We report a pseudoaneurysm (PSA) in a patient who underwent coronary angiography via left distal transradial access (ldTRA) 3 months previously. This is the reported case of pseudoaneurysm formation following ldTRA.
Left distal transradial access (ldTRA) is a newly emerging approach for cardiac intervention. It offers comfort for the patients and the operator. Several puncture complications had been reported for ldTRA, such as radial artery occlusion, hematoma, and dissection.1-2
A 64-year-old female presenting with non-ST elevation myocardial infarction (NSTEMI) with history of return of spontaneous circulation (ROSC) following sudden cardiac arrest was referred to our hospital for coronary angiography. A previous electrocardiogram (ECG) showed intermittent left bundle branch block (LBBB) and persistent atrial fibrillation (AF). Cardiovascular risk factors were hypertension and dyslipidemia. She had history of hyperthyroidism. Several medications were given, including aspirin, clopidogrel, thiamazole and fondaparinux. Echocardiography showed a mildly dilated left ventricle and left atrium with mild-moderate mitral regurgitation and borderline anterior wall hypokinesia. The left ventricle systolic function was normal.
The patient underwent coronary angiography via ldTRA access using a 6 French (Fr) sheath. Anterior puncture without an ultrasound guide was performed without any difficulty. An intra-arterial bolus of 300 mcg of nitroglycerine trinitrate was administered after access was obtained. Diagnostic coronary angiography was done using a 5 Fr TIG diagnostic catheter (Terumo). Coronary angiogram revealed ulcerated plaque at the distal left main and a severe diffusely calcified lesion of the ostial to mid left anterior descending (LAD) coronary artery. There were mild-moderate stenoses of the left circumflex (LCX) and right coronary artery (RCA). The procedure took 12 minutes. Based on diagnostic angiography findings in a hemodynamically stable patient without chest pain, the procedure was stopped. The patient was offered coronary artery bypass graft (CABG) surgery. The 6 Fr sheath was removed from the distal radial artery and manual hemostasis with a small pile of gauze and semi-elastic bandage was placed over the puncture site for 1 hour. There was no hematoma after bandage removal. The patient turned down CABG and opted to have percutaneous coronary intervention (PCI), to take place 10 days following coronary angiography.
Considering the complexity of the procedure and the intended use of a Rotablator (Boston Scientific), the femoral approach was chosen. Intravascular ultrasound (IVUS)-guided PCI was successfully performed and 3 drug-eluting stents were placed in the left main and LAD. Two days after the procedure, the patient was discharged on aspirin 81 mg, clopidogrel 20 mg, and rivaroxaban 20 mg daily.
There was no significant complaint up to two months after hospital discharge. At the third month, the patient noticed a gradually increasing swelling at the puncture site in the left hand. The swelling was tender and pulsatile (Figure 1). Doppler examination confirmed the presence of a pseudoaneurysm (Figure 2). Surgery with local anesthesia was successfully performed while the patient was on dual antiplatelet therapy and rivaroxaban. The pseudoaneurysm was removed, and the radial artery was ligated (Figure 3). The patient was discharged the day after surgery.
On follow-up, there was no swelling or tenderness at the surgical site. Radial artery pulsation could be detected at the distal artery and there was no sign of pallor at the thumb (Figures 4-5).
A review of the most recent literature on distal radial access reveals relatively few reported procedure-related complications. Most reported are hand hematomas of varying degrees, low incidences of distal and proximal radial artery occlusion, post procedural numbness, post procedural congestion, and temporary pain and hand dysfunction. Rare complications such as arteriovenous fistula and distal arterial dissection have also been reported. Thus far, no digital ischemia has been described.
Pseudoaneurysm complication in the radial artery is extremely rare, with a rate of occurrence at about 0.05%3-4, and the radial artery itself is the most atypical arterial site for pseudoaneurysm formation.5 Risk factors for pseudoaneurysm in the radial artery are repeated arterial puncture, catheter infection, advanced age, longer duration of catheterization, coagulation disorders or use of anticoagulants/antiplatelet agents, large sheath diameter, and incomplete hemostasis.4-6
What could have been the contributing factors in our case?
Access. The radial artery was successfully punctured at first attempt. Although no ultrasound has been used, it was a clean, single-wall puncture. The distal radial artery diameter, however, was not assessed. The choice of a 6 Fr sheath might have been too large for this artery. Mismatch between arterial inner diameter and sheath outer diameter might have been a contributing factor.
Procedural time. We can imagine that a long indwelling sheath during a long procedure can contribute in pseudoaneurysm formation. However, the procedure took only 12 minutes.
Medication. The patient was given additional rivaroxaban on top of dual antiplatelet therapy (triple drugs) due to persistent AF in this patient with coronary artery disease and hypertension after PCI. In addition, a few days after distal radial access, the patient was again heparinized. This intensive medical regimen might have delayed proper hemostasis, resulting in minimal but relevant arterial leakage at the site of sheath insertion.
Hemostasis. In the light of the above-mentioned factors, our compression method was too light for this patient who also had hypertension. Manual hemostasis was achieved with a small pile of gauze and a semi-elastic bandage, placed over the puncture site for only 1 hour. A more conservative hemostasis method might have been a better option in this patient who had multiple risk factors for a vascular or bleeding complication.
We have been unable to find a definitive timeframe by which a pseudoaneurysm forms. As reported in the literature, it can vary from within 24 hours to days after the procedure.5-7 The pseudoaneurysm in our patient was noted 3 months after the procedure.
The aim of radial pseudoaneurysm management is to repair the wall lesion or discontinue the flow communication between the artery and the parenchymal haematoma.5 Stable, asymptomatic pseudoaneurysms with small size (<3 cm) may be monitored, as the majority will thrombose spontaneously within 4 weeks.8 Alternatively, ultrasound-guided compression for 10-minute intervals until occlusion is achieved can be used in a compressible hematoma and ultrasound-guided thrombin injection can be used in the treatment of radial artery aneurysms, but fewer successful case reports exist for the radial artery.5,9-12 In addition, thrombin injection in the distal radial artery poses a significant risk for distal embolization and digital ischemia. This treatment has not been seriously considered. Surgical management is recommended in patients with large pseudoaneurysms, or those that are symptomatic, expanding, infected, subacute, or that failed initial conservative management.13 Our patient underwent surgical correction due to her symptoms and the size of the hematoma. Surgical correction was successful and the patient remains free from any complications.
1Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadja-ran/Dr.Hasan Sadikin Hospital, Bandung, Indonesia;
2Department of Surgery, Faculty of Medicine Universitas Padjadjaran/Dr.Hasan Sadikin Hospital, Bandung, Indonesia; 3Department of Cardiology, MC Zuiderzee Hospital, Lelystad, Netherlands
Disclosures: The authors report no conflicts of interest regarding the content herein.
Dr. Achmad Fauzi Yahya can be contacted at firstname.lastname@example.org.
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