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Complications of Transradial Catheterization and Cannulation
CURRENT CONCEPTS
Complications of Transradial Catheterization and Cannulation Matthew J. Hadad, BS,* Varun Puvanesarajah, MD,* E. Gene Deune, MD*
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. (J Hand Surg Am. 2019;(-):-e-. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Key words Compartment syndrome, complications, radial artery, transradial cannulation, transradial catheterization.
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emerged as an attractive option for cannulation for hemodynamic monitoring and catheterization for interventional cardiac procedures. The transradial approach has largely replaced the transfemoral approach for percutaneous cardiac intervention because the transradial approach is associated with fewer vascular complications.1,2 Similarly, transradial cannulation remains a common form of continuous hemodynamic monitoring. Transradial catheterization and cannulation have favorable risk profiles, but considering the large number of these procedures performed, the number of complications becomes clinically important. Complications of transradial cannulation and catheterization include radial artery occlusion (RAO), hematoma, radial artery laceration, pseudoaneurysm, HE RADIAL ARTERY HAS
From the *Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. Received for publication March 6, 2019; accepted in revised form June 19, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: E. Gene Deune, MD, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD 21287; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.06.018
abscess, and compartment syndrome. Symptomatic complications require treatment. When complications involve the distal wrist and hand, the primary treatment team may consult a hand surgeon to address the underlying condition. The purpose of this review is to present the potential complications of transradial cannulation and catheterization and methods for prevention and treatment. RADIAL ARTERY OCCLUSION Radial artery occlusion, caused by thrombus formation, is a common complication of transradial cannulation and catheterization. Iatrogenic vascular wall injury, often compounded by peripheral vasoconstriction or hemodynamic instability, likely contributes to the formation of thrombi.3 Reported risk factors for RAO are inconsistent, but age, sex, body mass index, sheath-to-artery diameter, and procedure duration have been implicated as predictors of RAO.4,5 Radial artery occlusion may be asymptomatic or symptomatic, with the latter involving symptoms of ischemia distal to the site of blockage. The reported incidence of asymptomatic and symptomatic RAO after radial artery catheterization is 7.7% and 0.04%, respectively.1,4 Anatomically, complete superficial and deep palmar arches typically ensure adequate collateral circulation. Radial artery occlusion is likely
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to be asymptomatic in patients who have complete superficial and deep palmar arches. Complete superficial and deep arches are estimated to be present in 80% or greater and 90% or greater of hands, respectively.6 Patients with symptomatic RAO require treatment to prevent permanent ischemic damage and subsequent tissue loss. Anticoagulation, vasodilators, and patent hemostasis are some measures available to reduce the risk of RAO. Anticoagulation before percutaneous intervention is considered the standard of care to reduce the incidence of RAO. Bivalirudin and heparin have shown similar efficacy in preventing RAO.5 A recent randomized prospective study showed that high-dose heparin (100 IU/kg body weight) significantly reduced the rate of RAO in patients who underwent coronary angiography compared with standard-dose heparin (50 IU/kg body weight).7 Vasodilators are often used to treat radial artery spasm after unsuccessful radial artery puncture, but there is also utility in prophylactically increasing the diameter of the radial artery to prevent RAO. In a prospective, randomized, placebo-controlled trial of approximately 1,700 patients, 1 vasodilator, nitroglycerin, reduced the incidence of RAO when administered after transradial catheterization.8 One nonchemical method of preventing RAO is patent hemostasis. Patent hemostasis is the practice of providing enough pressure on the radial artery to prevent bleeding but not enough to prevent blood flow. Interventionalists often use patent hemostasis for several hours after transradial procedures. Patent hemostasis is more effective at preventing RAO compared with compressive hemostasis.9 In addition, the use of patent hemostasis in conjunction with ipsilateral ulnar artery compression reduces the rate of RAO compared with patent hemostasis alone.10 Symptomatic RAO that is refractory to standard treatment may need additional intervention; however, there is no standard nonsurgical treatment. Jaradat et al11 reported on 4 patients with symptomatic RAO who were treated successfully with balloon angioplasty and a 90-second infusion of intra-arterial abciximab. Notably, a fifth patient in this series was treated with balloon angioplasty alone, but this patient developed symptomatic reocclusion of the radial artery. Although vasodilators and anticoagulation can prevent RAO, there is insufficient evidence to support their independent use in the treatment of RAO. Valentine et al12 reported on a patient with acute RAO and spasms of the ulnar, palmar, and interosseous arteries, which were treated successfully with intra-arterial verapamil. Another patient in this series J Hand Surg Am.
