Abstract
Radial access has been increasingly utilized for coronary intervention due to higher safety profile in comparison to femoral access site with lower bleeding rate. Radial artery occlusion is not uncommon with radial access site. This usually does not lead to any harm due to ulnar artery collaterals that are sufficient to prevent hand ischemia and is usually left alone. However, in the case of significant hand ischemia, treatment is often necessary. We are reporting an interesting case of symptomatic radial artery thrombosis leading to arm ischemia that was successfully treated percutaneously using femoral access. Using femoral access for radial artery intervention has not been reported previously. This case is followed by review of the literature.
1
Introduction
Lucien Campeau for the first time described the use of the radial access for the diagnostic coronary angiography in 1989 . It was refined by Kiemeneij and Laarman for coronary artery stenting in 1993 . Over the period of years, subsequent developments have been made in this new approach. Transradial access (TRA) for cardiac catheterization is safe with lower risk of vascular complications in comparison to transfemoral access . Other benefits of TRA include short hospital stay, increasing cost effectiveness, and early mobility after the procedure with higher success rates in patients with peripheral vascular disease . In one study, TRA was also associated with lower mortality in high risk patients such as those with ST segment elevation myocardial infarction (STEMI) . Despite its lower complication rate, it has its own risks. The rare documented complications of TRA include radial arterial spasm, perforation, catheter kinking, occlusion, thrombosis, perforation, pseudoaneurysm, arteriovenous fistula, non-occlusive radial artery injury, compartment syndrome, granuloma, minor nerve damage, and complex regional pain syndromes . Radial artery occlusion during cardiac catheterization is not uncommon and it is usually asymptomatic due to the presence of ulnar artery collaterals. However, in the case of significant hand ischemia, treatment is often necessary. We are reporting an interesting rare case of symptomatic radial artery thrombosis leading to arm ischemia that was successfully treated percutaneously using femoral access site.
2
Case report
A 42 year old African-American woman with past medical history significant for dyslipidemia and smoking had been referred for coronary angiography due to chest pain and abnormal myocardial perfusion stress testing. The patient had a negative Allen’s test and underwent transradial cardiac catheterization. Using a micropuncture kit, her right radial artery was engaged using a micropuncture needle. A 6-French sheath was advanced over the wire in the radial artery. A cocktail of nitroglycerine (400 μg), verapamil (500 μg), and unfractionated heparin (5000 U) was given into the right radial arterial sheath. Angiogram revealed normal coronary arteries with normal left ventricular systolic function. Procedural time was less than 30 minutes. At the end of the procedure, a TR band was used for hemostasis. TR band was gradually removed one hour post procedure using gradual deflation. Her procedure was uneventful and she was discharged home the same day. After two weeks, she presented to the emergency department with pain and swelling in her right wrist. She was diagnosed with an abscess at the entry site from her 6-French sheath insertion into the right radial artery. Right upper extremity ultrasound revealed an occlusive disease within her right radial artery at the distal forearm. The patient was taken to the cardiac catheterization laboratory for further assessment due to the suspected arm ischemia. Right femoral artery access was obtained using a micropunture kit and a 6-French sheath was inserted into the right common femoral artery. A 0.035 Versacore wire was inserted in the aortic arch following 5000 U of unfractionated heparin administration. Next, a Vitek catheter was used to cannulate innominate and subclavian arteries. A J wire was advanced to the level of mid brachial artery followed by the removal of Vitek catheter. It was replaced with angled Glidecath, which was inserted into distal brachial artery. Selective angiography was performed showing patent brachial artery, ulnar artery and flow arch; however, 4 cm segment of radial artery was occluded with reconstitution just in the proximal palm ( Fig. 1 ). Using the 0.014 wire, occlusion site was crossed and entered the palm. Subsequently, 0.014 Quick-Cross was used and carried across the lesion. Repeat angiography confirmed the correct position. At this point, the decision was made to perform balloon angioplasty. The wire was exchanged for 0.035 Quick-Cross and the 6-French short sheath was exchanged for a long 6-French shallow sheath which was advanced into the distal brachial artery. Using the 0.014 wire, a 2.0 × 30 mm sprinter angioplasty balloon was advanced across the lesion inflating to 10 atm. Residual 40% stenosis was treated with 3.0 × 40 mm sprinter balloon. Angiogram showed 30% residual narrowing. The patient received a cocktail of nitroglycerine (400 μg) and verapamil (500 μg). In addition, she was given tPA and 2000 U of unfractionated heparin ( Fig. 2 ). Ulnar artery and palmar arch remained intact. Procedure was concluded at this time with improvement in her symptoms with palpable distal radial and ulnar pulses. She was admitted for intravenous antibiotics and Solu-Medrol treatment for the suspected sterile abscess secondary to Teflon reaction from the sheath use during her prior cardiac catheterization. She was discharged later and remained symptom free in subsequent outpatient visits without any injury to her digits.
