Radial catheterization complications

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Ayokunle Olubaniyi, M.B,B.S [2]

Overview

Like any other arterial puncture in any part of the body, complications are not uncommon, including radial artery spasms and occlusion, bleeding, radiation exposure, e.t.c. However, these complications can be minimized by the use of appropriate medications, radiation protective devices, and most importantly, by implementing efficient, high-quality, and personalized transradial training programs that educate the entire catheterization laboratory team.[1]

Complications

Radial Artery Spasm

Radial artery spasm (RAS) remains one of the major limitations of transradial approach for PCI.[2] The radial artery was demonstrated to have stronger contractions to common vasoactive substances, thus, increasing its propensity to spasm especially in situations of trauma.[3] The incidence of RAS varies from 12% among high risk patients in whom transfemoral approach was contraindicated[4] to 22% among patients without prior administration of intra-arterial vasodilators.[5] The increased incidence in RAS may be due to the small size of radial artery, female gender, long and difficult procedures with multiple catheter exchanges, sheath size, and operator inexperience.[6]

Some of the measures that have been shown to reduce the incidence and severity of RAS include:

  • Generous patient sedation
  • Use of spasmolytic cocktails such as verapamil, nitroprusside or combination of both[7][8][9]
  • Use of a hydrophilic sheath of the smallest possible diameter
  • Wiping and flushing catheters with solutions containing calcium channel blocker or nitrates
  • Using a smaller catheter size
  • Use of intra-arterial Papaverine for the treatment of severe arterial spasm[10]
  • Adequate time should be given for the artery to relax before removing catheters or sheaths to prevent arterial evulsion

Radial Artery Occlusion

Although most cases of radial artery occlusion are asymptomatic, cases of hand ischemia have been reported.[11] As a result of this, coupled with the fact that a persistent RAO could make future access of the ipsilateral radial artery for angioplasty, intra-arterial pressure monitoring, coronary artery bypass surgery, or hemodialysis impossible or difficult, more aggressive measures should be implemented to prevent RAO, especially nowadays where greater than 50% of physicians performing transradial PCI do not routinely evaluate radial arterial patency before discharging their patients.[12]

According to the Best Practices for Transradial Angiography and Intervention (2013), the evidence-base practices associated with a reduced risk of RAO include:

REDUCES RISK
MAY REDUCE RISK
NO EFFECT OR INCREASES RISK
Anticoagulationa Enoxaparin at 60 mg given through the radial arterial sheath Sheath length
Patent (non-occlusive) hemostasisb Hydrophillic sheaths Sheathless guide catheters
Sheath diameter less than radial artery diameter Routine use of drugs to reduce radial artery spasm
Avoiding repeat access of the radial artery Limiting the duration of radial artery compression

aUnfractionated heparin 70 units/Kg up to 5000 units and bivalirudin 0.75 mg/kg bolus followed by 1.75 mg/kg/hr infusion during procedure. bThis is the most effective strategy to reduce the risk of RAO[1][13]

Below are the steps involved in the patent hemostasis process:

“ Step 1: Withdraw the arterial sheath 2–3 cm.

Step 2: Apply the hemostatic compression device, 2 to 3 mm proximal to the skin entry site, and tighten it or inflate it, then remove the sheath.

Step 3: Decrease the pressure of the hemostatic compression device to the point of mild pulsatile bleeding at the skin entry site. After 2 to 3 cycles of pulsatile bleeding, retighten the hemostatic compression device gradually to eliminate this pulsatile bleeding.

Step 4: Evaluate radial artery patency by using the reverse Barbeau’s test: Place the plethysmographic sensor on the index finger of the involved upper extremity with the observation of pulsatile waveforms Compress the Ulnar artery at the level of the wrist, and observe the behavior of the waveform. Absence of plethysmographic waveform is indicative of interruption of radial artery flow. If this occurs, the hemostatic compression pressure should be lowered to the point where plethysmographic waveform returns. This is evidence of antegrade radial artery flow.

”
Catheter Knot

Hematoma

Varying degrees and severities of hematomas have been reported. The most common location occurs at the puncture site, but rare cases involving the mediastinum,[14] mediastinum and neck,[15] or even the forearm muscle[12][16] have been reported in association with the transradial approach. A grading system similar to the femoral approach have also been used: Grade 1 (<5cm), grade 2 (<10cm), grade 3 (distal to the elbow) and grade 4 (proximal to the elbow). The independent predictors of bleeding were identified as: creatinine clearance <60 mL/min, procedure duration, and sheath size.[17]

