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 Table of Contents  
CURRICULUM IN CARDIOLOGY - IMAGES
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 139-141

Unusual complication of transradial intervention: A Case Report


1 Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
2 Department of Cardiology, ESIC MH - Sri Jayadeva Institute of Cardiovascular Sciences and Research Unit, ESIC Model Hospital, Bengaluru, Karnataka, India
3 Department of Cardiothoracic and Vascular Surgery, ESIC MH - Sri Jayadeva Institute of Cardiovascular Sciences and Research Unit, ESIC Model Hospital, Bengaluru, Karnataka, India

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. Chetana Krishnegowda
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, 9th Block, Bannerghatta Road, Bengaluru - 560 069, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_24_18

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  Abstract 

Transradial cardiac catheterization is frequently performed and is the preferred approach for coronary intervention over the last few years, mainly due to the dramatic decrease in access site complications, shorter hospital stay, and patient comfort. Radial artery pseudoaneurysm (RAP) following cardiac catheterization is an unusual, but serious complication which is rarely reported with very limited data on the clinical manifestations and management strategies. Although myriad noninvasive treatment options have surfaced in the recent years, surgical management remains the standard treatment for RAP. We herein describe a rare case of RAP following transradial access for coronary angiogram managed successfully by surgical resection of the pseudoaneurysm and radial artery ligation with complete alleviation of symptoms immediately postoperative and at follow-up.

Keywords: Access site complication, radial artery pseudoaneurysm, transradial interventions


How to cite this article:
Krishnegowda C, Nanjappa MC, Sunilkumar K R, Ramesh H C. Unusual complication of transradial intervention: A Case Report. J Pract Cardiovasc Sci 2018;4:139-41

How to cite this URL:
Krishnegowda C, Nanjappa MC, Sunilkumar K R, Ramesh H C. Unusual complication of transradial intervention: A Case Report. J Pract Cardiovasc Sci [serial online] 2018 [cited 2018 Dec 12];4:139-41. Available from: http://www.j-pcs.org/text.asp?2018/4/2/139/240956


  Introduction Top


Transradial coronary interventions are becoming increasing popular worldwide mainly due to uncommon vascular complications. However, although rare, access site complications like radial artery occlusion, hand ischemia, arteriovenous fistula and pseudoaneurysm do occur and sometimes catastrophic and limb threatening.[1],[2] Here we report a case of radial artery pseudoaneurysm (RAP) following coronary angiogram which was treated surgically.


  Case Report Top


A 52-year-old female, hypertensive, hypothyroid, nondiabetic patient presented with exertional dyspnea of 5-month duration. Resting electrocardiogram showed left ventricular hypertrophy (LVH) with strain pattern, and two-dimensional echo was unremarkable except for concentric LVH. She was subjected to computed tomography (CT) coronary angiogram (CAG) which revealed left main coronary artery 30% stenosis extending to ostial left anterior descending. In view of intermediate lesion in CT-CAG and her clinical symptoms, she was taken up for conventional CAG using transradial access. CAG was normal and the radial sheath was immediately removed in catheterization laboratory and hemostatic compression bandage was applied. Thirty minutes later, the patient had agonizing pain in the right hand with venous congestion [Figure 1]. Hence, the compression bandage was partially released and reapplied. The following day swelling and induration were noted at the puncture site with a small bleb on the surface. On palpation, the swelling was tender and pulsatile measuring about 2 cm × 3 cm.
Figure 1: Pulsatile swelling at the right wrist just proximal to the puncture point of radial artery with a bleb on the surface.

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Doppler examination of the right forearm [Figure 2] revealed pseudoaneurysm measuring 1.9 cm × 1.3 cm in the distal forearm arising from radial artery which was confirmed by CT peripheral angiogram [Figure 3].
Figure 2: Doppler scan demonstrated dual-chamber pseudoaneurysm of radial artery with turbulent blood flow and narrow neck connection with radial artery lumen. Pseudoaneurysm sac was partially filled with thrombus.

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Figure 3: Computed tomography image showing pseudoaneurysm of radial artery measuring 19 mm × 13 mm with 2-mm narrow neck.

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Given the size of the pseudoaneurysm and its tendency to rupture, compression techniques were deemed inappropriate. In view of nonavailability of thrombin injection at that point of time, the patient was subjected to surgical repair.

Under local anesthesia and total intravenous anesthesia, right radial artery and the pseudoaneurysm sac was exposed. During the procedure, the sac accidently ruptured with profuse bleeding, and therefore, the proximal radial artery was transfixed after distal perfusion of the hand was confirmed with pulse oximetry. The redundant pseudoaneurysm sac was excised successfully [Figure 4] and [Video 1]. Postoperatively, the swelling and tenderness of the right hand dramatically reduced, and the patient was discharged without any sequele to the involved limb.
Figure 4: Intraoperative image of radial artery ligation following pseudoaneurysm excision.