experienced some improvement of ischemia symptoms after oral nifedipine treatment for acute RAO. If nonsurgical treatment of RAO fails, thrombectomy remains an option of last resort. Garg et al3 reported on the surgical treatment of symptomatic RAO in 15 patients after radial artery catheterization. All patients underwent thrombectomy with vein patch angioplasty (n ¼ 13), prosthetic patch angioplasty (n ¼ 1), or primary repair (n ¼ 1). Two patients with vein patch angioplasty and the patient with primary repair developed thrombosis of the repaired radial artery, which required reoperation with repeat thrombectomy and patch angioplasty. Although there was a substantial (56%) in-hospital mortality rate in this group of critically ill patients, all reconstructions remained patent, and no amputations were needed. In contrast, Valentine et al12 reported on 5 patients with grade IIB ischemia after radial artery cannulation, 4 of whom underwent thrombectomy and patch angioplasty and 1 of whom underwent vein graft interposition. Three of these repairs had thrombosis within 24 hours. One patient with thrombosis died of multisystem organ failure, and 1 patient underwent reoperation for thrombosis. The remaining 4 patients, including the 3 patients with patent radial arteries and the 1 patient after reoperation, developed digital gangrene, necessitating amputation in 2 patients. Although these preliminary studies suggest that thrombectomy may be a reasonable option to treat RAO, thrombosis is likely to recur, and distal digital embolization may cause distal ischemia. HEMATOMA OF THE DISTAL UPPER EXTREMITY Hematoma formation at the site of transradial cannulation or catheterization (Fig. 1) is common, with a reported incidence of 14%, and usually benign; however, the presence of a hematoma is associated with a higher incidence of RAO.13 Substantial bleeding and hematoma formation are also rarely associated with the development of compartment syndrome.14 Hematoma development should raise clinical suspicion for additional underlying pathology. It is appropriate to observe asymptomatic, nonexpanding hematomas. The use of warm compresses and elevation may hasten resolution. If there is any concern that a hematoma is expanding, the borders of the hematoma should be marked with skin-safe ink to provide reference for size change. A rapidly expanding hematoma or a hematoma with signs of neurovascular compromise warrants an urgent physical examination to evaluate for patent radial and r
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treatment. Gelberman et al16 reported on 14 patients with radial artery laceration from noniatrogenic causes. All patients underwent primary repair or repair with vein grafting, and 9 patients had patent radial arteries at a mean 12-month follow-up. The authors noted that even temporary patency of the repaired vessel may allow time for the development of collateral vessels. Asymptomatic radial artery lacerations may not require treatment. Radial artery repair and ligation are associated with similar rates of postoperative cold sensitivity in patients with intact collateral circulation via the ulnar artery.17 PSEUDOANEURYSM A pseudoaneurysm is the collection of blood between the tunica media and the adventitia of an artery. A pseudoaneurysm may manifest as an expanding mass, pulsating mass, and/or erythema at the site of transradial intervention (Figs. 3, 4). The diagnosis can be confirmed with duplex ultrasonography. Pseudoaneurysm has an estimated incidence of 0.09%.13 One study reported that patients with hypertension, atrial fibrillation, or chronic kidney disease were more likely to develop a pseudoaneurysm than those without these conditions.18 There may also be an association of pseudoaneurysm with concurrent infection.3,19 Nonsurgical interventions for pseudoaneurysms include intra-arterial thrombin injection and external compression. Although there is substantial evidence for the efficacy of thrombin injections to treat iatrogenic femoral pseudoaneurysm, there are limited data supporting the use of thrombin to treat radial pseudoaneurysms. Garvin et al18 reported the successful treatment of 14 of 18 radial or brachial artery pseudoaneurysms (78%) with 300 to 8,000 IU of intra-arterial thrombin injections. In another study, compression with a pneumatic device or ultrasound probe was successful in treating 3 of 5 radial artery pseudoaneurysms, and thrombin injections were successful for the remaining 2 cases.20 One case in this series that was ultimately treated with thrombin injection was complicated by a late asymptomatic RAO. These limited studies suggest that thrombin and external compression may be effective in treating upper extremity pseudoaneurysms. When nonsurgical interventions for pseudoaneurysms fail, surgical treatment is an option. Tosti et al21 reported on the treatment of catheter-related radial pseudoaneurysms in 11 patients. Four patients had not responded to compression therapy, and nonsurgical interventions were not attempted in
FIGURE 1: Photograph of a left forearm hematoma in a 41-yearold woman after radial artery cannulation while on enoxaparin. She developed a pseudoaneurysm with eventual thrombosis and ischemia to the hand. She underwent urgent surgery with resection of the pseudoaneurysm and primary repair.
ulnar circulation, digital perfusion via Doppler imaging, and compartment pressures via a pressure monitor. The presence of or the impending threat of forearm or hand compartment syndrome would warrant surgical evacuation. RADIAL ARTERY LACERATION Laceration at the site of cannulation or catheterization, such as intimal tears, which occur at the puncture site in approximately 67% of transradial catheterization procedures, often resolve without treatment.15 Repeat interventions in the same artery are associated with a significantly higher rate of acute injury compared with interventions in naïve arteries.15 A laceration may serve as the nidus for RAO (via exposure of collagen and subsequent provocation of the coagulation cascade), pseudoaneurysm (via disruption of the tunica intima), hematoma formation (via a direct bleeding source), and compartment syndrome (from hematoma formation; Fig. 2A). Radial artery laceration with evidence of impaired hand perfusion requires immediate surgical intervention. In such cases, arterial repair is the standard J Hand Surg Am.
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FIGURE 2: Intraoperative photographs of a radial artery laceration and compartment syndrome. A 41-year-old woman developed compartment syndrome of the right upper extremity 3 hours after transradial cardiac catheterization. A A radial artery laceration is identified that resulted in the hematoma formation. The patient underwent volar and dorsal (not shown) forearm fasciotomies. Proximal muscles were dusky (white arrow in B).
