1. Transradial PCI Complication
Asim R. Zaidi, MD
Cardiology Fellow

2. Financial Disclosures
None

3. 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.

4. 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

5. 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

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

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

8. 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

9. 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

10. 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Guiding catheter and wire withdrawn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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Bertrand Classification of Forearm Hematomas

21. 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 Oct;21(5):380-4
Retrosepctive review of the transradial cases in Laval Hospital from 1994 to This included 51,296 procedures.
Incidence of compartment syndrome in their instituition was 0.004% (2 patients)

22. 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 Oct;21(5): 380-4

23. 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.

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