Transradial Perforation During Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Transradial arterial access for percutaneous coronary intervention is safe and effective in patients with acute myocardial infarction. In the recent MATRIX trial, 8,404 patients with acute coronary syndromes were randomized to transradial vs transfemoral arterial access, and patients who underwent transradial catheterization had less access site-related bleeding and lower all-cause mortality than those randomized to femoral access.¹ Consequently, transradial arterial access is now the preferred approach to treat patients with acute coronary syndromes at many centers. 

Although rare, vascular complications of transradial access can occur. Radial artery perforation, or rupture, is a serious vascular complication of transradial access that is reported in fewer than 0.1% of transradial coronary procedures.^2,3 Perforations are most likely to occur in the setting of radial arterial spasm, or tortuous, looped, or small-caliber vessels. Radial artery perforations are frequently attributed to aggressive guidewire manipulation or the “razor effect” from the distal tip of large-caliber catheters as they are advanced towards the brachial artery. 

The initial clinical presentation of radial artery perforation is usually severe pain in the arm at the site of arterial trauma. Once perforation occurs, it leads to arterial hemorrhage and the development of a forearm hematoma, which can be exacerbated by the administration of antiplatelet and anticoagulant therapy prior to and during the procedure. If perforation is suspected, prompt angiography of the radial artery is essential to establish the diagnosis. When the diagnosis of radial artery perforation is delayed or appropriate management is not promptly initiated, the resulting hematoma can progress to cause forearm compartment syndrome and limb ischemia requiring emergent surgical intervention. Consequently, it is essential that interventional cardiologists are familiar with the diagnosis of radial artery perforation and contemporary management strategies. Here, we present a case of radial artery perforation during primary percutaneous coronary intervention for ST-elevation myocardial infarction that illustrates the optimal management of this rare vascular complication.

Case presentation 

A 50-year-old man with a history of tobacco use and ulcerative colitis presented with 3 days of intermittent sub-sternal chest discomfort. Initial electrocardiogram (ECG) in the emergency department was notable for inferior ST-segment elevations. The patient was administered dual antiplatelet therapy, and was taken emergently for transradial cardiac catheterization and coronary angiography. After right radial arterial access was obtained with a short 6 French (Fr) sheath, there was difficulty advancing a 6 Fr M-Radial guide catheter (Medtronic) beyond the antecubital fossa over a standard .035-inch J-wire and using a hydrophilic, angled guidewire (Terumo). Selective angiography of the right radial artery at the antecubital fossa was performed via the guide catheter from the distal radial artery, which demonstrated contrast extravasation consistent with a radial artery perforation (Figure 1). Next, a hydrophilic .014-inch Runthrough coronary wire (Terumo) was advanced into the brachial artery and the guide catheter was advanced past the perforation and into the ascending aorta. For additional hemostasis, a sphygmomanometer cuff was placed over the elbow and was inflated to 80 mmHg for the duration of the procedure. Right coronary artery (RCA) angiography revealed a thrombotic 100% occlusion of the distal vessel (Figure 2). There was no significant disease in the left coronary artery system. Bivalirudin was administered and the Runthrough coronary wire was advanced past the thrombotic RCA occlusion into the distal vessel. Manual aspiration thrombectomy was performed, followed by delivery of a 3.0 x 23 mm Xience cobalt chromium everolimus drug-eluting stent (Abbott Vascular) to the site of the lesion. After stent deployment, post-dilatation was performed with a 3.5 x 15 mm non-compliant balloon (Quantum Apex, Boston Scientific), yielding an excellent angiographic result and TIMI-3 flow in the distal vessel (Figure 3). Following successful percutaneous coronary intervention, the guide catheter was carefully withdrawn distal to the site of the radial artery perforation. Repeat angiography of the radial artery through the tip of the guide revealed no further contrast extravasation and angiographic resolution of the perforation (Figure 4). The radial access site was secured with a TR Band (Terumo) and the sphygmomanometer cuff at the elbow was gradually deflated and removed. The patient did well post-procedure with no additional vascular complications.