FIGURE 3: Photographs of a distal radial artery pseudoaneurysm. A 47-year-old man with Marfan syndrome presented with an asymptomatic right dorsal radial artery pseudoaneurysm 9 years after transradial cannulation for hemodynamic monitoring. A Physical examination showed a 3.0 1.5-cm pulsatile lesion without neurological deficits or erythema. Appearance of the pseudoaneurysm B before resection and C after resection. D Dorsal radial artery after pseudoaneurysm resection. E Primary repair of the radial artery after pseudoaneurysm resection.
flexion contracture, reoperation for wound breakdown, reoperation for persistent pain and hematoma evacuation, and digital ischemia and death. Garg et al3 reported on 10 patients with pseudoaneurysms. Two patients experienced pseudoaneurysm rupture and were treated with radial artery ligation; 8 patients with unruptured pseudoaneurysms underwent primary repair (n ¼ 5), formal radial artery ligation (n ¼ 2), or vein patch angioplasty (n ¼ 1). The decision to use patch or direct repair was determined by the size of the defect, although the cutoff defect size is unavailable. No complications were reported for these 10 patients, although 6 patients had
7 patients. Four patients with a pseudoaneurysm diameter less than 3 cm experienced resolution of the pseudoaneurysm without further intervention. Seven patients underwent surgery. The indications for surgery were persistent pain or pseudoaneurysm diameter greater than 3 cm. Four patients underwent excision of the pseudoaneurysm with primary arterial repair, 2 patients underwent excision of the pseudoaneurysm without primary arterial repair, and 1 patient underwent embolization of a proximal forearm pseudoaneurysm with endovascular coils. Complications in 5 patients included 1 case each of compressive median nerve neuropathy, elbow
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FIGURE 4: Radial pseudoaneurysm images. A 76-year-old woman developed a right radial pseudoaneurysm after transradial catheterization. A Representative coronal computed tomography image shows a 1.8 0.9 0.8-cm right pseudoaneurysm (arrow). B Threedimensional reconstruction of computed tomography image shows the pseudoaneurysm (arrow).
positive blood cultures for Staphylococcus aureus. Swanson et al19 reported on 12 patients with radial artery infections after catheterization, of whom 5 patients developed pseudoaneurysms. All 5 patients underwent excision of the pseudoaneurysm without complications. We agree that it is reasonable to observe pseudoaneurysms smaller than 3 cm with serial Doppler ultrasonography to monitor for size change or resolution. External compression may hasten resolution. For pseudoaneurysms larger than 3 cm with a narrow neck, clinicians can consider interventional radiologyedirected thrombin injection. There is no formal definition of a narrow neck, and it is usually a subjective determination by the consulting interventional radiologist. For pseudoaneurysms larger than 3 cm without a narrow neck, excision with arterial repair may be indicated to prevent further enlargement and subsequent morbidity.
Local infection may present as a superficial or deep abscess. A hand surgeon may be consulted to surgically treat a deep abscess. The standard treatment for a deep abscess of the wrist is surgical incision and drainage (I&D). Garg et al3 discussed the surgical treatment of 5 patients with deep abscesses after indwelling radial artery catheterization. Three patients had concomitant ipsilateral asymptomatic RAO, and 4 patients had concomitant ipsilateral radial arteritis. All patients underwent I&D, and the 4 patients with ipsilateral radial arteritis also underwent excision and ligation of the radial artery. In all patients, blood cultures were positive for S. aureus. No reoperations were reported for these 5 patients. Before performing I&D of a deep abscess near the radial artery, it is important to perform a thorough vascular examination to determine patency of the radial artery and collateral ulnar and palmar circulation. Evidence of radial arteritis with sufficient collateral flow may be an indication for excision and ligation of the radial artery. Typical fungal and acidfast bacilli cultures should be performed for deep abscesses, regardless of the appearance of the abscess’s contents. A recent study by Kazmers et al22 suggested that atypical cultures should be performed
ABSCESS As do all percutaneous interventions, transradial cannulation and catheterization present risk of infection. Local infections occur in 0.72% of radial artery cannulations.13
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regardless of the appearance of the fluid because 3 of 46 deep abscesses of the upper extremity in their study had purulent fluid and positive fungal or acidfast bacilli cultures.
artery lacerations are common after transradial access procedures and often resolve without treatment; hematomas are rarely associated with RAO and compartment syndrome. Pseudoaneurysms can often be treated nonsurgically with external compression and intra-arterial thrombin injections. Small pseudoaneurysms (< 3 cm) may resolve without treatment, whereas painful and/or large pseudoaneurysms (> 3 cm) may require surgical excision. Pseudoaneurysms may be associated with concurrent infection. Standard treatment of deep abscess(es) of the distal forearm is I&D. Typical and atypical cultures should be analyzed, regardless of the appearance of abscess fluid. Suspected compartment syndrome of the forearm or hand necessitates emergency decompressive fasciotomy of all compartments.
COMPARTMENT SYNDROME Compartment syndrome is a rare yet potentially devastating complication of transradial cannulation and catheterization, with an estimated incidence of 0.004%.23 Bleeding from the arterial puncture site may lead to increased pressures within the forearm and hand. This process can be acute or can occur slowly over several days. Symptoms of compartment syndrome may include paresthesia in the medial, ulnar, or radial nerve distributions and/or pain associated with passive movement of the fingers. Any 1 of these symptoms should prompt urgent measurement of compartment pressures with a pressure monitor. A compartment pressure within 30 mm Hg of the diastolic blood pressure is diagnostic of compartment syndrome. Given the low incidence of compartment syndrome after radial artery cannulation or catheterization, the risk factors of compartment syndrome are difficult to discern. The causes of excess bleeding, such as supratherapeutic anticoagulation and atherosclerosis, may be predictive factors. Low patient body mass index may also increase the risk of compartment syndrome because of the low baseline volume capacity of the upper extremity.23 Compartment syndrome can occur in the forearm1,23 or hand.14 A patient with suspected compartment syndrome of the distal forearm should undergo emergency decompressive fasciotomy of the volar and dorsal compartments and carpal tunnel release (Fig. 2B). Suspected compartment syndrome of the hand should be treated similarly with emergency fasciotomy of all hand compartments. Failure to identify and promptly treat compartment syndrome increases the risk of irreversible ischemic damage.
