increased experience with trans-radial approach, PCI of coronary lesions via radial route was associated with a relatively small but significant radiation exposure in our study. Compared to femoral access, diagnostic CA via radial access was not related to an increased radiation exposure.

Iatrogenic Radial Recurrent Artery Perforation in Coronary Intervention

An 80-year-old man underwent percutaneous coronary intervention of the left anterior descending coronary artery for intractable angina. During catheter advancement, he experienced an iatrogenic perforation of the radial recurrent artery that was successfully managed by covered stent placement in the radial artery, effectively occluding the radial recurrent branch. (Level of Difficulty: Intermediate.)

Development and treatment of two distinct pseudoaneurysms following transradial coronary catheterization in a patient with high bleeding risk: a case report

Background

A pseudoaneurysm is a rare but serious complication after transradial coronary catheterization. Although different treatment modalities have been proposed to treat post-catheterization pseudoaneurysm, only limited data are available to guide the treatment approach.

Case presentation

We report a rare case of two distinct pseudoaneurysms complicating transradial percutaneous coronary intervention in a 75-year-old Hispanic woman being treated with dual antiplatelet agents for myocardial infarction and warfarin for atrial fibrillation. The pseudoaneurysms were diagnosed with ultrasound and were successfully treated with a series of Terumo Corporation (TR) band compressions.

Conclusions

This case demonstrates the efficacy of compression therapy in managing post-catheterization radial artery pseudoaneurysm in patients with high bleeding risk.

Pseudoaneurysm: a rare complication of distal transradial access in the anatomical snuffbox

BACKGROUND

This report presents a case of distal radial artery pseudoaneurysm following cardiac catheterization and its successful endovascular management. Due to its novelty as a catheterization site, few to no reports exist regarding the complications associated with distal radial access.

CASE PRESENTATION

A patient presented to the emergency department with severe wrist and hand swelling 48 h after successful cardiac catheterization via distal radial artery access. Angiography revealed a pseudoaneurysm which was embolized with Onyx™. Post intervention angiogram showed exclusion of the pseudoaneurysm and preservation of the left palmar arch vasculature.

CONCLUSION

The case presented herein demonstrates a rare complication of distal radial access at the anatomical snuffbox.

Arteriovenous fistula after radial catheterization with cardiopulmonary repercussions

This article describes the case of an 86-year-old coronary disease patient who underwent cardiac catheterization via a left radial access. Around 16 months after the procedure, he presented with dyspnea, unrelated to effort, but associated with nocturnal hypoxia. There was a palpable thrill in the left wrist and he was diagnosed with a radiocephalic arteriovenous fistula in the left wrist. A duplex scan revealed an abnormal wave pattern and increased diastolic velocity compatible with arteriovenous fistula. The fistula was repaired surgically and the patient exhibited improvement in clinical and laboratory parameters after the procedure. Radial access is increasingly being used for cardiac catheterization, primarily because it is associated with fewer and less harmful complications than femoral access. However, complications such as arteriovenous fistula occur and can be particularly harmful in octogenarian patients.

Salvage therapy for subclavian artery perforation resulting in mediastinal hematoma during percutaneous coronary intervention: A case report

RATIONALE

Transradial access (TRA) is a widely used technique during percutaneous coronary intervention (PCI). However, mediastinal and cervical hematomas, the rare and severe complications of transradial approach, have extremely high mortality rates. To the best of our knowledge, there were no medical literatures about the successful anticoagulation reversal procedure of mediastinal hematoma in PCI till now.

PATIENT CONCERNS

We here present a 54-year-old male Han patient who underwent PCI. Immediately after PCI, he reported an episode of neck and chest discomfort, dyspnea, cough recurrence, and cold sweats. Emergency chest computed tomography (CT) revealed a perforation of the subclavian artery resulting in a large mediastinal hematoma with potentially lethal tracheal compression.

DIAGNOSIS

A diagnosis of the large mediastinal hematoma was made based on the enhanced computed tomography.

INTERVENTIONS

The patient was successfully managed with palliative therapy of anticoagulation reversal instead of a covered stent graft and surgical operation.

OUTCOMES

Angiography confirmed the absence of leakage after anticoagulation reversal. The patient had an apparent remission of clinical dyspnea. Follow-up CT confirmed an almost entire absorption of the mediastinal hematoma 35 days postdischarge.

