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Complete “In Situ” Avulsion of the Radial Artery Complicating Transradial Coronary Rotational Atherectomy
Complete ‘‘In Situ’’ Avulsion of the Radial Artery Complicating Transradial Coronary Rotational Atherectomy Nicolas J. Mouawad,1 Quinn Capers IV,2 Christopher Allen,2 Iyore James,3 and Mounir J. Haurani,1 Columbus, Ohio
Background: Transradial percutaneous access (TR) is promoted because of increased patient comfort and convenience as well as a lower risk of access site and cardiac complications in the literature. Increased use of the TR purports a new set of possible complications for which the vascular surgeon must be capable to recognize and manage. Methods: A 48-year-old, devout Jehovah’s Witness, woman with a history of coronary artery bypass surgery presented with a noneST-segment elevation acute myocardial infarction. Pretransfer catheterization demonstrated a heavily calcified, 90% distal left main stenosis with an occluded left internal mammary artery graft to the left anterior descending coronary artery. To minimize the risk of bleeding requiring a blood transfusion, a coronary rotational atherectomy via a TR was performed. A nonhydrophilic, 7F sheath was used to accommodate the larger rotational atherectomy burr sizes. The coronary procedure was successful, but the sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. Post procedure she developed a hematoma with motor and neurological deficits of her hand. Results: Emergent surgical exploration with fasciotomy was planned. The radial artery was explored and found to be redundant and pulseless, prompting proximal evaluation and revealing complete avulsion of the radial artery at its origin. An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch and surgical ligation of the radial artery was conducted. Conclusion: Vascular surgeons need to be aware of potential complications related to TR which are likely to increase as this method is more widely disseminated.
Presented at the 24th Annual Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, February 1, 2014. 1 Division of Vascular Diseases and Surgery, The Ohio State University Wexner Medical Center, Columbus, OH. 2 Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. 3 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
Correspondence to: Nicolas J. Mouawad, MD, MPH, MBA, MRCS, Division of Vascular Diseases and Surgery, The Ohio State University Wexner Medical Center, 376 West 10th Avenue, Prior Hall Suite 701C, Columbus, OH 43210, USA; E-mail: nicolas.mouawad@osumc. edu Ann Vasc Surg 2015; 29: 123.e7e123.e11 http://dx.doi.org/10.1016/j.avsg.2014.07.024 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: February 4, 2014; manuscript accepted: July 27, 2014; published online: September 2, 2014.
Recent studies document a lower risk of access site and cardiac complications when percutaneous coronary intervention (PCI) is performed via the radial artery as opposed to the femoral artery.1,2 Increased safety, patient comfort, and convenience will likely drive an increase in PCI being performed via the transradial approach. As transradial procedures increase in frequency and complexity, vascular surgeons are likely to encounter some complications that were previously unknown. An awareness of these complications and thoughtful approaches to limit and avoid them will benefit PCI patients. We report a case of radial artery avulsion in situ complicating a transradial coronary rotational atherectomy procedure resulting in a compartment syndrome. We also describe the prompt management of this 123.e7
123.e8 Case reports
Annals of Vascular Surgery
Fig. 1. (A) Coronary angiogram demonstrating complex and heavily calcified 90% stenosis of the distal left main coronary artery as denoted by white arrow. (B) Postatherectomy and stenting coronary angiogram.
complication and provide suggestions to avoid similar problems.
