Radial Artery Pseudoaneurysms Treated by Ultrasound-Guided Differential Compression: An Effective and Simple Method.

Transradial approach has become preferable to conventional femoral artery access for both diagnostic coronary angiography and percutaneous coronary intervention. A rare but recognizable complication of radial access is radial artery pseudoaneurysm (RAp), which represents a potentially catastrophic complication. Treatment options comprise ultrasound (USG)-guided manual compression or thrombin injection or surgical correction. In this case series, we report four cases of RAps that we encountered at a single tertiary care center from July 2015 to January 2018. We compressed the radial artery using a sphygmomanometer cuff differentially rather than a TR band proximal to the pseudoaneurysm to treat three of them. One of the patients underwent surgical repair of the pseudoaneurysm as the location of the aneurysm was not suitable for compression or thrombin injection. In our series of cases, we conclude that RAp, a rare complication of radial catheterization, was seen more commonly in elderly female patients and can be easily treated by the USG-guided differential compression, a simple and readily available method. Prevention and early diagnosis is the key to avoid serious consequences.

INTRODUCTION

Transradial approach has become preferable to conventional femoral artery access for both diagnostic coronary angiography and percutaneous coronary intervention (PCI). This is explained by the significant reduction in the occurrence of access-site complications (reported to be 0.6% and 1.5%, in a single -center study). when selecting a transradial over transfemoral technique – study.[1] This is of particular relevance to patients who are at high risk for femoral access-site complications, including patients with a high body mass index and individuals receiving a glycoprotein IIb/IIIa inhibitor.[123]

A rare but recognizable complication of radial access is radial artery pseudoaneurysm (RAp), which represents a potentially catastrophic complication. Treatment options comprise manual compression, surgery, and thrombin injection. The total volume of interventional procedures at our center is 3500–4000 annually. Between July 1, 2015, and January 31, 2018, 5532 patients underwent intervention through radial route at our center. 2160 patients underwent PCI through radial route. We captured our index cases by retrospective review of records during the review period. We encountered four cases of RAps during this period. Three of them were treated by ultrasound (USG)-guided compression and one patient underwent surgical repair.

METHOD

RAps are fragile when compared to femoral artery ones. We modified the method as advocated by Zegrí et al.[4] from Spain in a small way. We compressed the radial artery using a sphygmomanometer cuff rather than a TR band proximal to the pseudoaneurysm differentially. Before applying a tourniquet around the forearm, we identified the radial artery on Doppler scan and placed a small firm object wrapped in a gauze roll directly over radial artery and tourniquet wrapped around it. The cuff inflated to a certain pressure until radial artery has absent flow and ulnar is still patent. The inflated cuff is left in place for 2 h. After that, a semi-compressive Dynaplast bandage was applied directly over pseudoaneurysm for 24 h.

Case 1

A 65-year-old male patient with crescendo angina underwent a coronary angiogram (CAG) in December 2016 through the right radial route. He had a critical right coronary artery (RCA) lesion, and he underwent a staged PCI to RCA.

He had mild pain in the forearm; neither a hematoma nor a bruit could be felt over the forearm, and the distal radial pulse was palpable. We proceeded with PCI to RCA through right radial route initially; however, as the Terumo wire could not cross forearm, we converted to the femoral route and completed PCI. He was discharged after 48 h.

He came back after a week with swelling, redness, bruit, and severe pain over the right forearm. USG showed a large 6 cm × 8 cm pseudoaneurysm of radial artery extending into intramuscular plane. He underwent USG-guided differential compression of the pseudoaneurysm with complete thrombosis and resolution of the aneurysm [Figures 1–5].

Figure 1

Radial artery pseudoaneurysm

Figure 5

Thrombosed radial artery pseudoaneurysm

Differential compression showing absent flow in radial artery and patent flow in ulnar artery

Differential compression of radial artery using a sphygmomanometer

Semicompressive occlusive bandage

Case 2

A 74-year-old hypertensive, diabetic and hypothyroid female patient with coronary artery disease underwent PCI to RCA in June 2006. She presented to us with acute coronary syndrome, severe LV dysfunction and congestive heart failure. Coronary angiography (right radial approach) after stabilization showed critical RCA disease proximal to previous stent and critical left circumflex artery (LCX) disease (proximal and involving two major obtuse marginals) with minimal left anterior descending (LAD) disease. She underwent ad hoc PCI to RCA. PCI to LCX was planned at a later date. She presented 1 week after the index procedure with swelling at the right wrist. USG Doppler showed a large pseudoaneurysm of radial artery. USG-guided compression was performed as described with successful thrombosis and resolution of pseudoaneurysm [Figures 6–9, Videos 1 and 2].