Compartment Syndrome

Bleeding is a common complication of r-PCI which can result into devastating consequences. Compartment syndrome is a limb-threatening surgical emergency which requires a high index of suspicion and timely application of appropriate protocols once local bleeding is suspected such as discontinuation of anticoagulant therapy, pain and blood pressure control, external compression with a blood pressure cuff, close monitoring of distal perfusion of the hand (plethysmography) and consultation to a vascular surgeon is also recommended in cases of limb ischemia.[18]

Increased Exposure to Radiation

Some observational studies have shown that the transradial approach to PCI is associated with an increased radiation exposure in the patient, and especially, the operator.[19] According to a large study, radial artery catheterization was associated with a 23% increase in radiation exposure when compared with the transfemoral access.[20] This is largely dependent on operator proficiency. Two studies demonstrated that increasing operator experience with the transradial approach is associated with a lower patient and operator radiation exposure.[21][22] Some measures which have been shown to reduce exposure to radiation include the use of transradial protection board,[23] lead-free radiation shield over the right sheath insertion site,[24] and the use of left radial artery, which is associated with a lower fluoroscopy time and radiation dose compared with the right radial angiography.[25]

Other complications associated with the transradial approach are listed below:

  • Local pain and swelling
  • Thrombosis[26]
  • Embolization[27]
  • Infection[28]
  • Pseudoaneurysm[29]
  • Blood loss[30]
  • Limb ischemia
  • Arteriovenous fistula
  • Cerebral embolization[31]
  • Peripheral neuropathy
  • Accelerated atherosclerosis
  • Transient vocal cord paralysis
  • Delayed reflex sympathetic dystrophy
  • Subcutaneous granulomatous reaction (hydrophilic coating) or sheath-associated sterile abscesses

Optical coherence tomography (OCT) has been used by Yonetsu et al to define the damage to the radial artery in 73 arteries of 69 patients [32]. 32% of patients developed intimal tears and 16% of patients developed medial dissections. Repeat catheterization was associated with increased fibro-intimal hyperplasia. Cardiac catheterization via the radial approach may render the radial artery unsuitable for coronary artery bypass grafting. There can be a loss of pulse in about 4% of cases. Use of smaller guide catheters and sheathless guides may potentially reduce the risk of these complications.