Management of radial artery perforation

In the early years of transradial access, radial artery perforations were managed by aborting radial access and applying external manual pressure to the site using a sphygmomanometer cuff inflated to the patient’s systolic blood pressure. This approach, although effective to establish hemostasis, increased the risks of post-procedure radial artery occlusion. Furthermore, it subjected patients to the additional risks of vascular complications at the second access site (either transfemoral or contralateral transradial access) that was necessary to complete the coronary procedure.⁴ 

Guide catheter tamponade, as described in the case above, is now the preferred approach to control bleeding from radial artery perforation. Successful management of radial artery perforation using this approach has been reported in case series from a number of large transradial centers.^2,5-8 Once the extravasation of contrast is angiographically visualized and the diagnosis of radial artery perforation is made, the operator should attempt to cross the perforated arterial segment with a wire. This is typically achieved using the soft tip of an .014-inch coronary wire from the distal radial arterial access site. Once the coronary wire has been delivered past the perforation and into the brachial artery, a standard 6 Fr guide catheter can be advanced. In many cases, balloon-assisted tracking is useful to facilitate delivery of the guide catheter beyond the perforated arterial segment and avoid additional trauma to the vessel wall.^6,9 

Once the guide catheter has been delivered past the radial artery, the body of the catheter opposes the perforated arterial segment and prevents further extravasation of blood into the surrounding tissues. Guide catheter tamponade can also be combined with external manual compression using a sphygmomanometer cuff inflated to the patient’s systolic blood pressure to augment hemostasis. This hybrid approach permits the interventional operator to continue with diagnostic angiography and percutaneous coronary intervention while hemostasis is obtained. After successful completion of the coronary procedure, the guide catheter should be carefully withdrawn into the distal radial artery and repeat angiography of the perforated segment should be performed. Hemostasis is achieved in the majority of cases without any further intervention, even in the setting of therapeutic anticoagulation necessary for percutaneous coronary intervention. In rare instances when guide catheter tamponade and external compression fail to achieve hemostasis at the site of a radial artery perforation, prolonged intravascular balloon inflation across the perforated segment may also be attempted. If (and only if) all of these conservative measures fail, placement of a polytetrafluoroethylene (PTFE)-covered coronary stent to seal the radial artery perforation has also been reported.¹⁰

In summary, we illustrate a straightforward and effective solution to resolve the complex problem of radial artery perforation. Guide catheter tamponade facilitates hemostasis at the site of the rupture and permits successful completion of the coronary procedure. 

References

1. Valgimigli M, Gagnor A, Calabro P, Frigoli E, Leonardi S, Zaro T, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015; 385: 2465-2476.
2. Patel T, Shah S, Sanghavi K, Pancholy S. Management of radial and brachial artery perforations during transradial procedures--a practical approach. J Invasive Cardiol. 2009; 21: 544-547.
3. Tatli E, Buturak A, Cakar A, Vatan BM, Degirmencioglu A, Agac TM, et al. Unusual vascular complications associated with transradial coronary procedures among 10,324 patients: case based experience and treatment options. J Interv Cardiol. 2015; 28: 305-312.
4. Rashid M, Kwok CS, Pancholy S, Chugh S, Kedev SA, Bernat I, et al. Radial artery occlusion after transradial interventions: a systematic review and meta-analysis. J Am Heart Assoc. 2016 Jan 25;5(1). pii: e002686. doi: 10.1161/JAHA.115.002686.
5. Calvino-Santos RA, Vazquez-Rodriguez JM, Salgado-Fernandez J, Vazquez-Gonzalez N, Perez-Fernandez R, Vazquez-Rey E, Castro-Beiras A. Management of iatrogenic radial artery perforation. Catheter Cardiovasc Interv. 2004; 61: 74-78.
6. George S, Mamas M, Nolan J, Ratib K. Radial artery perforation treated with balloon tracking and guide catheter tamponade - a case series. Cardiovasc Revasc Med. 2016 Jun 27. pii: S1553-8389(16)30164-6. doi: 10.1016/j.carrev.2016.06.005. [Epub ahead of print].
7. Liang M, Devlin G, Harding SA. Radial artery spasm and perforation: simple solutions for challenging cases. Heart Lung Circ. 2015 Jun; 24(6): e71-e74. doi: 10.1016/j.hlc.2014.12.165.
8. Pujara K, Wood A, Roberts EB. Management of radial artery perforation during coronary angiography and angioplasty--a report of two cases. Catheter Cardiovasc Interv. 2011 Jul 1; 78(1): 54-57. doi: 10.1002/ccd.22866.
9. Deora S, Shah S, Patel T. Balloon-assisted tracking of guide catheter dealing with radial artery perforation and subclavian loop during percutaneous coronary intervention by transradial approach. Int J Cardiol. 2013 Sep 10; 167(6): e161-162. doi: 10.1016/j.ijcard.2013.04.173.
10. Al-Sekaiti R, Ali M, Sallam M. Radial artery perforation after coronary intervention: is there a role for covered coronary stent? Catheter Cardiovasc Interv. 2011; 78: 632-635.

Disclosures: The authors report no relationships that could be construed as a conflict of interest.

The authors can be contacted via Sripal Bangalore, MD, MHA, Director of Research, Cardiac Catheterization Laboratory; Director, Cardiovascular Outcomes Group; Associate Professor of Medicine, New York University School of Medicine, at sripalbangalore@gmail.com