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

Acute Compartment Syndrome as a Complication of Radial Artery Catheterization

Acute compartment syndrome is a rare complication of radial artery catheterization. If not identified and treated emergently, it can lead to profound disability or limb loss. Here, we discuss a rare case of acute compartment syndrome in the forearm of a 54-year-old man after transradial catheterization and anticoagulation for myocardial infarction, which ultimately required emergent fasciotomies and prolonged hospital care. The benefits of a percutaneous intervention performed through radial artery catheterization will almost always outweigh the risks of the catheterization itself; however, the serious complication of forearm hematoma leading to acute compartment syndrome should be discussed with patients as a potential procedural risk. The signs and symptoms of acute compartment syndrome should be reviewed by perioperative staff and physicians to rapidly identify the evolving condition and initiate appropriate treatment. This case report follows CARE guidelines.

Acute Carpal Tunnel Syndrome After Radial Artery Cannulation: A Case Report

CASE

A 20-year-old postpartum woman developed paresthesias and intolerable pain over the volar aspect of the first through fourth fingers, after radial artery cannulation (RAC) during cesarean section. Ultrasonography did not show any hematoma in the forearm. Urgent carpal tunnel release and median nerve decompression were performed, resulting in complete disappearance of symptoms.

CONCLUSION

Acute median nerve compression is a rare injury in its own, but it is even rarer as a complication of RAC. Urgent decompression should be performed as soon as possible to avoid future neurological deficits.

Forearm hematoma as a complication of transradial coronary intervention: an Indian single-center experience

BACKGROUND

Forearm hematomas are not uncommon after transradial coronary interventions. The present study describes the incidence and predictors of forearm hematoma formation after transradial coronary interventions.

METHODS

This was a prospective study in 1754 patients undergoing angiography/angioplasty through transradial access. Each procedure was performed using optimum levels of anticoagulation, hydrophilic sheaths, and post-procedural patent hemostasis protocols. Patients were evaluated for forearm hematoma immediately after the procedure, after radial band removal, and on the next day of the procedure. Severity of hematomas was graded according to the Early Discharge after Transradial Stenting of Coronary Arteries Study scale. Univariate and multivariate logistic regression analyses were done to determine the predictors of hematoma formation.

RESULTS

Mean age of the patients was 56.31 years and 82.2% were males. A total of 1374 (78.3%) patients underwent angioplasty while 380 (21.7%) underwent angiography. Forearm hematoma developed in 187 (10.7%) patients. Grade I hematoma was most common (3.53%) followed by Grade II (3.08%), Grade III (2.83%) and Grade IV (1.25%) hematoma. None of the patients required vascular or surgical interventions for this complication. Female gender, multiple puncture attempts, intensive antiplatelet therapy, complex procedure and longer hemostasis time were significant predictors of forearm hematoma formation post transradial coronary interventions.

CONCLUSIONS

Forearm hematoma developed in substantial proportion of patients undergoing transradial coronary interventions and interventional variables were predominantly associated with hematoma formation. Pre-emptive knowledge of modifiable interventional risk factors can help in reducing the burden of this complication.

Compartment syndrome of the hand following iatrogenic intra-arterial administration of epinephrine during cardiopulmonary resuscitation

A 26-year-old woman developed acute compartment syndrome (ACS) of her right hand secondary to reperfusion syndrome. She suffered an out-of-hospital cardiac arrest following a pregabalin overdose. Attending paramedics mistakenly gave intra-arterial epinephrine into her right brachial artery. On resolution of her brachial artery spasm, she developed a reperfusion injury to her right hand and subsequently ACS. A four-incision fasciotomy with carpal tunnel decompression was performed and was successful in reversing focal ischaemia and an irreversible functional deficit. This case demonstrates an unusual case of hand ACS secondary to temporary limb ischaemia and reperfusion syndrome following iatrogenic intra-arterial epinephrine administration. We also summarise the current available literature on ACS of the hand including the aetiology, treatment and use of an intracompartmental monitor.

Acute idiopathic thenar and hypothenar compartment syndrome

Compartment syndrome (CS) is a condition associated with intra-compartment pressures exceeding the perfusion pressure of the tissue. This condition can occur in any body compartment surrounded by fascia, however CS of some regions like the thenar and hypothenar is extremely rare. Acute CS is often caused by major trauma and idiopathic acute CS is sparsely reported in literature. We present a case report of a 39-year-old male, with a medical history of rheumatoid arthritis (RA) for which he uses adalimumab and low-dose prednisone, with idiopathic acute CS of thenar and hypothenar compartments. Unexplained tremendous pain, paresthesia and swelling of his hand were the only symptoms observed. Due to direct recognition of the condition there was no delay in time to treatment. Treatment involved a fasciotomy of the thenar and hypothenar compartments as well as a release of the carpal tunnel. This direct surgical approach resulted in retaining excellent function and appearance of the hand. We hypothesized several causes for the etiology of the condition (e.g. rhabdomyolysis, rheumatologic disease-related condition, other systemic diseases, trauma, infection), but all could be rejected based on laboratory or clinical findings. Remarkable is that the patient experienced a comparable episode in his other hand two years earlier. Although the acute CS is of unknown origin in the presented case, the development of acute CS in both hands over time suggests a predisposing factor in idiopathic acute CS that is far from being elucidated.

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.

Complications of Transradial Catheterization and Cannulation

Transradial catheterization and cannulation are typically well-tolerated procedures, but they are associated with various vascular, infectious, and orthopedic complications. Potential complications include radial artery occlusion, hematoma formation, radial artery laceration, pseudoaneurysm, abscess formation, and compartment syndrome. Hand surgeons are commonly consulted to treat such complications. We review recent evidence available to guide decisions about nonsurgical and surgical interventions to treat and prevent the complications associated with transradial access procedures.

Incidence and predictors of forearm hematoma during the transradial approach for percutaneous coronary interventions

Background

The transradial approach for percutaneous coronary intervention (TRA-PCI) reduces vascular complications compared with the transfemoral approach (TFA). Although hematoma formation is less frequent with the TRA than TFA, it is not uncommon, and its presentation ranges from mild hematoma to compartment syndrome. Incidence and predictors of hematoma have not been well studied.

Methods and results

The present study was conducted to prospectively evaluate the incidence and predictors of forearm hematoma after TRA-PCI. The study population consisted of consecutive patients undergoing TRA-PCI. Baseline and procedural characteristics and clinical outcomes were prospectively collected. All patients were observed for forearm/arm hematoma immediately after procedure, after band removal, before discharge, and whenever the patient complained of pain/swelling in the limb. Logistic regression analysis was performed to determine the predictors for hematoma formation. A total of 520 patients who had successfully completed TRA-PCI were included in the final analysis. The mean age was 55.2 ± 9.5 years, and 24% patients were women. Hematoma occurred in 53 (10.2%) patients. Hematomas were of grade I, II, III, and IV in 22 (4.2%), 9 (1.7%), 18 (3.5%), and 4 (0.8%) patients, respectively. On multivariate logistic regression analysis, age, body mass index, multiple puncture attempt, glycoprotein IIb/IIIa receptor blocker use, nonclopidogrel agent use for dual antiplatelet therapy, and multiple catheter exchanges emerged as independent predictors for hematoma formation.

Conclusions

Forearm hematoma following TRA-PCI occurs in about 10% patients. Most hematomas occur near the puncture area. The independent predictors for hematoma formation are age, body mass index, multiple puncture attempts, intensive antiplatelet therapy, and multiple catheter exchanges.

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.