REFERENCES 1. Cauley R, Wu WW, Doval A, Chaikof E, Ho KKL, Iorio ML. Identifying complications and optimizing consultations following transradial arterial access for cardiac procedures. Ann Vasc Surg. 2019;56:87e96. 2. Brueck M, Bandorski D, Kramer W, Wieczorek M, Holtgen R, Tillmanns H. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv. 2009;2(11):1047e1054. 3. Garg K, Howell BW, Saltzberg SS, et al. Open surgical management of complications from indwelling radial artery catheters. J Vasc Surg. 2013;58(5):1325e1330. 4. Rashid M, Kwok CS, Pancholy S, et al. Radial artery occlusion after transradial interventions: a systematic review and meta-analysis. J Am Heart Assoc. 2016;5(1):1e22. 5. Plante S, Cantor WJ, Goldman L, et al. Comparison of bivalirudin versus heparin on radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv. 2010;76(5):654e658. 6. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009;109(6):1763e1781. 7. Hahalis GN, Leopoulou M, Tsigkas G, et al. Multicenter randomized evaluation of high versus standard heparin dose on incident radial arterial occlusion after transradial coronary angiography: the Spirit of Artemis study. JACC Cardiovasc Interv. 2018;11(22):2241e2250. 8. Dharma S, Kedev S, Patel T, Kiemeneij F, Gilchrist IC. A novel approach to reduce radial artery occlusion after transradial catheterization: postprocedural/prehemostasis intra-arterial nitroglycerin. Catheter Cardiovasc Interv. 2015;85(5):818e825. 9. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008;72(3):335e340. 10. Pancholy SB, Bernat I, Bertrand OF, Patel TM. Prevention of radial artery occlusion after transradial catheterization: the PROPHET-II randomized trial. JACC Cardiovasc Interv. 2016;9(19):1992e1999. 11. Jaradat Z, Basir B, Revtyak G. Treatment of radial artery occlusions using balloon angioplasty and localized intra-arterial abciximab. J Interv Cardiol. 2014;27(2):217e222. 12. Valentine RJ, Modrall JG, Clagett GP. Hand ischemia after radial artery cannulation. J Am Coll Surg. 2005;201(1):18e22. 13. Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002;6(3):199e204.
DISCUSSION Transradial access procedures are typically well tolerated, but substantial complications are associated with these procedures. Prevention and management of complications have been reported in literature. Periprocedural or postprocedural anticoagulation, vasodilators, and compression reduce the risk of RAO. Balloon angioplasty with intra-arterial anticoagulation may be effective in treating symptomatic RAO, and thrombectomy remains a last-resort option with high complication rates. Hematomas and radial J Hand Surg Am.
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19. Swanson E, Freiberg A, Salter DR. Radial artery infections and aneurysms after catheterization. J Hand Surg Am. 1990;15(1): 166e171. 20. Zegri I, Garcia-Touchard A, Cuenca S, Oteo JF, Fernandez-Diaz JA, Goicolea J. Radial artery pseudoaneurysm following cardiac catheterization: clinical features and nonsurgical treatment results. Rev Esp Cardiol (Engl Ed). 2015;68(4):349e351. 21. Tosti R, Ozkan S, Schainfeld RM, Eberlin KR. Radial artery pseudoaneurysm. J Hand Surg Am. 2017;42(4):295.e6. 22. Kazmers NH, Fryhofer GW, Gittings D, Bozentka DJ, Steinberg DR, Gray BL. Acute deep infections of the upper extremity: the utility of obtaining atypical cultures in the presence of purulence. J Hand Surg Am. 2017;42(8):663.e8. 23. Tizon-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(5):380e384.
14. Jue J, Karam JA, Mejia A, Shroff A. Compartment syndrome of the hand: a rare sequela of transradial cardiac catheterization. Tex Heart Inst J. 2017;44(1):73e76. 15. Yonetsu T, Kakuta T, Lee T, et al. Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography. Eur Heart J. 2010;31(13):1608e1615. 16. Gelberman RH, Nunley JA, Koman LA, et al. The results of radial and ulnar arterial repair in the forearm. Experience in three medical centers. J Bone Joint Surg Am. 1982;64(3):383e387. 17. Schippers SM, Hajewski C, Glass NA, Caldwell L. single forearm vessel injury in a perfused hand: repair or ligate? A systematic review. Iowa Orthop J. 2018;38:159. 18. Garvin RP, Ryer EJ, Yoon HR, et al. Ultrasound-guided percutaneous thrombin injection of iatrogenic upper extremity pseudoaneurysms. J Vasc Surg. 2014;59(6):1664e1669.