Figure 6

Puncture site swelling

Figure 9

Resolution of pseudoaneurysm

Flow in the radial artery pseudoaneurysm

“To and Fro” sign or “Yin-Yang” sign in radial artery pseudoaneurysm. *In Chinese philosophy, Yin and Yang describe how opposite or contrary forces are actually complementary, interconnected and interdependent in the natural world, and how they give rise to each other as they interrelate to one another

Case 3

A 69-year-old female presented with acute anterior wall myocardial infarction (AWMI), thrombolysed with reteplase at another facility. There was a history of recurrent primary ventricular tachycardia requiring electrical cardioversion. She underwent CAG though right radial route. She had swelling 3 days postcatheterization in the forearm. USG revealed a well-defined hypoechoic lesion of size 3.8 cm × 1.8 cm × 1.5 cm arising from the origin of right radial artery extending superiorly over brachial artery with a thick wall and inflammation around. As the pseudoaneurysm was originating from proximal radial artery and extending directly over the brachial artery with large hematoma in the forearm, we ruled out USG-guided compression. Thrombin injection was also not considered in view of proximity to brachial artery. She underwent surgery with successful repair of pseudoaneurysm.

Case 4

A 69-year-old female presented with acute coronary syndrome, non-ST-elevation myocardial infarction, mild LV dysfunction. CAG showed triple vessel disease (TVD) with critical LAD, moderate RCA, and LCX disease. She underwent PCI to LAD. Post-PCI, she developed a painful swelling at the right wrist. USG revealed an 11 mm × 7 mm distal pseudoaneurysm at wrist level, successfully treated with USG-guided compression.

The sheath sizes, antiplatelet and anticoagulation protocol in our patients, mode of hemostasis achieved, duration between index case intervention and recognition of Rap, and treatment modality for RAp are summarized in Table 1.

Table 1

Sheath size, anticoagulation protocol and mode of hemostasis

Case	Sheath size	Age/sex	Antiplatelet and anticoagulation protocol	Mode of hemostasis	Duration between index procedure and diagnosis of RAp (days)	Treatment modality
Case 1	6 F	65/male	Aspirin, ticagrelor, UFH	Manual compression	7	USG-guided compression
Case 2	6 F	74/female	Aspirin, ticagrelor, UFH + GPIIb3	Manual compression	7	USG-guided compression
Case 3	6 F	69/female	Aspirin, ticagrelor, UFH	TR band	3	Surgery
Case 4	5 F	69/female	Aspirin, clopidogrel, UFH	Manual compression	2	USG-guided compression

RAp: Radial artery pseudoaneurysm, UFH: Unfractionated heparin, USG: Ultrasound, TR band: A radial compression device from terumo

DISCUSSION

The increased adoption of transradial cardiac catheterization has led to a significant reduction in access-site complication rates. Complications of transradial catheterization include radial artery occlusion, spasm, hand ischemia, nerve damage, bleeding, and pseudoaneurysm formation.[2] RAp is rare, with an incidence of <0.1% reported in a large case series.[5] In our series, the incidence is 0.07%. Although it is a rare complication, sometimes, it can be catastrophic. Focus on obtaining both optimal individualized postprocedure compression pressure and duration may prevent it.

The presence of a hematoma in the forearm, along with any of the predisposing factors, such as ongoing systemic anticoagulation, use of higher sheath sizes, elderly frail patient, history of multiple catheter exchanges, and vascular site infection, may contribute to the development of RAp.[236789] Doppler scan may rule out or confirm a RAp.

Among our patients, two patients had RAp at the puncture site (Cases 2 and 4). The rest of the cases had RAp in the forearm.

Vascular injury during catheterization with wires or catheters, elderly age, female sex (3 out of 4), and frail habitus might have contributed to the development of RAp in our series. Careful manipulation of wires and catheters, early recognition of forearm hematoma, and adequate proper compression after sheath removal could have prevented RAp in our cases.

Many physicians still prefer surgery as the treatment modality. Nonsurgical treatment is an alternative to surgery. USG-guided/blind compression and thrombin injection are the two modalities of nonsurgical treatment. Compression may be done manually or by using a pneumatic device. Manual compression has its own disadvantages such as availability of workforce, increased time, pain, prolonged hospital stay due to the requirement for multiple attempts, and increased failure in the presence of anticoagulation. Pneumatic devices like a TR band are effective.[10] However, their availability and cost are the issues in the places with limited resources. In our patients, we did a USG-guided compression using sphygmomanometer as a compression device. This was effective in all three of our cases and is easily available. RAp is very fragile and can rupture, resulting in external bleeding. An individualized approach to management based on the severity of the pseudoaneurysm is recommended. When the defect is small-to-intermediate sized, compression with a view to thrombosis of the false aneurysm may suffice as in our Cases 1, 2, and 4; when larger, surgical intervention becomes necessary. Sometimes, surgery may be necessary in view of its location precluding manual compression or thrombin injection as in our Case 3. Management using thrombin injection has also been reported and effective.[11] Although safe and effective, given the anatomical location of a RAp and the ease of surgical access, this approach has been deemed unlikely to offer significant advantage over surgical intervention.[3] We have not used thrombin in any of our cases.

CONCLUSION

We conclude that RAp, a rare complication of radial catheterization in our series of cases (0.07%), was seen more commonly in elderly female patients and can be easily treated by the USG-guided differential compression, a simple and readily available method. Prevention and early diagnosis is the key to avoid serious consequences.

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.