Abstract
Critical hand ischemia is an extremely rare and serious complication of transradial coronary angiography. It is almost always associated with radial artery occlusion. Early recognition and involvement of vascular surgery is imperative for optimal management. Up to our knowledge, there have been only 5 cases reported in the medical literature. Herein, we describe a case of an 81-year-old male who had undergone transradial coronary intervention complicated by critical hand ischemia requiring amputation of the right 4th finger.
Highlights
- •
Critical hand ischemia is an extremely rare and serious complication of transradial coronary angiography.
- •
It is almost always associated with radial artery occlusion. Early recognition and involvement of vascular surgery is imperative for optimal management.
- •
Up to our knowledge, there have been only 5 cases reported in the medical literature.
- •
Herein, we describe a case of an 81-year-old male who had undergone transradial coronary intervention complicated by critical hand ischemia requiring amputation of the right 4th finger.
- •
Furthermore, this mini-review will provide an overview into the prior reported cases.
1
Introduction
Although it has been more than 2 decades since Lucien Campeau performed the first transradial coronary angiogram (CAG), the use of transradial approach is still low comprising 6.3% of all procedures in the United States . The radial artery approach offers several advantages over the standard transfemoral approach. However, it is technically more difficult and, in very exceptional cases, it can cause serious complications such as radial artery dissection, avulsion and critical hand ischemia. Better understanding of such complications and their management could improve the overall outcome of transradial approach procedures. Herein, we report a case of critical right hand ischemia leading to 4th digit gangrene after transradial coronary intervention.
2
Case presentation
An 81 year-old male with known history of hypertension, atrial fibrillation on oral anticoagulant and coronary artery disease presented with exertional angina. Two years earlier, he had undergone percutaneous coronary intervention (PCI) to the mid-left anterior descending artery (LAD) through right radial artery access. The initial electrocardiogram (ECG) showed atrial fibrillation with nonspecific ST-T wave changes. Laboratory results were unremarkable including cardiac biomarkers. Transthoracic echocardiogram showed preserved left ventricular systolic function with no regional wall motion abnormality. Patient was sent to cardiac catheterization laboratory for transradial coronary angiography. The right radial artery was palpable, and Allen test was performed to confirm the presence of a sufficient palmar arch. Under local anesthesia with 1% xylocaine the right radial artery was punctured about 3.5 cm proximal to the base of the thumb using 22-gauge needle and 0.035 InQwire merit guide wire, and 6-Fr supersheath (Boston Scientific) was introduced. After sheath placement, 5000 units of heparin, 100 mcg of nitroglycerin, and 2 cc 2% xylocaine were given via the sheath, to minimize the risk of radial artery spasm. Total procedure time was 2:15 hours and total Fluoro time was 22.5 minutes. The CAG revealed 90% in-stent restenosis of the pre-existing LAD stent. He also had 75% discrete stenosis in the proximal obtuse marginal artery. A 3.0 mm × 18 mm and 3.0 mm × 28 mm drug eluting stents (RX XIENCE Expedition, Abbott) were successfully deployed to the LAD and OM, respectively. Subsequently, the sheath was removed and a hemoband was applied for 2 hours. Radial pulse was palpable after the procedure. The patient was discharged the following day in stable condition. However, few days later he started experiencing symptoms of pain, paresthesia, numbness, tingling sensation, and decreased strength in the right hand. 3 weeks later, he noticed skin discoloration and small ulcers with skin splitting in the right hand fingers sparing the thumb ( Fig. 1 ). He was re-admitted for further evaluation. Upon examination, right radial pulse was absent. The differential diagnosis was hand ischemia versus nerve injury. Thromboembolic event was also considered, but his prothrombin time was within the therapeutic range. Doppler ultrasound of the right upper extremity showed patent subclavian, axillary, brachial and ulnar arteries. However, there was no flow noted in the right radial artery ( Fig. 2 ). Magnetic resonance imaging (MRI) of the right wrist showed normal appearance of the median and ulnar nerves ( Fig. 3 ). No osseous abnormality was noted. Since he had an adequate collateral supply from the ulnar artery and no neurological abnormality noted on MRI and electromyography (EMG) testing, he was initially managed conservatively per vascular surgery and neurology recommendations. Unfortunately, his symptoms continued to deteriorate afterwards and the patient developed gangrene of the tip of fourth digit required amputation of the distal phalanx of right ring finger. He was doing well at one month follow-up visit.
2
Case presentation
An 81 year-old male with known history of hypertension, atrial fibrillation on oral anticoagulant and coronary artery disease presented with exertional angina. Two years earlier, he had undergone percutaneous coronary intervention (PCI) to the mid-left anterior descending artery (LAD) through right radial artery access. The initial electrocardiogram (ECG) showed atrial fibrillation with nonspecific ST-T wave changes. Laboratory results were unremarkable including cardiac biomarkers. Transthoracic echocardiogram showed preserved left ventricular systolic function with no regional wall motion abnormality. Patient was sent to cardiac catheterization laboratory for transradial coronary angiography. The right radial artery was palpable, and Allen test was performed to confirm the presence of a sufficient palmar arch. Under local anesthesia with 1% xylocaine the right radial artery was punctured about 3.5 cm proximal to the base of the thumb using 22-gauge needle and 0.035 InQwire merit guide wire, and 6-Fr supersheath (Boston Scientific) was introduced. After sheath placement, 5000 units of heparin, 100 mcg of nitroglycerin, and 2 cc 2% xylocaine were given via the sheath, to minimize the risk of radial artery spasm. Total procedure time was 2:15 hours and total Fluoro time was 22.5 minutes. The CAG revealed 90% in-stent restenosis of the pre-existing LAD stent. He also had 75% discrete stenosis in the proximal obtuse marginal artery. A 3.0 mm × 18 mm and 3.0 mm × 28 mm drug eluting stents (RX XIENCE Expedition, Abbott) were successfully deployed to the LAD and OM, respectively. Subsequently, the sheath was removed and a hemoband was applied for 2 hours. Radial pulse was palpable after the procedure. The patient was discharged the following day in stable condition. However, few days later he started experiencing symptoms of pain, paresthesia, numbness, tingling sensation, and decreased strength in the right hand. 3 weeks later, he noticed skin discoloration and small ulcers with skin splitting in the right hand fingers sparing the thumb ( Fig. 1 ). He was re-admitted for further evaluation. Upon examination, right radial pulse was absent. The differential diagnosis was hand ischemia versus nerve injury. Thromboembolic event was also considered, but his prothrombin time was within the therapeutic range. Doppler ultrasound of the right upper extremity showed patent subclavian, axillary, brachial and ulnar arteries. However, there was no flow noted in the right radial artery ( Fig. 2 ). Magnetic resonance imaging (MRI) of the right wrist showed normal appearance of the median and ulnar nerves ( Fig. 3 ). No osseous abnormality was noted. Since he had an adequate collateral supply from the ulnar artery and no neurological abnormality noted on MRI and electromyography (EMG) testing, he was initially managed conservatively per vascular surgery and neurology recommendations. Unfortunately, his symptoms continued to deteriorate afterwards and the patient developed gangrene of the tip of fourth digit required amputation of the distal phalanx of right ring finger. He was doing well at one month follow-up visit.