CASE DESCRIPTION A 48-year-old woman with a history of prior coronary artery bypass surgery was referred to our institution after a noneST-segment elevation acute myocardial infarction. Coronary angiography before transfer demonstrated a heavily calcified, 90% distal left main coronary artery (LM) stenosis with an occluded left internal mammary artery bypass graft to the left anterior descending coronary artery. The patient is a devout Jehovah’s Witness and refused transfusion of any blood products. To minimize the risk of bleeding requiring a blood transfusion, interventional cardiology decided to perform coronary rotational atherectomy via a transradial approach. After confirming adequate collateral circulation to the hand via a modified Allen’s test using waveform plethysmography, a 6F hydrophilic sheath was inserted in the right radial artery over a 0.018 inch wire. This was upsized to a nonhydrophilic, 7F sheath to accommodate larger rotational atherectomy burr sizes, if needed. Several attempts to pass the sheath over a 0.035 inch wire were necessary, with 2 separate intra-arterial injections of a mixture of nitroglycerin and verapamil required to reduce spasm and allow passage of the sheath. The sheath was finally passed on a third attempt, with the patient complaining of moderately severe pain on successful passage of the sheath. This pain resolved as the case continued. A 7F EBU (Medtronic, Minneapolis, MN) guide catheter was
advanced to the left coronary artery after which rotational atherectomy of the LM with a 2.0 mm burr was performed (Fig. 1). A bare metal stent was subsequently deployed using standard techniques and adjunctive medications. On successful completion of the procedure, sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. On removal, inspection of the sheath showed an intact sheath without adherent tissue. Hemostasis was achieved by placing a TR Band (Terumo, Tokyo, JAPAN) over the arteriotomy site. Within 15 minutes, the patient reported mild paresthesia in the hand and pain in the right forearm which was tense and appeared to be rapidly expanding, despite adequate hemostasis at the radial arteriotomy site. Immediate vascular surgical consultation was obtained and based on her physical examination findings, she was taken to the operating suite for an exploration of the radial artery with possible decompressive fasciotomy. The radial artery was explored and found to be redundant and pulseless, prompting suspicion of a more proximal injury or avulsion (Fig. 2). Further exploration of the forearm and fasciotomy of the flexor compartment revealed a complete avulsion of the radial artery just distal to its origin off the brachial artery. The flexor compartments were bulging and there was significant hematoma within the flexor compartment once the fascia was released (Fig. 3). An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch. Given that the artery had been completely avulsed and the ulnar artery was satisfactorily perfusing the hand and palmar arch, the decision was made to ligate the radial artery at its origin. At the end
Vol. 29, No. 1, January 2015
Fig. 2. Intraoperative photography demonstrating a complete proximal avulsion of the radial artery from the brachial artery bifurcation. The radial artery was redundant and pulseless.
Fig. 3. Intraoperative photograph during proximal surgical dissection. The radial artery was completely avulsed. The 2 arrows indicate the separated ends of the radial artery. Significant hematoma is present inside the flexor compartment. of the procedure the patient had a pink, well perfused hand. Postoperatively she had return of a normal neuromuscular examination in her hand. She was discharged from the hospital 4 days later with normal hand function and no further sequelae.
DISCUSSION The increase in complex percutaneous interventions has brought with it a myriad of new complications that require a contemporary awareness for diagnosis and management. Herein, we report a case of complete radial artery avulsion ‘‘in situ’’ complicating a transradial coronary rotational
Case reports 123.e9
atherectomy procedure resulting in compartment syndrome of the forearm. To our knowledge, this is the first report of the complete avulsion, of the radial artery in situ complicating a transradial coronary intervention. Partial avulsion and exteriorization of segments of radial artery and eversion endarterectomy have been reported.3 Arzamendi et al. describe a case of a transradial coronary angiogram in which a tubular structure was protruding from the radial arteriotomy site after removal of the 6F sheath. This structure was shown by microscopic examination to be an arterial structure containing all 3 vascular wall layers. However, a Dopplerable radial artery signal was present after this tissue was removed, no hematoma developed, and no surgery was necessary, indicating that this was likely an incomplete avulsion. Incomplete separation or tearing of the arterial layers was also likely observed in another case as well, as ‘‘a faint Dopplerable signal’’ was present after excision of the arterial segment protruding through the arteriotomy, and surgery was not required either.4 Abu-Ful et al.5 report a similar case of partial extraction of the radial artery with the removal of a 6F sheath. Similar to our case, in 2 of these 3 cases, nonhydrophilic sheaths were used, the patients complained of pain during sheath removal, and there was significant resistance to sheath withdrawal.4,5 Acute compartment syndrome complicating transradial coronary procedures is rare and is most commonly associated with bleeding. A MEDLINE/ PubMed query with keywords ‘‘compartment syndrome’’ and ‘‘transradial angioplasty’’ or ‘‘percutaneous coronary interventions’’ limited to the English language yielded only 4 articles.6e9 The incidence of compartment syndrome reported by Lotan et al.7 was 0.4% in 250 patients. In a single institution retrospective review of 51,296 patients undergoing transradial approach for coronary procedures, 2 patients, both women, developed compartment syndrome giving an incidence of 0.004%. Both patients complained of pain, swelling, hypoesthesia, or paresthesia.8 Araki et al.9 reported a case of acute compartment syndrome not associated with bleeding; ischemia of the forearm muscles was attributed to arterial spasm induced by the radial sheath or catheter. Like our case of complete avulsion in situ and the citations above describing partial tears or eversion of the radial artery, none of the patients with compartment syndrome experienced limb ischemia threatening viability of the hand, emphasizing the importance of documenting normal collateral blood flow to the hand before proceeding with any transradial procedures.