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Complications of Transradial Catheterization and Cannulation Matthew J. Hadad, BS,* Varun Puvanesarajah, MD,* E. Gene Deune, MD*
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. (J Hand Surg Am. 2019;(-):-e-. Copyright Ó 2019 by the American Society for Surgery of the Hand. All rights reserved.) Key words Compartment syndrome, complications, radial artery, transradial cannulation, transradial catheterization.
T
emerged as an attractive option for cannulation for hemodynamic monitoring and catheterization for interventional cardiac procedures. The transradial approach has largely replaced the transfemoral approach for percutaneous cardiac intervention because the transradial approach is associated with fewer vascular complications.1,2 Similarly, transradial cannulation remains a common form of continuous hemodynamic monitoring. Transradial catheterization and cannulation have favorable risk profiles, but considering the large number of these procedures performed, the number of complications becomes clinically important. Complications of transradial cannulation and catheterization include radial artery occlusion (RAO), hematoma, radial artery laceration, pseudoaneurysm, HE RADIAL ARTERY HAS
From the *Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD. Received for publication March 6, 2019; accepted in revised form June 19, 2019. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: E. Gene Deune, MD, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline St., Baltimore, MD 21287; e-mail: [email protected]. 0363-5023/19/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2019.06.018
abscess, and compartment syndrome. Symptomatic complications require treatment. When complications involve the distal wrist and hand, the primary treatment team may consult a hand surgeon to address the underlying condition. The purpose of this review is to present the potential complications of transradial cannulation and catheterization and methods for prevention and treatment. RADIAL ARTERY OCCLUSION Radial artery occlusion, caused by thrombus formation, is a common complication of transradial cannulation and catheterization. Iatrogenic vascular wall injury, often compounded by peripheral vasoconstriction or hemodynamic instability, likely contributes to the formation of thrombi.3 Reported risk factors for RAO are inconsistent, but age, sex, body mass index, sheath-to-artery diameter, and procedure duration have been implicated as predictors of RAO.4,5 Radial artery occlusion may be asymptomatic or symptomatic, with the latter involving symptoms of ischemia distal to the site of blockage. The reported incidence of asymptomatic and symptomatic RAO after radial artery catheterization is 7.7% and 0.04%, respectively.1,4 Anatomically, complete superficial and deep palmar arches typically ensure adequate collateral circulation. Radial artery occlusion is likely
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to be asymptomatic in patients who have complete superficial and deep palmar arches. Complete superficial and deep arches are estimated to be present in 80% or greater and 90% or greater of hands, respectively.6 Patients with symptomatic RAO require treatment to prevent permanent ischemic damage and subsequent tissue loss. Anticoagulation, vasodilators, and patent hemostasis are some measures available to reduce the risk of RAO. Anticoagulation before percutaneous intervention is considered the standard of care to reduce the incidence of RAO. Bivalirudin and heparin have shown similar efficacy in preventing RAO.5 A recent randomized prospective study showed that high-dose heparin (100 IU/kg body weight) significantly reduced the rate of RAO in patients who underwent coronary angiography compared with standard-dose heparin (50 IU/kg body weight).7 Vasodilators are often used to treat radial artery spasm after unsuccessful radial artery puncture, but there is also utility in prophylactically increasing the diameter of the radial artery to prevent RAO. In a prospective, randomized, placebo-controlled trial of approximately 1,700 patients, 1 vasodilator, nitroglycerin, reduced the incidence of RAO when administered after transradial catheterization.8 One nonchemical method of preventing RAO is patent hemostasis. Patent hemostasis is the practice of providing enough pressure on the radial artery to prevent bleeding but not enough to prevent blood flow. Interventionalists often use patent hemostasis for several hours after transradial procedures. Patent hemostasis is more effective at preventing RAO compared with compressive hemostasis.9 In addition, the use of patent hemostasis in conjunction with ipsilateral ulnar artery compression reduces the rate of RAO compared with patent hemostasis alone.10 Symptomatic RAO that is refractory to standard treatment may need additional intervention; however, there is no standard nonsurgical treatment. Jaradat et al11 reported on 4 patients with symptomatic RAO who were treated successfully with balloon angioplasty and a 90-second infusion of intra-arterial abciximab. Notably, a fifth patient in this series was treated with balloon angioplasty alone, but this patient developed symptomatic reocclusion of the radial artery. Although vasodilators and anticoagulation can prevent RAO, there is insufficient evidence to support their independent use in the treatment of RAO. Valentine et al12 reported on a patient with acute RAO and spasms of the ulnar, palmar, and interosseous arteries, which were treated successfully with intra-arterial verapamil. Another patient in this series J Hand Surg Am.
