With the increasing use of transradial access (TRA), an increase in TRA-related complications is expected. The radial artery (RA) is prone to spasm, with a thick media rich in alpha sympathetic receptors. Severe spasm is frequently associated with aberrant anatomy. With improved hardware and techniques, the ability to navigate difficult anatomy has improved. Although it is now easier to traverse aberrant anatomy, equipment removal may become problematic in view of the increased tendency of the radial artery wall to develop extreme spasm, occasionally causing entrapment. We describe a case where a hydrophilic introducer was entrapped in the radial artery, and with the use of a recently described non-pharmacologic technique, was successfully removed.
A 77-year-old male with severe peripheral vascular disease, left above-knee amputation, hypertension, and cigarette smoking presented with new onset congestive heart failure. Echocardiography revealed severe left ventricular dysfunction with a left ventricular ejection fraction of <25%. Mild elevation of CK-MB and troponin I was noted. The patient developed sustained ventricular tachycardia that terminated spontaneously. Cardiac catheterization was recommended. The patient was brought to the cardiac catheterization laboratory, a 5 French (Fr) hydrophilic introducer sheath was placed in the right antecubital vein, and a 5 Fr balloon occlusion catheter was used to perform right heart catheterization in a standard fashion. Severe secondary pulmonary arterial hypertension was found. A 5 Fr “Slender” introducer sheath (Terumo) was placed in the right radial artery using counterpuncture technique. A 5 Fr Tiger catheter (Terumo) was placed in the ascending aorta, and left and right coronary arteriography was performed in a standard fashion. The Tiger catheter was removed, with mild resistance noted upon withdrawal. An inflatable compression band was applied to the access site, and the introducer was withdrawn. Upon application of outward traction on the introducer sheath in order to remove it, the patient reported pain, and the introducer sheath appeared entrapped in the radial artery. Upon application of outward traction, a linear indentation was noted on the ventral aspect of the forearm along the course of the radial artery (Figure 1). The patient had a baseline blood pressure of 90/55 mmHg, with a heart rate of 55 beats per minute, making it difficult to administer further vasodilators. Anesthesiology was summoned for a possibility of deeper sedation that was deemed excessively risky. Despite waiting >20 minutes, the introducer remained entrapped.
At this time, a sphygmomanometer bladder was applied, encircling the upper arm, and was inflated to 140 mmHg pressure. It was left inflated for 5 minutes (Figure 2). Plethysmographic evidence of lack of flow to the digits was noted, although the patient reported no symptoms. The bladder was then deflated. Immediately after deflation of the sphygmomanometer bladder, with the hemostatic compression band at the access site, outward traction was applied on the introducer sheath, with its successful removal (Figures 3A, 3B and 3C), and hemostasis after inflation of the compression band. Patent hemostasis protocol was used to maintain hemostasis with re-establishment of radial artery patency (Figure 4).
Entrapment of hardware in the radial artery is a devastating complication of TRA. If treated with excessive force, severe damage to the RA has been shown to occur, including removal of large anatomical segment of the RA.1,2 Due to the associated discomfort, and the perceived increase in the level of staff and physician anxiety, the patient’s heightened sympathetic tone escalates spasm. Frequently, additional vasodilators are administered, with expected success, although in patients with borderline hemodynamics, administration of vasodilators is difficult, and use of deeper sedation is equally risky. The technique used in this patient has been described earlier3 and is an attractive option for many reasons. It exploits the effects of physiologic responses, and induces one of the most potent and localized spasmolytic responses. Creating a milieu of ischemia in the forearm liberates vasodilator substrates locally, causing local vasodilatation. Upon release of brachial compression, the abrupt and rapid return of blood flow through the ulnar and radial arteries leads to flow-mediated vasodilatation, further potentiating local vasodilatation. The localized nature of this response leads to sparing of the hemodynamics. The lack of need for specific and expensive equipment makes this technique even more attractive. Weighing the benefits and the potential risks (lack thereof), this technique should probably be used before other commonly used treatments, such as systemically active vasodilators and sedatives, and especially more intense interventions such as administration of anesthetics or a nerve block.
- Mouawad NJ, Capers Q, Allen C, James I, Haurani MJ. Complete “in situ” avulsion of the radial artery complicating transradial coronary rotational atherectomy. Ann Vasc Surg. 2015 Jan; 29(1): 123.e7-123.e11.
- Alkhouli M, Cohen HA, Bashir R. Radial artery avulsion--a rare complication of transradial catheterization. Catheter Cardiovasc Interv. 2015; 85(1):E32-E34.
- Pancholy SB, Karuparthi PR, Gulati R. A novel nonpharmacologic technique to remove entrapped radial sheath. Catheter Cardiovasc Interv. 2015; 85(1): E35-E38.
Disclosures: Dr. Nanavaty, Dr. Gaurav Patel, and Dr. Saurabh Patel have no conflicts of interest regarding the content herein. Dr. Pancholy reports he is currently serving as a speaker for Medtronic and Terumo, and has equity interest in Vasoinnovations, Inc.
The authors can be contacted via Dr. Samir Pancholy at firstname.lastname@example.org