123.e10 Case reports
Our case is unique in that both ends of the avulsed radial artery remained inside the forearm; no portions of the radial artery were removed with the sheath. A delay in diagnosis can occur in such a situation if the clinician misinterprets the scenario as a forearm hematoma resulting from a partial tear or perforation of the radial artery and attempts to correct the problem by compressing the forearm with tight gauze wraps or an inflated blood pressure cuff. Such measures would not only be futile, but would lead to costly delays in the case of complete avulsion of the radial artery with subsequent severe functional impairment. It is imperative that immediate vascular surgical consultation is requested even if temporizing techniques are instituted by interventionalists, as doing so maximizes the potential for an outcome with normal hand function. Four reports exist describing the use of rotational atherectomy via the radial artery. A 6F sheath was the default size; however, both 6F and 7F sheaths have been used. Two of the publications report using the Cook radial artery sheath (Cook, Bloomington, IN) which contains a hydrophilic coating.10,11 The other report does not comment on the presence of hydrophilic coating of the sheaths.12 Another report specifically describing the safety of 7F sheaths in the radial artery used the hydrophilic-coated Terumo sheath.13 Transradial coronary rotational atherectomy has been shown to be feasible in these reports which detail the procedure in a total of 132 patients. Overall, only 1 access site complication was reported. These reports coupled with our personal experience suggest that coronary rotational atherectomy is feasible and is unlikely to have a different cardiac complication rate with a transradial approach compared with a transfemoral approach. However, care must be taken to avoid injury to the radial artery when performing complex coronary procedures, particularly with sheath sizes larger than 6F. A review of our case and the pertinent literature yields some important lessons which can potentially help operators avoid or minimize severe radial artery injuries during complex transradial coronary artery intervention. First, it was noted that sheath insertion proceeded despite some degree of resistance and some discomfort to the patient. Although both were lessened by repeat injections of verapamil and nitroglycerin into the radial artery, forcible insertion of a sheath should never be done. Second, a 7F, nonhydrophilic sheath was used. On multidisciplinary review, the interventional cardiologists now recommend exclusive use of hydrophilic sheaths in transradial artery coronary procedures. This is likely more important in women, who tend
Annals of Vascular Surgery
to have smaller radial arteries that are more prone to spasm.14 Several reports document decreased radial artery spasm, decreased pain, and less force required during sheath removal with hydrophiliccoated sheaths.15e18 A randomized evaluation of hydrophilic versus nonhydrophilic sheaths found significantly reduced pain and less force required during removal of hydrophilic sheaths.17 Finally, intravascular ultrasound (IVUS) of the radial artery was not employed before using a larger-than-usual sheath size. Gioia et al.11 first demonstrated a strategy of IVUS imaging of the radial artery before selection of a sheath to ensure radial artery/sheath diameter concordance. Although this technique was used in our institution in the past, we did not do so in this case. Doing so might have helped avoid this complication. Although not necessary for most transradial coronary intervention procedures, a strategy of radial artery IVUS through a 5F sheath (the default sheath size for coronary interventions) is employed by our interventionalists before inserting any sheath size greater than 6F. We report a case of complete avulsion in situ of the radial artery