Transradial PCI Complication Asim R. Zaidi, MD Cardiology Fellow

Financial Disclosures None

Transradial Angiography 1950: First left heart catheterization reported by Henry Zimmerman 1995: First transradial intervention in the United States, by Tift Mann The first transradial left heart catheterization was reported by Henry Zimmerman in 1950. The United States has been a relatively late bloomer in the use of transradial approach with its use well below 10% nationwide. It was in 1995 that Tift Mann performed the first coronary intervention via radial access.

Our Patient (1) 62 year old Caucasian female Symptoms of exertional angina CCS Angina Class I Risk factors: Hypertension, tobacco use Myocardial perfusion imaging: Anterior & antero-lateral ischemia Canadian Cardiovascular Society Angina Class I

Coronary Angiography Left main stem: ostial 50% stenosis Although this can typically be seen on a cranial view, pressure dampening was observed and intra-vascular US was performed

Intravascular Ultrasound (IVUS) Minimum luminal area (MLA): 6.75 mm2 Stenosis diameter: 55% Minimum luminal cross-sectional area: 6.75mm2 Stenosis 55%

Our Patient (2) Surgical revascularization recommended Patient chose upon elective PCI to left main coronary artery

PCI Strategy Right transradial approach 21G micro-puncture needle for access 6 Fr hydrophilic sheath and 21G straight-tip wire 6 Fr extra back-up guiding catheter Anticoagulation: Bivalirudin Drug-eluting stent Post-PCI IVUS Antiplatelet therapy: Aspirin 325 mg orally Clopidogrel 600 mg loading dose and 75 mg maintenance dose initiated 7 days prior to PCI PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Procedure (1) Front wall puncture Easy wire advancement No excessive manipulation required Sheath introduced without difficulty or resistance Anti-spasmodics: Nitroglycerin 200 mcg intra-arterial Diltiazem 200 mcg intra-arterial PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Procedure (2) 6Fr guiding catheter 0.035 J-tip wire Resistance of wire observed at level of the radio-humeral joint Patient reported pain Wire could not be advanced further Guiding catheter and wire withdrawn PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME Selective radial artery angiography was performed revealing perforation of the radial artery just after its takeoff from the brachial artery. Faint filling and antegrade flow seen in the ulnar artery. PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME Radial Recurrent Artery Brachial Artery Selective radial artery angiorgaphy was performed revealing perforation of the radial artey just after its takeoff from the brachial artery. Faint filling and antegrade flow seen in the ulnar artery. Radial Artery PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Management (1) Unsuccessful attempt to cross with 0.014 wire Bivalirudin infusion stopped Radial artery sheath removed Transradial (TR) band applied In a retrograde fashion PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Management (2) Blood pressure cuff placed over perforation site Inflated 20 mmHg above systolic BP Pulse oximeter placed on finger with uninterpretable waveform or saturation reading ACT >350 seconds PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Management (3) Patient reports: “I cannot feel my fingers” Disappearance of capillary refill Marked expansion of forearm with visible hematoma Severe pain Bradycardia and hypotension requiring: Atropine 1 mg IV Saline bolus 500 ml PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Management (4) Vascular surgery consultation Emergent right forearm fasciotomy Exploration of right forearm Repair of radial artery arteriotomy Mechanical thrombectomy Vein patch angioplasty of radial artery PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Timeline to Complication Bivalirudin administered Arterial puncture BP cuff placed 2 8 45 Time (minutes) 5 14 Sheath inserted Radial artery perforation diagnosed Emergency surgery

Outcome Patient made full recovery and discharged on hospital day 4 Small forearm scar Patient underwent uncomplicated PCI to left main coronary artery via femoral approach 2 months later PLAN PROCEDURE COMPLICATION MANAGEMENT OUTCOME

Radial Artery Perforation Rare, but more likely in: Patients with small radial arteries Elderly patients Tortuous radial arteries Radial artery loops Hypertensive patients Inadvertent forceful manipulation of the guidewire and catheter

Bertrand Classification of Forearm Hematomas

Management Options (1) Tizon-Marcos et al. Incidence of Compartment Syndrome of the Arm in a Large Series of Transradial Approach for Coronary Procedures J Inter Cardiol. 2008 Oct;21(5):380-4 Retrosepctive review of the transradial cases in Laval Hospital from 1994 to 2007. This included 51,296 procedures. Incidence of compartment syndrome in their instituition was 0.004% (2 patients)

Management Options (2) Suggested protocol: Apply pressure cuff at site of induration Inflate cuff ≤15 mmHg below systolic pressure for 15 minutes Monitor arterial flow with oximetry and adjust cuff pressure to obtain signal Manage pain and hypertension Consider stopping anticoagulants Consider protamine, if heparin in use If persistence of swelling, pain or induration after two inflations of 15 minutes, consider urgent surgical consultation Tizon-Marcos et al. J Inter Cardiol. 2008 Oct;21(5): 380-4

Management Options (3) No removal of guiding catheter Re-crossing the radial artery from the contra-lateral side and occluding the vessel with a balloon Anticoagulant initiation after engagement of coronary artery Management option in this situation is to use the guiding catheter to tamponade the perforation and continue to planned procedure. In our case, we were not able to cross with a wire therefore the catheter had to be removed. Yes, but due to the progressive signs and symptoms of vascular and neurological signs, there was no time for this Definitely an option, especially for operators with less transradial experience. In essence, when concerning signs or symptoms develop indicating neurovascular compromise, just as PAIN or DECREASED SENSATION, emergent vascular surgery opinion is required.

and finally… Special thanks to: Mladen I. Vidovich, MD, FACC, FSCAI Adhir R. Shroff, MD, MPH, FACC, FSCAI