A 63-year-old woman develops progressive pain, tenderness, and discoloration in the right wrist within several days of undergoing a cardiac catheterization using a radial artery approach. Her examination is remarkable for a tender, ecchymotic, and pulsatile protuberance along the distal radial artery. The right hand and fingers are warm and without distal embolic phenomena. Sensorimotor function of the right upper extremity is intact, and the forearm muscle compartments are soft. A duplex arterial ultrasound of the affected area documents a 1.5-cm pseudoaneurysm involving the distal radial artery.

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  Brachial artery access is declining for coronary angiography but still holds an important role for complex endovascular interventions, particularly in cases of concomitant severe peripheral artery disease. The majority of brachial access is achieved percutaneously, with a small minority of cases requiring brachial cutdown.

  
  
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  Transradial artery access for cardiac catheterization is widely embraced in Europe and increasingly is being adopted in the United States as a potentially safer means of access than the conventional transfemoral approach.

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  Brachial artery access site complications occur in up to 7% of cases. In a review of 323 cases using brachial artery access, the first and second most common complications were pseudoaneurysm and brachial artery thrombosis, respectively (Figures 12-1,12-2, and 12-3).¹

  
  
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  This relatively high complication rate is probably a function of low operator volume and declining experience in this access over the transradial approach.

  
  
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  Radial artery catheterization is typically associated with a complication rate between 0.5% and 15%.^2,3 However, the incidence may be higher than reported due to excellent collateral circulation supplying the hand. For instance, in a 2012 prospective ultrasound-assisted registry, radial access complications developed in 33% of patients when a 6F sheath was utilized.⁴

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  The majority of brachial and radial artery complications arise in women. This gender difference is attributed to a smaller arterial caliber in females.

Brachial Artery

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  Potential complications of brachial artery access include pseudoaneurysm, hematoma, bleeding, thrombotic occlusion, distal emboli, infection, dissection, and arteriovenous fistula.

  
  
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  Brachial artery pseudoaneurysm is the most commonly encountered complication (Figure 12-2).¹

  
  
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  The rate of access site complications increases with sheath diameter at or above 8F and lengths greater than 10 cm, due to the greater strain exerted by these sheaths on a mobile brachial artery.

  
  
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  Women are anywhere from two to five times more likely than males to develop a complication with brachial artery access.

  
  
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  Periprocedural aspirin reduces the risk of thrombotic occlusion without increasing the bleeding risk. Conversely, concurrent warfarin use increases the risk of complications.

Radial Artery

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  Reported complications of radial artery access include occlusion, pseudoaneurysm, perforation with bleeding, spasm, compartment syndrome, sterile abscess, cutaneous infection, and even complex regional pain syndrome.

  
  
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  Radial artery occlusion is the most common access site complication with a variable incidence between 0.5% and 10%.

  
  
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  When duplex ultrasonography was used to prospectively follow the radial artery, radial artery occlusion occurred in 14% with 5F sheaths compared with 31% with 6F sheaths (p < .001).⁴

  
  
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  Factors influencing radial artery occlusion include sheath size, ratio of the radial artery diameter to the sheath outer diameter, adequacy of anticoagulation, number of cannulation attempts, duration of cannulation and compression, as well as device adopted. Statin use appears to decrease this complication risk.⁵

  
  
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  Radial artery pseudoaneurysm is extremely rare with an incidence of only 0.1%. It arises in cases of repeated puncture attempts, aggressive anticoagulation, larger sheath size, and inadequate compression postsheath removal (Figure 12-4).

  
  
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  Radial artery perforation is a rare complication with an incidence between 0.1% and 1% of cases. Perforation is more likely in women of short stature and with difficult to traverse, tortuous arteries. If undetected, a large hematoma, with or without compartment syndrome, may ensue.

  
  
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  Radial arterial harvesting for coronary artery bypass grafting (CABG) has led to the identification of nonocclusive radial artery injury. The pathophysiology is related to radial artery trauma at the time of sheath insertion, thereby triggering neointimal hyperplasia. Repeated cannulation increases the risk of this phenomenon. Usually nonocclusive radial artery injury is of little clinical significance, having no impact on quality of life or dexterity. However, it does have a potential impact on graft patency when harvested as a conduit for CABG.