complicating transradial coronary rotational atherectomy resulting in a compartment syndrome requiring surgical repair. Complex transradial coronary interventions will become more popular as transradial coronary interventions continue to proliferate in the United States. Careful attention to techniques to reduce the risk of radial artery injury will be important to avoid an upswing in serious radial artery access site complications. We advocate using hydrophilic-coated sheaths exclusively, imaging the radial artery with IVUS before inserting sheaths larger than 6F, and abandoning the site or sheath size if the operator detects significant resistance or if the patient experiences significant discomfort during sheath insertion. Finally, our patient had a good outcome largely because of timely, expert vascular surgical consultation, pointing out the need for urgent surgical assessment at the first suspicion of an impending compartment syndrome. REFERENCES 1. Rao SV, Cohen MG, Kandzari DE, et al. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol 2010;55:2187e95. 2. Jolly SS, Yusuf S, Cairns J, et al., for the RIVAL trial group. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 2011;377:1409e20. 3. Arzamendi D, Romeo P, Gosselin G. Radial artery avulsion: a rare complication of percutaneous coronary intervention. Rev Esp Cardiol 2011;64:62.
Vol. 29, No. 1, January 2015
4. Dieter RS, Akef A, Wolff M. Eversion endarterectomy complicating radial artery access for left heart catheterization. Catheter Cardiovasc Interv 2003;58:478e80. 5. Abu-Ful A, Benharroch D, Henfin Y. Extraction of the radial artery during transradial coronary angiography: an unusual complication. J Invasive Cardiol 2003;15:351e2. 6. Lin YJ, Chu CC, Tsai CW. Acute compartment syndrome after transradial coronary angioplasty. Int J Cardiol 2004; 97:311. 7. Lotan C, Hasin Y, Salmoirago E, et al. The radial artery: an applicable approach to complex coronary angioplasty. J Invasive Cardiol 1997;9:518e22. 8. Tiz on-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a large series of transradial approach for coronary procedures. J Interv Cardiol 2008;21:380e4. 9. Araki T, Itaya H, Yamamoto M. Acute compartment syndrome of the forearm that occurred after transradial intervention and was not caused by bleeding or hematoma formation. Catheter Cardiovasc Interv 2010;75:362e5. 10. Egred M, Andron M, Alahmar A, et al. High-speed rotational atherectomy during transradial percutaneous coronary intervention. J Invasive Cardiol 2008;20:219e21. 11. Gioia G, Comito C, Moreyra AE. Coronary rotational atherectomy via transradial approach: a study using radial
Case reports 123.e11
12.
13. 14.
15.
16.
17.
18.
artery intravascular ultrasound. Catheter Cardiovasc Interv 2000;51:234e8. Watt J, Oldroyd KG. Radial versus femoral approach for high-speed rotational atherectomy. Catheter Cardiovasc Interv 2009;74:550e4. Egred M. Feasibility and safety of 7-Fr radial approach for complex PCI. J Interv Cardiol 2011;24:383e8. Lawton JS, Barner HB, Bailey MS, et al. Radial artery grafts in women: utilization and results. Ann Thorac Surg 2005;80: 559e63. Dery JP, Simard S, Barbeau GR. Reduction of discomfort at sheath removal during transradial coronary procedures with the use of a hydrophilic-coated sheath. Catheter Cardiovasc Interv 2001;54:289e94. Saito S, Tanaka S, Hiroe Y, et al. Usefulness of hydrophilic coating on arterial sheath introducer in transradial coronary intervention. Catheter Cardiovasc Interv 2002;56:328e32. Kiemeneij F, Fraser D, Slagboom T, et al. Hydrophilic coating aids radial sheath withdrawal and reduces patient discomfort following transradial coronary intervention: a randomized double-blind comparison of coated and uncoated sheaths. Catheter Cardiovasc Interv 2003;59:161e4. Caussin C, Gharbi M, Durier C, et al. Reduction in spasm with a long hydrophilic transradial sheath. Catheter Cardiovasc Interv 2010;76:668e72.
