Abstract
Transradial cardiac catheterization has lower rates of arterial access site complications than transfemoral procedures. However, there are complications that are unique to the transradial route. We present the case of a sterile granuloma occurring at the site of radial arterial access as a reaction to the hydrophilic coating on the sheath. The clinical presentation was suggestive of an infected pseudoaneurysm. Awareness of this entity may help clinicians avoid unnecessary surgical procedures, as these granulomata are transient self-limiting reactions.
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Introduction
A 59-year-old woman with a history of systemic lupus erythematosis, hypertension, and hyperlipidemia was referred for evaluation of worsening shortness of breath and dyspnea on exertion. Examination of her cardiovascular and pulmonary systems was normal. Chest X-ray and electrocardiogram results were normal. Echocardiogram revealed elevated pulmonary artery pressure and borderline left ventricular systolic function. Computed tomography of the chest showed no interstitial lung disease, ventilation/perfusion scintigraphy excluded pulmonary thromboembolic disease, and a cardiac catheterization was requested for further evaluation. Right heart catheterization revealed normal right atrial and pulmonary capillary wedge pressures, right ventricular pressure of 34/6 mmHg, and pulmonary artery (PA) pressure of 34/12 (mean 20) mmHg at rest. Pulmonary vascular resistance was 2.5 Wood units. Supine bicycle exercise was performed for 8 min, achieving 5.8 mets; PA pressure rose to 67/24 (mean 42) mmHg, meeting criteria for exercise-induced pulmonary hypertension. Left heart catheterization was performed via the right radial artery using a 5-French hydrophilic-coated sheath (Cook, Inc., Bloomington, IN, USA). This revealed no significant angiographic coronary artery disease and normal left ventricular end-diastolic pressure. Medications given were intravenous heparin 3000 U, intra-arterial verapamil 3 mg, and intra-arterial nitroglycerin 200 μg. After removal of left heart catheters, the sheath was removed without difficulty. Hemostasis at the arterial puncture site was achieved with a HemoBand for 2 h. The procedure was uncomplicated and the patient was discharged the same day.
Eight days after the cardiac catheterization, she presented to her physician complaining of redness, swelling, and tenderness at the arterial access site. Antibiotics were prescribed with no change in clinical status. Ultrasound demonstrated a mass at the radial artery site with no flow in the mass, but with normal flow through the radial artery ( Fig. 1 ). This was thought to reflect a thrombosed pseudoaneurysm. A total of 18 days after the procedure, because of persistent redness and swelling, she was referred to a vascular surgeon for a presumed diagnosis of infected, thrombosed pseudoaneurysm of the radial artery. White blood cell count was normal, the patient was afebrile, and blood cultures were negative. She was brought to the operating room, where her radial artery was resected. Pathology revealed the diagnosis ( Fig. 2 ). There was amorphous grey material in the vessel wall and the extravascular space, and associated with this was granulomatous inflammation consistent with a foreign body reaction to the hydrophilic coating on the sheath. No pseudoaneurysm was identified. No infectious organisms or pus was seen.