References

  1. ↑ 1.0 1.1 Rao, SV.; Tremmel, JA.; Gilchrist, IC.; Shah, PB.; Gulati, R.; Shroff, AR.; Crisco, V.; Woody, W.; Zoghbi, G. (2013). "Best practices for transradial angiography and intervention: A consensus statement from the society for cardiovascular angiography and intervention's transradial working group". Catheter Cardiovasc Interv. doi:10.1002/ccd.25209. PMID 24123781. Unknown parameter |month= ignored (help)
  2. ↑ Varenne, O.; Jégou, A.; Cohen, R.; Empana, JP.; Salengro, E.; Ohanessian, A.; Gaultier, C.; Allouch, P.; Walspurger, S. (2006). "Prevention of arterial spasm during percutaneous coronary interventions through radial artery: the SPASM study". Catheter Cardiovasc Interv. 68 (2): 231–5. doi:10.1002/ccd.20812. PMID 16819768. Unknown parameter |month= ignored (help)
  3. ↑ Chardigny, C.; Jebara, VA.; Acar, C.; Descombes, JJ.; Verbeuren, TJ.; Carpentier, A.; Fabiani, JN. (1993). "Vasoreactivity of the radial artery. Comparison with the internal mammary and gastroepiploic arteries with implications for coronary artery surgery". Circulation. 88 (5 Pt 2): II115–27. PMID 8222146. Unknown parameter |month= ignored (help)
  4. ↑ Hildick-Smith, DJ.; Walsh, JT.; Lowe, MD.; Shapiro, LM.; Petch, MC. (2004). "Transradial coronary angiography in patients with contraindications to the femoral approach: an analysis of 500 cases". Catheter Cardiovasc Interv. 61 (1): 60–6. doi:10.1002/ccd.10708. PMID 14696161. Unknown parameter |month= ignored (help)
  5. ↑ Kiemeneij, F.; Vajifdar, BU.; Eccleshall, SC.; Laarman, G.; Slagboom, T.; van der Wieken, R. (2003). "Evaluation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures". Catheter Cardiovasc Interv. 58 (3): 281–4. doi:10.1002/ccd.10445. PMID 12594687. Unknown parameter |month= ignored (help)
  6. ↑ Varenne, O.; Jégou, A.; Cohen, R.; Empana, JP.; Salengro, E.; Ohanessian, A.; Gaultier, C.; Allouch, P.; Walspurger, S. (2006). "Prevention of arterial spasm during percutaneous coronary interventions through radial artery: the SPASM study". Catheter Cardiovasc Interv. 68 (2): 231–5. doi:10.1002/ccd.20812. PMID 16819768. Unknown parameter |month= ignored (help)
  7. ↑ Attaran, S.; John, L.; El-Gamel, A. (2008). "Clinical and potential use of pharmacological agents to reduce radial artery spasm in coronary artery surgery". Ann Thorac Surg. 85 (4): 1483–9. doi:10.1016/j.athoracsur.2007.10.042. PMID 18355566. Unknown parameter |month= ignored (help)
  8. ↑ Kiemeneij, F.; Vajifdar, BU.; Eccleshall, SC.; Laarman, G.; Slagboom, T.; van der Wieken, R. (2003). "Evaluation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures". Catheter Cardiovasc Interv. 58 (3): 281–4. doi:10.1002/ccd.10445. PMID 12594687. Unknown parameter |month= ignored (help)
  9. ↑ Varenne, O.; Jégou, A.; Cohen, R.; Empana, JP.; Salengro, E.; Ohanessian, A.; Gaultier, C.; Allouch, P.; Walspurger, S. (2006). "Prevention of arterial spasm during percutaneous coronary interventions through radial artery: the SPASM study". Catheter Cardiovasc Interv. 68 (2): 231–5. doi:10.1002/ccd.20812. PMID 16819768. Unknown parameter |month= ignored (help)
  10. ↑ Osman, F.; Buller, N.; Steeds, R. (2008). "Use of intra-arterial papaverine for severe arterial spasm during radial cardiac catheterization". J Invasive Cardiol. 20 (10): 551–2. PMID 18830002. Unknown parameter |month= ignored (help)
  11. ↑ Rhyne, D.; Mann, T. (2010). "Hand ischemia resulting from a transradial intervention: successful management with radial artery angioplasty". Catheter Cardiovasc Interv. 76 (3): 383–6. doi:10.1002/ccd.22460. PMID 20839353. Unknown parameter |month= ignored (help)
  12. ↑ 12.0 12.1 Bertrand, OF.; Rao, SV.; Pancholy, S.; Jolly, SS.; Rodés-Cabau, J.; Larose, E.; Costerousse, O.; Hamon, M.; Mann, T. (2010). "Transradial approach for coronary angiography and interventions: results of the first international transradial practice survey". JACC Cardiovasc Interv. 3 (10): 1022–31. doi:10.1016/j.jcin.2010.07.013. PMID 20965460. Unknown parameter |month= ignored (help)
  13. ↑ Pancholy, S.; Coppola, J.; Patel, T.; Roke-Thomas, M. (2008). "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. 72 (3): 335–40. doi:10.1002/ccd.21639. PMID 18726956. Unknown parameter |month= ignored (help)
  14. ↑ Park, KW.; Chung, JW.; Chang, SA.; Kim, KI.; Chung, WY.; Chae, IH. (2008). "Two cases of mediastinal hematoma after cardiac catheterization: A rare but real complication of the transradial approach". Int J Cardiol. 130 (3): e89–92. doi:10.1016/j.ijcard.2007.05.093. PMID 17673316. Unknown parameter |month= ignored (help)
  15. ↑ Jao, YT.; Chen, Y.; Fang, CC.; Wang, SP. (2003). "Mediastinal and neck hematoma after cardiac catheterization". Catheter Cardiovasc Interv. 58 (4): 467–72. doi:10.1002/ccd.10476. PMID 12652496. Unknown parameter |month= ignored (help)