Background: Transradial percutaneous access (TR) is promoted because of increased patient comfort and convenience as well as a lower risk of access site and cardiac complications in the literature. Increased use of the TR purports a new set of possible complications for which the vascular surgeon must be capable to recognize and manage. Methods: A 48-year-old, devout Jehovah’s Witness, woman with a history of coronary artery bypass surgery presented with a noneST-segment elevation acute myocardial infarction. Pretransfer catheterization demonstrated a heavily calcified, 90% distal left main stenosis with an occluded left internal mammary artery graft to the left anterior descending coronary artery. To minimize the risk of bleeding requiring a blood transfusion, a coronary rotational atherectomy via a TR was performed. A nonhydrophilic, 7F sheath was used to accommodate the larger rotational atherectomy burr sizes. The coronary procedure was successful, but the sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. Post procedure she developed a hematoma with motor and neurological deficits of her hand. Results: Emergent surgical exploration with fasciotomy was planned. The radial artery was explored and found to be redundant and pulseless, prompting proximal evaluation and revealing complete avulsion of the radial artery at its origin. An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch and surgical ligation of the radial artery was conducted. Conclusion: Vascular surgeons need to be aware of potential complications related to TR which are likely to increase as this method is more widely disseminated.
Presented at the 24th Annual Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, February 1, 2014. 1 Division of Vascular Diseases and Surgery, The Ohio State University Wexner Medical Center, Columbus, OH. 2 Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH. 3 Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
Correspondence to: Nicolas J. Mouawad, MD, MPH, MBA, MRCS, Division of Vascular Diseases and Surgery, The Ohio State University Wexner Medical Center, 376 West 10th Avenue, Prior Hall Suite 701C, Columbus, OH 43210, USA; E-mail: nicolas.mouawad@osumc. edu Ann Vasc Surg 2015; 29: 123.e7e123.e11 http://dx.doi.org/10.1016/j.avsg.2014.07.024 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: February 4, 2014; manuscript accepted: July 27, 2014; published online: September 2, 2014.
Recent studies document a lower risk of access site and cardiac complications when percutaneous coronary intervention (PCI) is performed via the radial artery as opposed to the femoral artery.1,2 Increased safety, patient comfort, and convenience will likely drive an increase in PCI being performed via the transradial approach. As transradial procedures increase in frequency and complexity, vascular surgeons are likely to encounter some complications that were previously unknown. An awareness of these complications and thoughtful approaches to limit and avoid them will benefit PCI patients. We report a case of radial artery avulsion in situ complicating a transradial coronary rotational atherectomy procedure resulting in a compartment syndrome. We also describe the prompt management of this 123.e7
123.e8 Case reports
Annals of Vascular Surgery
Fig. 1. (A) Coronary angiogram demonstrating complex and heavily calcified 90% stenosis of the distal left main coronary artery as denoted by white arrow. (B) Postatherectomy and stenting coronary angiogram.
complication and provide suggestions to avoid similar problems.