experienced some improvement of ischemia symptoms after oral nifedipine treatment for acute RAO. If nonsurgical treatment of RAO fails, thrombectomy remains an option of last resort. Garg et al3 reported on the surgical treatment of symptomatic RAO in 15 patients after radial artery catheterization. All patients underwent thrombectomy with vein patch angioplasty (n ¼ 13), prosthetic patch angioplasty (n ¼ 1), or primary repair (n ¼ 1). Two patients with vein patch angioplasty and the patient with primary repair developed thrombosis of the repaired radial artery, which required reoperation with repeat thrombectomy and patch angioplasty. Although there was a substantial (56%) in-hospital mortality rate in this group of critically ill patients, all reconstructions remained patent, and no amputations were needed. In contrast, Valentine et al12 reported on 5 patients with grade IIB ischemia after radial artery cannulation, 4 of whom underwent thrombectomy and patch angioplasty and 1 of whom underwent vein graft interposition. Three of these repairs had thrombosis within 24 hours. One patient with thrombosis died of multisystem organ failure, and 1 patient underwent reoperation for thrombosis. The remaining 4 patients, including the 3 patients with patent radial arteries and the 1 patient after reoperation, developed digital gangrene, necessitating amputation in 2 patients. Although these preliminary studies suggest that thrombectomy may be a reasonable option to treat RAO, thrombosis is likely to recur, and distal digital embolization may cause distal ischemia. HEMATOMA OF THE DISTAL UPPER EXTREMITY Hematoma formation at the site of transradial cannulation or catheterization (Fig. 1) is common, with a reported incidence of 14%, and usually benign; however, the presence of a hematoma is associated with a higher incidence of RAO.13 Substantial bleeding and hematoma formation are also rarely associated with the development of compartment syndrome.14 Hematoma development should raise clinical suspicion for additional underlying pathology. It is appropriate to observe asymptomatic, nonexpanding hematomas. The use of warm compresses and elevation may hasten resolution. If there is any concern that a hematoma is expanding, the borders of the hematoma should be marked with skin-safe ink to provide reference for size change. A rapidly expanding hematoma or a hematoma with signs of neurovascular compromise warrants an urgent physical examination to evaluate for patent radial and r
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treatment. Gelberman et al16 reported on 14 patients with radial artery laceration from noniatrogenic causes. All patients underwent primary repair or repair with vein grafting, and 9 patients had patent radial arteries at a mean 12-month follow-up. The authors noted that even temporary patency of the repaired vessel may allow time for the development of collateral vessels. Asymptomatic radial artery lacerations may not require treatment. Radial artery repair and ligation are associated with similar rates of postoperative cold sensitivity in patients with intact collateral circulation via the ulnar artery.17 PSEUDOANEURYSM A pseudoaneurysm is the collection of blood between the tunica media and the adventitia of an artery. A pseudoaneurysm may manifest as an expanding mass, pulsating mass, and/or erythema at the site of transradial intervention (Figs. 3, 4). The diagnosis can be confirmed with duplex ultrasonography. Pseudoaneurysm has an estimated incidence of 0.09%.13 One study reported that patients with hypertension, atrial fibrillation, or chronic kidney disease were more likely to develop a pseudoaneurysm than those without these conditions.18 There may also be an association of pseudoaneurysm with concurrent infection.3,19 Nonsurgical interventions for pseudoaneurysms include intra-arterial thrombin injection and external compression. Although there is substantial evidence for the efficacy of thrombin injections to treat iatrogenic femoral pseudoaneurysm, there are limited data supporting the use of thrombin to treat radial pseudoaneurysms. Garvin et al18 reported the successful treatment of 14 of 18 radial or brachial artery pseudoaneurysms (78%) with 300 to 8,000 IU of intra-arterial thrombin injections. In another study, compression with a pneumatic device or ultrasound probe was successful in treating 3 of 5 radial artery pseudoaneurysms, and thrombin injections were successful for the remaining 2 cases.20 One case in this series that was ultimately treated with thrombin injection was complicated by a late asymptomatic RAO. These limited studies suggest that thrombin and external compression may be effective in treating upper extremity pseudoaneurysms. When nonsurgical interventions for pseudoaneurysms fail, surgical treatment is an option. Tosti et al21 reported on the treatment of catheter-related radial pseudoaneurysms in 11 patients. Four patients had not responded to compression therapy, and nonsurgical interventions were not attempted in
FIGURE 1: Photograph of a left forearm hematoma in a 41-yearold woman after radial artery cannulation while on enoxaparin. She developed a pseudoaneurysm with eventual thrombosis and ischemia to the hand. She underwent urgent surgery with resection of the pseudoaneurysm and primary repair.
ulnar circulation, digital perfusion via Doppler imaging, and compartment pressures via a pressure monitor. The presence of or the impending threat of forearm or hand compartment syndrome would warrant surgical evacuation. RADIAL ARTERY LACERATION Laceration at the site of cannulation or catheterization, such as intimal tears, which occur at the puncture site in approximately 67% of transradial catheterization procedures, often resolve without treatment.15 Repeat interventions in the same artery are associated with a significantly higher rate of acute injury compared with interventions in naïve arteries.15 A laceration may serve as the nidus for RAO (via exposure of collagen and subsequent provocation of the coagulation cascade), pseudoaneurysm (via disruption of the tunica intima), hematoma formation (via a direct bleeding source), and compartment syndrome (from hematoma formation; Fig. 2A). Radial artery laceration with evidence of impaired hand perfusion requires immediate surgical intervention. In such cases, arterial repair is the standard J Hand Surg Am.
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FIGURE 2: Intraoperative photographs of a radial artery laceration and compartment syndrome. A 41-year-old woman developed compartment syndrome of the right upper extremity 3 hours after transradial cardiac catheterization. A A radial artery laceration is identified that resulted in the hematoma formation. The patient underwent volar and dorsal (not shown) forearm fasciotomies. Proximal muscles were dusky (white arrow in B).