  16. ↑ Araki T, Itaya H, Yamamoto M (2010). "Acute compartment syndrome of the forearm that occurred after transradial intervention and was not caused by bleeding or hematoma formation". Catheter Cardiovasc Interv. 75 (3): 362–5. doi:10.1002/ccd.22282. PMID 19821498.
  17. ↑ Bertrand, OF.; Larose, E.; Rodés-Cabau, J.; Gleeton, O.; Taillon, I.; Roy, L.; Poirier, P.; Costerousse, O.; Larochellière, RD. (2009). "Incidence, predictors, and clinical impact of bleeding after transradial coronary stenting and maximal antiplatelet therapy". Am Heart J. 157 (1): 164–9. doi:10.1016/j.ahj.2008.09.010. PMID 19081414. Unknown parameter |month= ignored (help)
  18. ↑ Caputo, RP.; Tremmel, JA.; Rao, S.; Gilchrist, IC.; Pyne, C.; Pancholy, S.; Frasier, D.; Gulati, R.; Skelding, K. (2011). "Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI". Catheter Cardiovasc Interv. 78 (6): 823–39. doi:10.1002/ccd.23052. PMID 21544927. Unknown parameter |month= ignored (help)
  19. ↑ Rao, SV.; Bernat, I.; Bertrand, OF. (2012). "Clinical update: Remaining challenges and opportunities for improvement in percutaneous transradial coronary procedures". Eur Heart J. 33 (20): 2521–6. doi:10.1093/eurheartj/ehs169. PMID 22815330. Unknown parameter |month= ignored (help)
  20. ↑ Mercuri, M.; Mehta, S.; Xie, C.; Valettas, N.; Velianou, JL.; Natarajan, MK. (2011). "Radial artery access as a predictor of increased radiation exposure during a diagnostic cardiac catheterization procedure". JACC Cardiovasc Interv. 4 (3): 347–52. doi:10.1016/j.jcin.2010.11.011. PMID 21435615. Unknown parameter |month= ignored (help)
  21. ↑ Jolly, SS.; Cairns, J.; Niemela, K.; Steg, PG.; Natarajan, MK.; Cheema, AN.; Rao, SV.; Cantor, WJ.; Džavík, V. (2013). "Effect of radial versus femoral access on radiation dose and the importance of procedural volume: a substudy of the multicenter randomized RIVAL trial". JACC Cardiovasc Interv. 6 (3): 258–66. doi:10.1016/j.jcin.2012.10.016. PMID 23517837. Unknown parameter |month= ignored (help)
  22. ↑ Lo, TS.; Ratib, K.; Chong, AY.; Bhatia, G.; Gunning, M.; Nolan, J. (2012). "Impact of access site selection and operator expertise on radiation exposure; a controlled prospective study". Am Heart J. 164 (4): 455–61. doi:10.1016/j.ahj.2012.06.011. PMID 23067901. Unknown parameter |month= ignored (help)
  23. ↑ Behan, M.; Haworth, P.; Colley, P.; Brittain, M.; Hince, A.; Clarke, M.; Ghuran, A.; Saha, M.; Hildick-Smith, D. (2010). "Decreasing operators' radiation exposure during coronary procedures: the transradial radiation protection board". Catheter Cardiovasc Interv. 76 (1): 79–84. doi:10.1002/ccd.22466. PMID 20578091. Unknown parameter |month= ignored (help)
  24. ↑ Politi, L.; Biondi-Zoccai, G.; Nocetti, L.; Costi, T.; Monopoli, D.; Rossi, R.; Sgura, F.; Modena, MG.; Sangiorgi, GM. (2012). "Reduction of scatter radiation during transradial percutaneous coronary angiography: a randomized trial using a lead-free radiation shield". Catheter Cardiovasc Interv. 79 (1): 97–102. doi:10.1002/ccd.22947. PMID 21520391. Unknown parameter |month= ignored (help)
  25. ↑ Sciahbasi, A.; Romagnoli, E.; Burzotta, F.; Trani, C.; Sarandrea, A.; Summaria, F.; Pendenza, G.; Tommasino, A.; Patrizi, R. (2011). "Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study". Am Heart J. 161 (1): 172–9. doi:10.1016/j.ahj.2010.10.003. PMID 21167351. Unknown parameter |month= ignored (help)
  26. ↑ Zankl, AR.; Andrassy, M.; Volz, C.; Ivandic, B.; Krumsdorf, U.; Katus, HA.; Blessing, E. (2010). "Radial artery thrombosis following transradial coronary angiography: incidence and rationale for treatment of symptomatic patients with low-molecular-weight heparins". Clin Res Cardiol. 99 (12): 841–7. doi:10.1007/s00392-010-0197-8. PMID 20625752. Unknown parameter |month= ignored (help)
  27. ↑ Downs JB, Rackstein AD, Klein EF, Hawkins IF (1973). "Hazards of radial-artery catheterization". Anesthesiology. 38 (3): 283–6. PMID 4698148.
  28. ↑ Mimoz O, Pieroni L, Lawrence C, Edouard A, Costa Y, Samii K; et al. (1996). "Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients". Crit Care Med. 24 (11): 1818–23. PMID 8917031.
  29. ↑ Inan MB, Acikgoz B, Yazicioglu L, Kaya B, Ozyurda U (2011). "A rare complication of radial artery catheterization". Vascular. 19 (3): 167–9. doi:10.1258/vasc.2010.cr0238. PMID 21652670.
  30. ↑ Smoller BR, Kruskall MS (1986). "Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements". N Engl J Med. 314 (19): 1233–5. doi:10.1056/NEJM198605083141906. PMID 3702919.
  31. ↑ Lund C, Nes RB, Ugelstad TP, Due-Tønnessen P, Andersen R, Hol PK; et al. (2005). "Cerebral emboli during left heart catheterization may cause acute brain injury". Eur Heart J. 26 (13): 1269–75. doi:10.1093/eurheartj/ehi148. PMID 15716287.
  32. ↑ 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;Epub ahead of print.

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