CASE DESCRIPTION A 48-year-old woman with a history of prior coronary artery bypass surgery was referred to our institution after a noneST-segment elevation acute myocardial infarction. Coronary angiography before transfer demonstrated a heavily calcified, 90% distal left main coronary artery (LM) stenosis with an occluded left internal mammary artery bypass graft to the left anterior descending coronary artery. The patient is a devout Jehovah’s Witness and refused transfusion of any blood products. To minimize the risk of bleeding requiring a blood transfusion, interventional cardiology decided to perform coronary rotational atherectomy via a transradial approach. After confirming adequate collateral circulation to the hand via a modified Allen’s test using waveform plethysmography, a 6F hydrophilic sheath was inserted in the right radial artery over a 0.018 inch wire. This was upsized to a nonhydrophilic, 7F sheath to accommodate larger rotational atherectomy burr sizes, if needed. Several attempts to pass the sheath over a 0.035 inch wire were necessary, with 2 separate intra-arterial injections of a mixture of nitroglycerin and verapamil required to reduce spasm and allow passage of the sheath. The sheath was finally passed on a third attempt, with the patient complaining of moderately severe pain on successful passage of the sheath. This pain resolved as the case continued. A 7F EBU (Medtronic, Minneapolis, MN) guide catheter was
advanced to the left coronary artery after which rotational atherectomy of the LM with a 2.0 mm burr was performed (Fig. 1). A bare metal stent was subsequently deployed using standard techniques and adjunctive medications. On successful completion of the procedure, sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. On removal, inspection of the sheath showed an intact sheath without adherent tissue. Hemostasis was achieved by placing a TR Band (Terumo, Tokyo, JAPAN) over the arteriotomy site. Within 15 minutes, the patient reported mild paresthesia in the hand and pain in the right forearm which was tense and appeared to be rapidly expanding, despite adequate hemostasis at the radial arteriotomy site. Immediate vascular surgical consultation was obtained and based on her physical examination findings, she was taken to the operating suite for an exploration of the radial artery with possible decompressive fasciotomy. The radial artery was explored and found to be redundant and pulseless, prompting suspicion of a more proximal injury or avulsion (Fig. 2). Further exploration of the forearm and fasciotomy of the flexor compartment revealed a complete avulsion of the radial artery just distal to its origin off the brachial artery. The flexor compartments were bulging and there was significant hematoma within the flexor compartment once the fascia was released (Fig. 3). An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch. Given that the artery had been completely avulsed and the ulnar artery was satisfactorily perfusing the hand and palmar arch, the decision was made to ligate the radial artery at its origin. At the end
Vol. 29, No. 1, January 2015
Fig. 2. Intraoperative photography demonstrating a complete proximal avulsion of the radial artery from the brachial artery bifurcation. The radial artery was redundant and pulseless.
Fig. 3. Intraoperative photograph during proximal surgical dissection. The radial artery was completely avulsed. The 2 arrows indicate the separated ends of the radial artery. Significant hematoma is present inside the flexor compartment. of the procedure the patient had a pink, well perfused hand. Postoperatively she had return of a normal neuromuscular examination in her hand. She was discharged from the hospital 4 days later with normal hand function and no further sequelae.
DISCUSSION The increase in complex percutaneous interventions has brought with it a myriad of new complications that require a contemporary awareness for diagnosis and management. Herein, we report a case of complete radial artery avulsion ‘‘in situ’’ complicating a transradial coronary rotational
Case reports 123.e9
atherectomy procedure resulting in compartment syndrome of the forearm. To our knowledge, this is the first report of the complete avulsion, of the radial artery in situ complicating a transradial coronary intervention. Partial avulsion and exteriorization of segments of radial artery and eversion endarterectomy have been reported.3 Arzamendi et al. describe a case of a transradial coronary angiogram in which a tubular structure was protruding from the radial arteriotomy site after removal of the 6F sheath. This structure was shown by microscopic examination to be an arterial structure containing all 3 vascular wall layers. However, a Dopplerable radial artery signal was present after this tissue was removed, no hematoma developed, and no surgery was necessary, indicating that this was likely an incomplete avulsion. Incomplete separation or tearing of the arterial layers was also likely observed in another case as well, as ‘‘a faint Dopplerable signal’’ was present after excision of the arterial segment protruding through the arteriotomy, and surgery was not required either.4 Abu-Ful et al.5 report a similar case of partial extraction of the radial artery with the removal of a 6F sheath. Similar to our case, in 2 of these 3 cases, nonhydrophilic sheaths were used, the patients complained of pain during sheath removal, and there was significant resistance to sheath withdrawal.4,5 Acute compartment syndrome complicating transradial coronary procedures is rare and is most commonly associated with bleeding. A MEDLINE/ PubMed query with keywords ‘‘compartment syndrome’’ and ‘‘transradial angioplasty’’ or ‘‘percutaneous coronary interventions’’ limited to the English language yielded only 4 articles.6e9 The incidence of compartment syndrome reported by Lotan et al.7 was 0.4% in 250 patients. In a single institution retrospective review of 51,296 patients undergoing transradial approach for coronary procedures, 2 patients, both women, developed compartment syndrome giving an incidence of 0.004%. Both patients complained of pain, swelling, hypoesthesia, or paresthesia.8 Araki et al.9 reported a case of acute compartment syndrome not associated with bleeding; ischemia of the forearm muscles was attributed to arterial spasm induced by the radial sheath or catheter. Like our case of complete avulsion in situ and the citations above describing partial tears or eversion of the radial artery, none of the patients with compartment syndrome experienced limb ischemia threatening viability of the hand, emphasizing the importance of documenting normal collateral blood flow to the hand before proceeding with any transradial procedures.