FIGURE 3: Photographs of a distal radial artery pseudoaneurysm. A 47-year-old man with Marfan syndrome presented with an asymptomatic right dorsal radial artery pseudoaneurysm 9 years after transradial cannulation for hemodynamic monitoring. A Physical examination showed a 3.0 1.5-cm pulsatile lesion without neurological deficits or erythema. Appearance of the pseudoaneurysm B before resection and C after resection. D Dorsal radial artery after pseudoaneurysm resection. E Primary repair of the radial artery after pseudoaneurysm resection.
flexion contracture, reoperation for wound breakdown, reoperation for persistent pain and hematoma evacuation, and digital ischemia and death. Garg et al3 reported on 10 patients with pseudoaneurysms. Two patients experienced pseudoaneurysm rupture and were treated with radial artery ligation; 8 patients with unruptured pseudoaneurysms underwent primary repair (n ¼ 5), formal radial artery ligation (n ¼ 2), or vein patch angioplasty (n ¼ 1). The decision to use patch or direct repair was determined by the size of the defect, although the cutoff defect size is unavailable. No complications were reported for these 10 patients, although 6 patients had
7 patients. Four patients with a pseudoaneurysm diameter less than 3 cm experienced resolution of the pseudoaneurysm without further intervention. Seven patients underwent surgery. The indications for surgery were persistent pain or pseudoaneurysm diameter greater than 3 cm. Four patients underwent excision of the pseudoaneurysm with primary arterial repair, 2 patients underwent excision of the pseudoaneurysm without primary arterial repair, and 1 patient underwent embolization of a proximal forearm pseudoaneurysm with endovascular coils. Complications in 5 patients included 1 case each of compressive median nerve neuropathy, elbow
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FIGURE 4: Radial pseudoaneurysm images. A 76-year-old woman developed a right radial pseudoaneurysm after transradial catheterization. A Representative coronal computed tomography image shows a 1.8 0.9 0.8-cm right pseudoaneurysm (arrow). B Threedimensional reconstruction of computed tomography image shows the pseudoaneurysm (arrow).
positive blood cultures for Staphylococcus aureus. Swanson et al19 reported on 12 patients with radial artery infections after catheterization, of whom 5 patients developed pseudoaneurysms. All 5 patients underwent excision of the pseudoaneurysm without complications. We agree that it is reasonable to observe pseudoaneurysms smaller than 3 cm with serial Doppler ultrasonography to monitor for size change or resolution. External compression may hasten resolution. For pseudoaneurysms larger than 3 cm with a narrow neck, clinicians can consider interventional radiologyedirected thrombin injection. There is no formal definition of a narrow neck, and it is usually a subjective determination by the consulting interventional radiologist. For pseudoaneurysms larger than 3 cm without a narrow neck, excision with arterial repair may be indicated to prevent further enlargement and subsequent morbidity.
Local infection may present as a superficial or deep abscess. A hand surgeon may be consulted to surgically treat a deep abscess. The standard treatment for a deep abscess of the wrist is surgical incision and drainage (I&D). Garg et al3 discussed the surgical treatment of 5 patients with deep abscesses after indwelling radial artery catheterization. Three patients had concomitant ipsilateral asymptomatic RAO, and 4 patients had concomitant ipsilateral radial arteritis. All patients underwent I&D, and the 4 patients with ipsilateral radial arteritis also underwent excision and ligation of the radial artery. In all patients, blood cultures were positive for S. aureus. No reoperations were reported for these 5 patients. Before performing I&D of a deep abscess near the radial artery, it is important to perform a thorough vascular examination to determine patency of the radial artery and collateral ulnar and palmar circulation. Evidence of radial arteritis with sufficient collateral flow may be an indication for excision and ligation of the radial artery. Typical fungal and acidfast bacilli cultures should be performed for deep abscesses, regardless of the appearance of the abscess’s contents. A recent study by Kazmers et al22 suggested that atypical cultures should be performed
ABSCESS As do all percutaneous interventions, transradial cannulation and catheterization present risk of infection. Local infections occur in 0.72% of radial artery cannulations.13
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regardless of the appearance of the fluid because 3 of 46 deep abscesses of the upper extremity in their study had purulent fluid and positive fungal or acidfast bacilli cultures.
artery lacerations are common after transradial access procedures and often resolve without treatment; hematomas are rarely associated with RAO and compartment syndrome. Pseudoaneurysms can often be treated nonsurgically with external compression and intra-arterial thrombin injections. Small pseudoaneurysms (< 3 cm) may resolve without treatment, whereas painful and/or large pseudoaneurysms (> 3 cm) may require surgical excision. Pseudoaneurysms may be associated with concurrent infection. Standard treatment of deep abscess(es) of the distal forearm is I&D. Typical and atypical cultures should be analyzed, regardless of the appearance of abscess fluid. Suspected compartment syndrome of the forearm or hand necessitates emergency decompressive fasciotomy of all compartments.
COMPARTMENT SYNDROME Compartment syndrome is a rare yet potentially devastating complication of transradial cannulation and catheterization, with an estimated incidence of 0.004%.23 Bleeding from the arterial puncture site may lead to increased pressures within the forearm and hand. This process can be acute or can occur slowly over several days. Symptoms of compartment syndrome may include paresthesia in the medial, ulnar, or radial nerve distributions and/or pain associated with passive movement of the fingers. Any 1 of these symptoms should prompt urgent measurement of compartment pressures with a pressure monitor. A compartment pressure within 30 mm Hg of the diastolic blood pressure is diagnostic of compartment syndrome. Given the low incidence of compartment syndrome after radial artery cannulation or catheterization, the risk factors of compartment syndrome are difficult to discern. The causes of excess bleeding, such as supratherapeutic anticoagulation and atherosclerosis, may be predictive factors. Low patient body mass index may also increase the risk of compartment syndrome because of the low baseline volume capacity of the upper extremity.23 Compartment syndrome can occur in the forearm1,23 or hand.14 A patient with suspected compartment syndrome of the distal forearm should undergo emergency decompressive fasciotomy of the volar and dorsal compartments and carpal tunnel release (Fig. 2B). Suspected compartment syndrome of the hand should be treated similarly with emergency fasciotomy of all hand compartments. Failure to identify and promptly treat compartment syndrome increases the risk of irreversible ischemic damage.