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  Discussion Top


Radial artery pseudoaneurysm (RAP) is a rare complication of transradial access with the reported incidence of 0.03% compared to 0.6% in transfemoral access.[3],[4] Pseudoaneurysm occurs as a result of tear in the arterial wall with hematoma formation associated with persistence of blood flow between arterial adventitia and the hematoma. Over time, arterial blood flow under high pressure creates a cavity outlined by inflammatory cells and fibroblasts subsequently replaced by fibrous tissue and the inner surface covered by endothelium. The possible predisposing factors are multiple puncture attempts, larger sheath size, inadequate compression, and aggressive anticoagulation, especially with gpIIb/IIIa inhibitors.[5]

Postcatheterization pseudoaneurysms which are smaller in size tend to spontaneously thrombose over time. However, large pseudoaneurysms should be treated because potent complications of RAP like thromboembolism, digital ischemia, hemarthrosis, adjacent nerve irritation, limited wrist mobility, skin ulceration, secondary infection, and rupture with significant bleeding requiring urgent surgery can occur.[6] The surgical techniques include radial artery ligation, patch angioplasty using vein segment, RAP ligation, and excision with end-to-end anastomosis.

Several nonsurgical methods have largely replaced surgery in the last few years such as ultrasound-guided compression and percutaneous thrombin injection to RAP sac under ultrasound guidance.[7],[8] Ultrasonographically guided compression has significant limitations, including prolonged compression time resulting in patient discomfort and pain and the risk of external rupture with torrential bleeding. Sometimes, there are recurrences after compression requiring further compression attempts and surgery. Moreover, pseudoaneurysm with rigid fibrous wall may require forceful and prolonged compression that may cause local complications, such as deep vein thrombosis or chronic regional pain syndrome and also favors radial artery occlusion. Ultrasound-guided thrombin injection is a quick and effective technique in almost all cases even in patients with anticoagulation therapy but not without risk. Some of the reported complications are escape of thrombin into adjacent main artery, resulting in thromboembolism to the distal arterial bed and necrosis, anaphylaxis or generalized urticaria after bovine thrombin injection, and pseudoaneurysm rupture.

Despite multiple noninvasive treatment options, a standardized protocol for RAP is lacking. There is no definitive time frame regarding maintenance of compression or the dosage of thrombin injection in RAP, unlike femoral artery pseudoaneurysms. The choice of treatment modality should depend on the severity and anatomical characteristics of the pseudoaneurysm. Although small pseudoaneurysms with narrow neck can be conservatively managed with external compression and thrombin injection, in cases of large pseudoaneurysms, surgical repair is recommended.[9] In our case, we have successfully managed a case of RAP by surgical ligation of radial artery efficiently without any vascular compromise.


  Conclusion Top


The incidence of rare complications such as RAP may increase in the future due to growing popularity of transradial approach for coronary angiography and interventions. It is important for the clinicians to be vigilant as these rare complications may lead to serious clinical sequela and significant morbidity. Prevention, timely diagnosis, and appropriate management of complications are instrumental in safe and effective transradial interventions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Truong AT, Thakar DR. Radial artery pseudoaneurysm: A rare complication with serious risk to life and limb. Anesthesiology 2013;118:188.  Back to cited text no. 1
    
2.
Ganchi PA, Wilhelmi BJ, Fujita K, Lee WP. Ruptured pseudoaneurysm complicating an infected radial artery catheter: Case report and review of the literature. Ann Plast Surg 2001;46:647-50.  Back to cited text no. 2
    
3.
Lemaitre J, Goffin C, Bellens B. Digital embolus arising from a pseudoaneurysm after radial artery catheterization: A case report. Acta Chir Belg 2006;106:246-8.  Back to cited text no. 3
    
4.
Zegrí I, García-Touchard A, Cuenca S, Oteo JF, Fernández-Díaz JA, Goicolea J, et al. Radial artery pseudoaneurysm following cardiac catheterization: Clinical features and nonsurgical treatment results. Rev Esp Cardiol (Engl Ed) 2015;68:349-51.  Back to cited text no. 4
    
5.
Kanei Y, Kwan T, Nakra NC, Liou M, Huang Y, Vales LL, et al. Transradial cardiac catheterization: A review of access site complications. Catheter Cardiovasc Interv 2011;78:840-6.  Back to cited text no. 5
    
6.
Poirier RA, Stansel HC Jr. Arterial aneurysms of the hand. Am J Surg 1972;124:72-4.  Back to cited text no. 6
    
7.
Teh LG, Sieunarine K. Thrombin injection for repair of pseudoaneurysms: A case for caution. Australas Radiol 2003;47:64-6.  Back to cited text no. 7
    
8.
Harkin DW, Connolly D, Chandrasekar R, Anderson M, Blair PH, Hood JM, et al. Radial artery mycotic pseudoaneurysm in a haemophiliac: A potentially fatal complication of arterial catheterization. Haemophilia 2002;8:721-4.  Back to cited text no. 8
    
9.
Cozzi DA, Morini F, Casati A, Pacilli M, Salvini V, Cozzi F, et al. Radial artery pseudoaneurysm successfully treated by compression bandage. Arch Dis Child 2003;88:165-6.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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