123.e10 Case reports
Our case is unique in that both ends of the avulsed radial artery remained inside the forearm; no portions of the radial artery were removed with the sheath. A delay in diagnosis can occur in such a situation if the clinician misinterprets the scenario as a forearm hematoma resulting from a partial tear or perforation of the radial artery and attempts to correct the problem by compressing the forearm with tight gauze wraps or an inflated blood pressure cuff. Such measures would not only be futile, but would lead to costly delays in the case of complete avulsion of the radial artery with subsequent severe functional impairment. It is imperative that immediate vascular surgical consultation is requested even if temporizing techniques are instituted by interventionalists, as doing so maximizes the potential for an outcome with normal hand function. Four reports exist describing the use of rotational atherectomy via the radial artery. A 6F sheath was the default size; however, both 6F and 7F sheaths have been used. Two of the publications report using the Cook radial artery sheath (Cook, Bloomington, IN) which contains a hydrophilic coating.10,11 The other report does not comment on the presence of hydrophilic coating of the sheaths.12 Another report specifically describing the safety of 7F sheaths in the radial artery used the hydrophilic-coated Terumo sheath.13 Transradial coronary rotational atherectomy has been shown to be feasible in these reports which detail the procedure in a total of 132 patients. Overall, only 1 access site complication was reported. These reports coupled with our personal experience suggest that coronary rotational atherectomy is feasible and is unlikely to have a different cardiac complication rate with a transradial approach compared with a transfemoral approach. However, care must be taken to avoid injury to the radial artery when performing complex coronary procedures, particularly with sheath sizes larger than 6F. A review of our case and the pertinent literature yields some important lessons which can potentially help operators avoid or minimize severe radial artery injuries during complex transradial coronary artery intervention. First, it was noted that sheath insertion proceeded despite some degree of resistance and some discomfort to the patient. Although both were lessened by repeat injections of verapamil and nitroglycerin into the radial artery, forcible insertion of a sheath should never be done. Second, a 7F, nonhydrophilic sheath was used. On multidisciplinary review, the interventional cardiologists now recommend exclusive use of hydrophilic sheaths in transradial artery coronary procedures. This is likely more important in women, who tend
Annals of Vascular Surgery
to have smaller radial arteries that are more prone to spasm.14 Several reports document decreased radial artery spasm, decreased pain, and less force required during sheath removal with hydrophiliccoated sheaths.15e18 A randomized evaluation of hydrophilic versus nonhydrophilic sheaths found significantly reduced pain and less force required during removal of hydrophilic sheaths.17 Finally, intravascular ultrasound (IVUS) of the radial artery was not employed before using a larger-than-usual sheath size. Gioia et al.11 first demonstrated a strategy of IVUS imaging of the radial artery before selection of a sheath to ensure radial artery/sheath diameter concordance. Although this technique was used in our institution in the past, we did not do so in this case. Doing so might have helped avoid this complication. Although not necessary for most transradial coronary intervention procedures, a strategy of radial artery IVUS through a 5F sheath (the default sheath size for coronary interventions) is employed by our interventionalists before inserting any sheath size greater than 6F. We report a case of complete avulsion in situ of the radial artery complicating transradial coronary rotational atherectomy resulting in a compartment syndrome requiring surgical repair. Complex transradial coronary interventions will become more popular as transradial coronary interventions continue to proliferate in the United States. Careful attention to techniques to reduce the risk of radial artery injury will be important to avoid an upswing in serious radial artery access site complications. We advocate using hydrophilic-coated sheaths exclusively, imaging the radial artery with IVUS before inserting sheaths larger than 6F, and abandoning the site or sheath size if the operator detects significant resistance or if the patient experiences significant discomfort during sheath insertion. Finally, our patient had a good outcome largely because of timely, expert vascular surgical consultation, pointing out the need for urgent surgical assessment at the first suspicion of an impending compartment syndrome. REFERENCES 1. Rao SV, Cohen MG, Kandzari DE, et al. The transradial approach to percutaneous coronary intervention: historical perspective, current concepts, and future directions. J Am Coll Cardiol 2010;55:2187e95. 2. Jolly SS, Yusuf S, Cairns J, et al., for the RIVAL trial group. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 2011;377:1409e20. 3. Arzamendi D, Romeo P, Gosselin G. Radial artery avulsion: a rare complication of percutaneous coronary intervention. Rev Esp Cardiol 2011;64:62.
