Case Files by Dr. George

Rare Complication of Pseudoaneurysm After Transradial Access Treated Successfully with External Compression Dressing

Renee Langstaff, MSPAS, PA-C, Brian Shaw, DO, and Jon C. George, MD, Division of Interventional Cardiology and Endovascular Medicine, Deborah Heart and Lung Center, Browns Mills, New Jersey

Renee Langstaff, MSPAS, PA-C, Brian Shaw, DO, and Jon C. George, MD, Division of Interventional Cardiology and Endovascular Medicine, Deborah Heart and Lung Center, Browns Mills, New Jersey

Disclosure: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Dr. Jon George at georgej@deborah.org.

Case

A 72-year-old female underwent coronary angiography for unstable angina. Past medical history was otherwise significant for hypertension and dyslipidemia, and the patient was a non-smoker. Coronary angiography was performed via right radial artery access, obtained using a micropuncture access kit (Terumo) for a single direct anterior wall puncture. Angiography revealed a significant mid left anterior descending artery stenosis requiring percutaneous coronary intervention with a bare metal stent. The patient was loaded with dual antiplatelet therapy in the cath lab (aspirin 325mg and clopidogrel 600mg) and the procedure was performed using heparin (9000 units) for anticoagulation with an activated clotting time (ACT) of 267 seconds. Hemostasis was achieved upon completion of the procedure using a TR Band (Terumo) with 11cc of air for compression. The TR Band was deflated per protocol over the next 2 hours and discontinued. There was forearm ecchymosis and hematoma noted upon removal of the TR Band, without oozing or tenderness to palpation. The patient was otherwise asymptomatic and was discharged home that evening, 6 hours following the procedure.

However, the patient called the following day with complaints of increasing right wrist pain despite using ice and elevation at home. She was brought into our triage unit, where physical evaluation revealed increased swelling of the entire right hand and forearm with resolving hematoma and persistent ecchymosis at the right wrist distal to the access site (Figure 1). A soft, tender, non-pulsatile mass was appreciated over the anatomical snuffbox, while the radial pulse, capillary refill, and active movement were intact and no bruit was appreciated. Sensation was normal except for decreased sensation over a small area of the medial right thumb.

An ultrasound of the right wrist demonstrated a pseudoaneurysm (PSA) of the radial artery measuring up to 1.4cm in diameter with a 2.2mm neck (Figure 2). The initial recommendation was to admit the patient for compression treatment with a RadAR band (Advanced Vascular Dynamics). However, the patient deferred and the decision was subsequently made to provide compression via external pressure wraps (Figure 3).

A 2-inch elastic wrap (McKesson) was used from the hand to distal forearm and a second 4-inch wrap (McKesson) from the wrist to the elbow, maintaining moderate tension during wrapping (Figure 4). Pulse oximetry tracings of all five digits were reviewed after application, which confirmed preserved perfusion. The patient was given pain control and scheduled to return to clinic in two days. Repeat ultrasound at that time showed that the neck of the pseudoaneurysm had thrombosed and there was no flow present (Figure 5). The patient had significant improvement in her symptoms, and gradual resolution of hematoma and ecchymosis over the course of 1 week (Figure 6). Serial subsequent ultrasounds confirmed successful treatment of PSA with preserved radial artery flow.

Discussion

Transradial (TR) cardiac catheterization has significantly reduced the incidence of access site complications.1 However, complications of TR access do occur, including radial artery occlusion, non-occlusive injury, spasm, hand ischemia, nerve damage, bleeding, and pseudoaneurysm (PSA) formation.2 

PSA is described as a tear through all the layers of the artery with resultant hemorrhage and hematoma formation contained by the surrounding tissue creating a false sac.3 PSA with TR access is rare, with <0.1% incidence reported in a large case series.4 There are several factors that predispose TR access to the development of PSA, including multiple puncture attempts, ongoing systemic anticoagulation, inadequate hemostasis or post-procedure compression, vascular site infection, and the use of larger sheaths.5 

Hemostatic compression devices are frequently used post-TR access for the prevention of pseudoaneurysm formation.6 Potential problems originating from compression devices include incorrect positioning and inadequate pressure for compression at the access site.7 However, the low incidence rate and limited literature on various hemostatic devices provide insufficient data to enable an assessment of the efficacy of various hemostatic devices to prevent radial artery PSA.

Treatment of radial artery PSA is based on the anatomic characteristics of the PSA. A small PSA may be treated with compression to occlude flow into the PSA8, while a large PSA may require surgical intervention7. Other treatment strategies include the use of an external compression device6 or thrombin injection when the PSA has a narrow neck9.

We present herein, a rare case of radial artery PSA following TR access for percutaneous coronary intervention treated successfully with external compression dressing. 

References

  1. Kiemeneji F, Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial, and femoral approaches: the access study. J Am Coll Cardiol. 1997 May; 29(6): 1269-1275.
  2. Kanei Y, Kwan T, Nakra NC, et al. Transradial cardiac catheterization: a review of access site complications. Catheter Cardiovasc Interven. 2011 Nov 15; 78(6): 840-846. doi: 10.1002/ccd.22978.
  3. Kerr CD, Duffey TP. Traumatic false aneurysm of the radial artery. J Trauma. 1988 Nov; 28(11): 1603-1604. 
  4. Sanmartin M, Cuevas D, Goicolea J, et al. Vascular complications associated with radial artery access for cardiac catheterization. Rev Esp Cardiol. 2004 Jun; 57(6): 581-584.
  5. Collins N, Wainstein R, Ward M, Bhagwandeen R, Dzavik V. Pseudoaneurysm after transradial cardiac catheterization: case series and review of the literature. Catheter Cardiovasc Interv. 2012 Aug 1; 80(2): 283-287. doi: 10.1002/ccd.23216.
  6. Liou M, Tung F, Kanei Y, Kwan T. Treatment of radial artery pseudoaneurysm using a novel compression device. J Invasive Cardiol. 2010 Jun; 22(6): 293-295.
  7. Hamid T, Harper L, McDonald J. Radial artery pseudoaneurysm following coronary angiography in two octogenerians. Exp Clin Cardiol. 2012 Winter; 17(4): 260-262.
  8. Cozzi DA, Morini F, Casati A, Pacilli M, Salvini V, Cozzi F. Radial artery pseudoaneurysm successfully treated by compression bandage. Arch Dis Child. 2003 Feb; 88(2): 165-166.
  9. D’Achille A, Sebben RA, Davies RP. Percutaneous ultrasound-guided thrombin injection for coagulation of post-traumatic pseudoaneurysms. Australas Radiol. 2001 May; 45(2): 218-221.