REFERENCES 1. Cauley R, Wu WW, Doval A, Chaikof E, Ho KKL, Iorio ML. Identifying complications and optimizing consultations following transradial arterial access for cardiac procedures. Ann Vasc Surg. 2019;56:87e96. 2. Brueck M, Bandorski D, Kramer W, Wieczorek M, Holtgen R, Tillmanns H. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv. 2009;2(11):1047e1054. 3. Garg K, Howell BW, Saltzberg SS, et al. Open surgical management of complications from indwelling radial artery catheters. J Vasc Surg. 2013;58(5):1325e1330. 4. Rashid M, Kwok CS, Pancholy S, et al. Radial artery occlusion after transradial interventions: a systematic review and meta-analysis. J Am Heart Assoc. 2016;5(1):1e22. 5. Plante S, Cantor WJ, Goldman L, et al. Comparison of bivalirudin versus heparin on radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv. 2010;76(5):654e658. 6. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009;109(6):1763e1781. 7. Hahalis GN, Leopoulou M, Tsigkas G, et al. Multicenter randomized evaluation of high versus standard heparin dose on incident radial arterial occlusion after transradial coronary angiography: the Spirit of Artemis study. JACC Cardiovasc Interv. 2018;11(22):2241e2250. 8. Dharma S, Kedev S, Patel T, Kiemeneij F, Gilchrist IC. A novel approach to reduce radial artery occlusion after transradial catheterization: postprocedural/prehemostasis intra-arterial nitroglycerin. Catheter Cardiovasc Interv. 2015;85(5):818e825. 9. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008;72(3):335e340. 10. Pancholy SB, Bernat I, Bertrand OF, Patel TM. Prevention of radial artery occlusion after transradial catheterization: the PROPHET-II randomized trial. JACC Cardiovasc Interv. 2016;9(19):1992e1999. 11. Jaradat Z, Basir B, Revtyak G. Treatment of radial artery occlusions using balloon angioplasty and localized intra-arterial abciximab. J Interv Cardiol. 2014;27(2):217e222. 12. Valentine RJ, Modrall JG, Clagett GP. Hand ischemia after radial artery cannulation. J Am Coll Surg. 2005;201(1):18e22. 13. Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002;6(3):199e204.
DISCUSSION Transradial access procedures are typically well tolerated, but substantial complications are associated with these procedures. Prevention and management of complications have been reported in literature. Periprocedural or postprocedural anticoagulation, vasodilators, and compression reduce the risk of RAO. Balloon angioplasty with intra-arterial anticoagulation may be effective in treating symptomatic RAO, and thrombectomy remains a last-resort option with high complication rates. Hematomas and radial J Hand Surg Am.
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19. Swanson E, Freiberg A, Salter DR. Radial artery infections and aneurysms after catheterization. J Hand Surg Am. 1990;15(1): 166e171. 20. Zegri I, Garcia-Touchard A, Cuenca S, Oteo JF, Fernandez-Diaz JA, Goicolea J. Radial artery pseudoaneurysm following cardiac catheterization: clinical features and nonsurgical treatment results. Rev Esp Cardiol (Engl Ed). 2015;68(4):349e351. 21. Tosti R, Ozkan S, Schainfeld RM, Eberlin KR. Radial artery pseudoaneurysm. J Hand Surg Am. 2017;42(4):295.e6. 22. Kazmers NH, Fryhofer GW, Gittings D, Bozentka DJ, Steinberg DR, Gray BL. Acute deep infections of the upper extremity: the utility of obtaining atypical cultures in the presence of purulence. J Hand Surg Am. 2017;42(8):663.e8. 23. Tizon-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(5):380e384.
14. Jue J, Karam JA, Mejia A, Shroff A. Compartment syndrome of the hand: a rare sequela of transradial cardiac catheterization. Tex Heart Inst J. 2017;44(1):73e76. 15. Yonetsu T, Kakuta T, Lee T, et al. Assessment of acute injuries and chronic intimal thickening of the radial artery after transradial coronary intervention by optical coherence tomography. Eur Heart J. 2010;31(13):1608e1615. 16. Gelberman RH, Nunley JA, Koman LA, et al. The results of radial and ulnar arterial repair in the forearm. Experience in three medical centers. J Bone Joint Surg Am. 1982;64(3):383e387. 17. Schippers SM, Hajewski C, Glass NA, Caldwell L. single forearm vessel injury in a perfused hand: repair or ligate? A systematic review. Iowa Orthop J. 2018;38:159. 18. Garvin RP, Ryer EJ, Yoon HR, et al. Ultrasound-guided percutaneous thrombin injection of iatrogenic upper extremity pseudoaneurysms. J Vasc Surg. 2014;59(6):1664e1669.
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