Vol. 29, No. 1, January 2015
4. Dieter RS, Akef A, Wolff M. Eversion endarterectomy complicating radial artery access for left heart catheterization. Catheter Cardiovasc Interv 2003;58:478e80. 5. Abu-Ful A, Benharroch D, Henfin Y. Extraction of the radial artery during transradial coronary angiography: an unusual complication. J Invasive Cardiol 2003;15:351e2. 6. Lin YJ, Chu CC, Tsai CW. Acute compartment syndrome after transradial coronary angioplasty. Int J Cardiol 2004; 97:311. 7. Lotan C, Hasin Y, Salmoirago E, et al. The radial artery: an applicable approach to complex coronary angioplasty. J Invasive Cardiol 1997;9:518e22. 8. Tiz on-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a large series of transradial approach for coronary procedures. J Interv Cardiol 2008;21:380e4. 9. Araki T, Itaya H, Yamamoto M. Acute compartment syndrome of the forearm that occurred after transradial intervention and was not caused by bleeding or hematoma formation. Catheter Cardiovasc Interv 2010;75:362e5. 10. Egred M, Andron M, Alahmar A, et al. High-speed rotational atherectomy during transradial percutaneous coronary intervention. J Invasive Cardiol 2008;20:219e21. 11. Gioia G, Comito C, Moreyra AE. Coronary rotational atherectomy via transradial approach: a study using radial
Case reports 123.e11
12.
13. 14.
15.
16.
17.
18.
artery intravascular ultrasound. Catheter Cardiovasc Interv 2000;51:234e8. Watt J, Oldroyd KG. Radial versus femoral approach for high-speed rotational atherectomy. Catheter Cardiovasc Interv 2009;74:550e4. Egred M. Feasibility and safety of 7-Fr radial approach for complex PCI. J Interv Cardiol 2011;24:383e8. Lawton JS, Barner HB, Bailey MS, et al. Radial artery grafts in women: utilization and results. Ann Thorac Surg 2005;80: 559e63. Dery JP, Simard S, Barbeau GR. Reduction of discomfort at sheath removal during transradial coronary procedures with the use of a hydrophilic-coated sheath. Catheter Cardiovasc Interv 2001;54:289e94. Saito S, Tanaka S, Hiroe Y, et al. Usefulness of hydrophilic coating on arterial sheath introducer in transradial coronary intervention. Catheter Cardiovasc Interv 2002;56:328e32. Kiemeneij F, Fraser D, Slagboom T, et al. Hydrophilic coating aids radial sheath withdrawal and reduces patient discomfort following transradial coronary intervention: a randomized double-blind comparison of coated and uncoated sheaths. Catheter Cardiovasc Interv 2003;59:161e4. Caussin C, Gharbi M, Durier C, et al. Reduction in spasm with a long hydrophilic transradial sheath. Catheter Cardiovasc Interv 2010;76:668e72.