Abstract
An 88-year-old woman underwent attempted percutaneous coronary intervention (PCI) through a right radial approach. Catheterization was complicated by radial artery perforation. Conservative therapeutic options including external compression, advancement of a diagnostic catheter distal to the perforation, and balloon tamponade failed to control the bleeding requiring deployment of a Polytetrafluoroethylene (PTFE)-covered stent to seal the perforation. We describe the stepwise approach advocated for managing a radial perforation and summarize relevant literature available for the same.
Highlights
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Radial artery perforation is an uncommon but potentially catastrophic complication of radial access coronary angiography and intervention.
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Conservative management is sufficient in majority of cases.
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Covered stents may be an effective alternative to vascular surgery for perforation unresponsive to conservative management.
1
Introduction
Transradial catheterization has become a popular alternative to traditional femoral artery approach for treatment of CAD. Potential benefits include early ambulation, patient comfort, and shortened hospital stay . Multiple studies have demonstrated the safety and benefits of a radial artery approach including the RIVAL (Radial Versus Femoral Access for Coronary Intervention) , RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) , STEMI-Radial (ST Elevation Myocardial Infarction Treated by RADIAL or Femoral Approach) , and MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox) trials. Most importantly these trials show a reduction in mortality attributed to decreased complications from bleeding. Despite the apparent reduction in events, complications using TRC still occur with reported radial artery perforation in 0.1%–1% of all patients undergoing radial artery access. Subsequent risks of perforation include uncontrolled bleeding, compartment syndrome, and neurovascular compromise. We describe a case of radial artery perforation which could not be managed by conservative strategies and required placement of a covered stent graft.
2
Case report
An 88-year-old African-American female with a history of atrial fibrillation (on chronic anticoagulation therapy with Rivaroxaban), hypertension, and hyperlipidemia was referred to our institution for consideration of percutaneous coronary intervention (PCI) of the left anterior descending artery (LAD). She had initially presented to an outlying hospital one day prior to the transfer with unstable angina. Diagnostic coronary angiography was performed at the referring hospital via right femoral artery access revealing 90% stenosis of the mid LAD as well as 70%–80% stenosis of the mid RCA. Notably her last dose of rivaroxaban had been on the day of presentation (< 24 h prior to PCI). On arrival she was administered 600 mg of clopidogrel and 325 mg of aspirin. A right radial artery approach was planned given the need for chronic oral anticoagulation. A 6Fr sheath was placed in the right radial artery using modified Seldinger technique without complication. 2 mg of verapamil and 0.2 mg of nitroglycerin were administered via the sheath along with an intravenous dose of 4000 units of unfractionated heparin. A 6Fr XB 3.0 cm guide catheter was advanced with a 0.035′ J tip Teflon coated wire and met resistance in the fore-arm. Angiogram was then performed which showed frank extravasation of contrast dye pointing to perforation in the radial artery ( Fig. 1A ). Immediately a sphygmomanometer cuff was placed on the arm and inflated above the systolic blood pressure to occlude blood flow. Protamine was also administered to counteract the heparin previously administered. The perforated segment was next crossed with a 0.035′ Abbott Versacore Hi-Torque guide wire and a 5F multipurpose guide catheter advanced across the perforation to the brachial artery in an attempt to cover the perforated segment. After 10 min, angiogram was repeated which showed persistent extravasation of dye. As the next step, we performed tamponade of the perforated segment with a 3.5 × 15 mm non-compliant balloon inflated up to 14 atm ( Fig. 1B ). This sealed the perforation with no dye leakage on angiograms. After 10 min of balloon tamponade, there still appeared to be some extravasation of dye. At this juncture, there was already considerable swelling in the forearm and we chose to deploy a covered stent graft as opposed to asking for operative repair by a vascular surgeon. A 3.5 × 16 mm Graftmaster PTFE covered stent was deployed over the perforation at 16 atm. The stent was post-dilated with the 3.5 × 15 mm NC balloon up to 18 atm. Angiogram following showed complete sealing of perforation with no further extravasation ( Fig. 1C ). Radial artery sheath was removed and a TR band™ applied for hemostasis. PCI was deferred and she was transferred to our coronary care unit for further monitoring overnight. Physical exam the following day revealed improved hematoma and ecchymosis in the fore-arm with a strong radial pulse which remained intact at her 6 month follow-up.
2
Case report
An 88-year-old African-American female with a history of atrial fibrillation (on chronic anticoagulation therapy with Rivaroxaban), hypertension, and hyperlipidemia was referred to our institution for consideration of percutaneous coronary intervention (PCI) of the left anterior descending artery (LAD). She had initially presented to an outlying hospital one day prior to the transfer with unstable angina. Diagnostic coronary angiography was performed at the referring hospital via right femoral artery access revealing 90% stenosis of the mid LAD as well as 70%–80% stenosis of the mid RCA. Notably her last dose of rivaroxaban had been on the day of presentation (< 24 h prior to PCI). On arrival she was administered 600 mg of clopidogrel and 325 mg of aspirin. A right radial artery approach was planned given the need for chronic oral anticoagulation. A 6Fr sheath was placed in the right radial artery using modified Seldinger technique without complication. 2 mg of verapamil and 0.2 mg of nitroglycerin were administered via the sheath along with an intravenous dose of 4000 units of unfractionated heparin. A 6Fr XB 3.0 cm guide catheter was advanced with a 0.035′ J tip Teflon coated wire and met resistance in the fore-arm. Angiogram was then performed which showed frank extravasation of contrast dye pointing to perforation in the radial artery ( Fig. 1A ). Immediately a sphygmomanometer cuff was placed on the arm and inflated above the systolic blood pressure to occlude blood flow. Protamine was also administered to counteract the heparin previously administered. The perforated segment was next crossed with a 0.035′ Abbott Versacore Hi-Torque guide wire and a 5F multipurpose guide catheter advanced across the perforation to the brachial artery in an attempt to cover the perforated segment. After 10 min, angiogram was repeated which showed persistent extravasation of dye. As the next step, we performed tamponade of the perforated segment with a 3.5 × 15 mm non-compliant balloon inflated up to 14 atm ( Fig. 1B ). This sealed the perforation with no dye leakage on angiograms. After 10 min of balloon tamponade, there still appeared to be some extravasation of dye. At this juncture, there was already considerable swelling in the forearm and we chose to deploy a covered stent graft as opposed to asking for operative repair by a vascular surgeon. A 3.5 × 16 mm Graftmaster PTFE covered stent was deployed over the perforation at 16 atm. The stent was post-dilated with the 3.5 × 15 mm NC balloon up to 18 atm. Angiogram following showed complete sealing of perforation with no further extravasation ( Fig. 1C ). Radial artery sheath was removed and a TR band™ applied for hemostasis. PCI was deferred and she was transferred to our coronary care unit for further monitoring overnight. Physical exam the following day revealed improved hematoma and ecchymosis in the fore-arm with a strong radial pulse which remained intact at her 6 month follow-up.