LESSONS

The current case highlights the importance of anticoagulation reversal as well as careful guidewire and guide catheter manipulation by the radial approach. Early evaluation, prompt identification, appropriate treatment, and close monitoring are all essential for invasive cardiology.

Identifying Complications and Optimizing Consultations following Transradial Arterial Access for Cardiac Procedures

BACKGROUND

The radial approach to cardiac procedures has become increasingly common. Although previous studies have suggested a favorable risk profile, serious complications can occur. The purpose of this study is to examine the incidence, subsequent treatment, and outcome of all suspected significant neurovascular complications following transradial cardiac procedures at a large US hospital.

METHODS

We reviewed all patients who underwent a left heart catheterization, coronary angiogram, or percutaneous coronary intervention via the transradial approach at a single large academic medical center in the United States between 2010 and 2016. Consultations to the vascular and hand surgery services were examined to assess demographic variables, risk factors, presenting symptoms, subsequent treatment, and outcome of all serious complications.

RESULTS

A total of 9,681 radial access cardiac procedures were performed during the study period. Twenty-four cases (0.25%) were suspected to have major complications and subsequently received consults. A total of 18 complications were diagnosed, including 8 vascular injuries or perforations, 4 hematomas, 4 radial artery occlusions, 1 case of compartment syndrome, and 1 severe radial artery spasm. Of the complications noted, 3 (16.7%) required operative interventions, but all recovered neurovascular function.

CONCLUSIONS

Radial artery access for cardiac procedures has become increasingly common and has been associated with a low rate of major peripheral neurovascular complications. The majority (83.3%) of complications were successfully treated with a nonoperative management algorithm.

Effect of transient ulnar artery compression on radial artery diameter

The transradial approach is widely preferred in coronary procedures. A small radial artery diameter (RAD) is the most important factor affecting successful access. Various maneuvers and medications have been used to increase the RAD and thereby facilitate RA cannulation. Ulnar artery compression (UAC) for 30 min has been indicated to be effective in increasing the RAD and facilitating RA access. The aim of the present preliminary study was to assess the effect of transient UAC for 1 min on the RAD. A total of 151 patients were included in the present study. RA ultrasonography was performed at the level of the wrist. The UA was compressed for 1 min. The RAD was measured at baseline, at the end of UAC and at 1 min thereafter. The results indicated that the RAD was significantly smaller in diabetic vs. non-diabetic patients (2.35±0.43 vs. 2.50±0.39 mm, P=0.024) and in women vs. men (2.25±0.38 vs. 2.56±0.38 mm, P<0.001). At the end of UAC, the RAD was increased compared with that at baseline (2.45±0.41 vs. 2.62±0.41 mm, P<0.001), but it started to decrease thereafter, and the RAD measured at 1 min after stopping UAC was significantly smaller (2.62±0.41 vs. 2.55±0.40 mm, P<0.001), while remaining significantly larger than that at baseline (P<0.001). The RA peak systolic flow velocity also increased significantly during UAC (35.3±8.9 vs. 60.3±19.2 cm/sec; P<0.001). In conclusion, Transient UAC for 1 min significantly increased the RAD and the peak systolic flow velocity. Further studies with clinical endpoints are required for further exploration of the feasibility of this approach.

Vascular access complications in patients undergoing percutaneous procedures in hemodynamics: a scoping review

OBJECTIVE

To map the production of knowledge on vascular access complications in patients undergoing percutaneous procedures in hemodynamic laboratories.

METHODS

Scoping review study. The search strategy was developed in three stages, considering the period from July 2005 to July 2015 in the PubMed, CINAHL, Scopus, and LILACS databases. The collected data were analyzed and summarized in a narrative form.

RESULTS

One-hundred twenty-eight publications that made it possible to map the contexts of study of complications, occurrence according to access routes, as well as an understanding of diagnosis and clinical management, were included. Three theme categories were identified: complications; predictive factors; and diagnosis/treatment.

CONCLUSION

Vascular access site complications range according to the access route used. Knowledge of factors that permeate the occurrence of these events may contribute to early detection, planning, and monitoring of the care implemented.

Mediastinal Hematoma and Tracheal Compression following Transradial Percutaneous Coronary Intervention

Vascular complications from transradial percutaneous coronary intervention (PCI) are rare. We report an unusual case of stridor after PCI due to brachiocephalic artery perforation, pseudoaneurysm formation, and development of a large mediastinal hematoma with tracheal compression. Endovascular repair of the brachiocephalic artery was achieved with covered stent placement at the neck of the pseudoaneurysm. This case highlights the importance of careful guide catheter placement from the right radial approach. Ultimately, rapid diagnosis of vascular perforation, appropriate airway management, and prompt endovascular repair of the injured vessel is critical to the successful management of this life-threatening condition.

Acute compartment syndrome: A rare but important complication of transradial cardiac catheterization

The transradial approach has become the gold-standard for coronary angiography. It is better tolerated by patients, associated with less bleeding, earlier post-procedure mobilization, and reduced mortality in patients with myocardial infarction. Given the hand's dual arterial supply and extensive collateral circulation, the risk of serious functional injury after radial catheterization is essentially reduced to zero. However, even a small amount of bleeding in the volar compartment can lead to compartment syndrome (CS) and permanent neurovascular injury. The purpose of this paper is to describe our experience with an unusual case of late-onset acute CS following transradial coronary angiography, and to summarize the available literature on this topic. <Learning objective: The transradial approach has become the gold-standard for coronary angiography. However, in rare cases, this approach may be associated with bleeding and acute compartment syndrome. Patients on anticoagulants, and those who have severe atherosclerosis appear to be at increased risk of this complication. The diagnosis relies upon clinician awareness and vigilance, and affected patients require early decompressive fasciotomy to prevent permanent neurovascular injury.>.

Cutaneous analgesia before transradial access for coronary intervention to prevent radial artery spasm

Aim:

Transradial access (TRA) for coronary intervention is increasingly used in current clinical practice. The aim of the present study was to evaluate the hypothesis that cutaneous analgesia before TRA for coronary intervention at a puncture site 30 minutes before puncture can reduce patient discomfort and the incidence of radial artery spasm (RAS).

Methods:

Patients (n=104) undergoing planned coronary interventions using TRA were prospectively randomized to receive either 1 mL of 1% lidocaine subcutaneously (n=52) (control group) or subcutaneous lidocaine plus 5% lidocaine cream (n=52) cutaneously 30 minutes before puncture (treatment group). The primary endpoint was angiographically or clinically confirmed RAS. Secondary endpoints were the occurrence of patient discomfort in the forearm during the procedure and access-site crossover to the femoral artery. Patient discomfort was quantified with a visual analogue scale (VAS) score.

Results:

Fifty-two patients in the treatment group (60.5±9.4 years of age and 16 female) and 52 patients in the control group (60.4±9.7 years of age and 16 female) were included in the final analysis. Radial artery spasm occurrence decreased in the treatment group compared to the control group (26.9% vs 9.6%; p=0.04) accompanied by a VAS score of 3.7±1.8 in the treatment group and 4.9±2.0 in the control group; p=0.02. The access site crossover rate did not differ between the groups (7.6% vs 21.1%; p=0.09).

Conclusion:

Cutaneous analgesia before TRA for coronary interventions is associated with a substantial reduction in the RAS and the procedure-related level of patient discomfort.

Radial Artery Pseudoaneurysm

PURPOSE

To review the causes, clinical course, and management of patients with catheter-associated radial artery pseudoaneurysm (PSA).

METHODS

We reviewed all patients diagnosed with radial artery PSA resulting from arterial line placement or radial artery access for cardiac procedures from 2010 to 2015.

RESULTS

We identified 11 cases: 5 caused by arterial lines and 6 by cardiac procedures. The diagnosis was confirmed by duplex ultrasound in all cases; PSA size ranged from less than 1 cm to 5 cm in diameter. Spontaneous thrombosis (over a mean of 27 days) occurred in 4 patients; each PSA was smaller than 3 cm. Surgery was performed in 7 patients with excision of the stalk and repair of the artery as the most common procedure. Only one case was performed emergently for acute carpal tunnel syndrome. Complications occurring owing to either the PSA or the treatment were recorded in 5 patients.

CONCLUSIONS

Spontaneous thrombosis may occur in smaller lesions over a few weeks. When required, surgery to evacuate the hematoma and repair the artery was effective in all cases.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Compartment Syndrome of the Hand: A Rare Sequela of Transradial Cardiac Catheterization

A 64-year-old man who underwent percutaneous coronary intervention via right radial artery access reported right-hand pain and swelling 2 hours after the procedure. He had developed compartment syndrome of the hand, specifically with muscular compromise of the thenar compartment but with no involvement of the forearm. He underwent emergency right-hand compartment release and carpal tunnel release, followed by an uneventful postoperative course. In addition to our patient's case, we discuss compartment syndrome of the hand and related issues.