Acute Hand Ischemia After Radial Intervention in Patient with CREST-Associated Pulmonary Hypertension: Successful Treatment With Manual Thromboaspiration

Download a PDF of this article.

Abstract: We describe the case of a 60-year-old woman with CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) associated pulmonary hypertension undergoing transradial coronary angiography. The day after the procedure, the patient complained of severe symptoms and signs of acute hand ischemia. Urgent right upper extremity angiography showed the lack of ulnar palmar arch and a severe narrowed radial artery with endoluminal filling defect. The patient was successfully treated with manual thromboaspiration leading to a complete flow restoration and symptom relief. This case shows that radial occlusion, one of the most common and usually asymptomatic complications following transradial cardiac catheterization, may cause severe hand ischemia in patients with small-vessel inflammatory disease. 

J INVASIVE CARDIOL 2013;25(2):89-91

Key words: transradial coronary intervention, hand ischemia, thromboaspiration

____________________________________________

Radial artery occlusion is the most common complication of transradial (TR) coronary intervention. It is usually asymptomatic owing to the dual blood supply of the hand. However, in the present case, we describe a severe acute hand ischemia following a TR coronary angiography in a patient with CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) associated pulmonary hypertension undergoing TR coronary angiography. The patient was successfully managed with manual thromboaspiration and thrombus formation was documented as the main mechanism leading to the radial occlusion.

Case Description

A 60-year-old woman with worsening heart failure (New York Heart Association class III/IV) due to CREST-associated pulmonary hypertension was admitted to our institution for screening for heart-lung transplantation. She had a history of insulin-dependent diabetes mellitus and sarcoidosis. Her weight and height were 49 kg and 1.60 m, respectively (body surface area, 1.40 m²). Physical examination findings included sclerodactyly, Raynaud phenomenon, and diffuse telangiectasias. Chronic medical treatment included oxygen therapy, warfarin, intravenous epoprostenol, bosentan, sildenafil, corticosteroid, and colchicine.

During hospitalization, the patient underwent TR coronary angiography in the context of screening examinations. The pre-procedure evaluation revealed a good palpable right radial pulse. No evaluation of ulnar artery patency was performed. International normalized ratio (INR) was 1.8. This finding along with female gender and small body size were perceived to increase the risk of bleeding associated with femoral access.

Radial access was obtained using a 20 gauge needle, a 0.025˝ guidewire and a 10-cm long, 6 Fr sheath (Radiofocus INTRODUCER II; Terumo Corporation). Verapamil (2 mg) was administered directly into the sheath. Coronary angiogram was normal. The radial sheath was removed and a TR band (Terumo) hemostasis device was applied. The patient was transferred to the cardiology ward and the TR band was removed after 6 hours. One day later (10 hours after TR band removal), the patient complained of right hand pain, numbness, and loss of sensitivity. Physical examination showed reduced hand motility, pallor, and severe hypoperfusion. The patient was then referred for urgent arteriography. Right brachial access was gained using an antegrade puncture with an 18 gauge needle, a 0.028˝ guidewire, and a 15 cm-long, 4 Fr sheath (Leader-Cath; Vygon). Selective arteriography of the ulnar artery showed diffuse disease of the distal branches with no visualization of the ulnar palmar arch (Figure 1A). Selective arteriography of the radial artery showed a long and severe thrombotic lesion with very poor distal flow (Figure 1B). This lesion was treated with manual thromboaspiration after changing the previously inserted sheath with a 6 Fr sheath (Radiofocus Introducer II; Terumo Corporation) and administration of intravenous unfractioned heparin (2500 UI). A Choice extra-support guidewire (Boston Scientific Corporation) was passed distal to the lesion and subsequently a catheter for manual thromboaspiration (6 Fr Eliminate; Terumo Corporation) was directly passed over the guidewire. Subsequent angiogram revealed the absence of residual thrombosis, a mild radial artery stenosis (Figure 1C) with a TIMI grade III flow, and good visualization of radial palmar arch (Figure 1D). Figure 2 shows the manually aspirated thrombus. The patient had a prompt improvement in her symptoms and signs of hypoperfusion improved. Brachial hemostasis was obtained the day after by manual compression. During the following hospitalization, no recurrence of hand-ischemia related symptoms occurred and the patient was discharged 2 weeks later after conclusion of planned examinations.

Discussion

The present case shows that radial occlusion after TR cardiac catheterization may result in a severe acute hand ischemia in patients with small-vessel inflammatory disease such as CREST syndrome. Manual thromboaspiration within 12 hours of symptom onset successfully obtained flow restoration and symptom relief.

During the few past years, the TR approach for cardiac catheterization has gained popularity worldwide. It has been associated with a lower incidence of major access-related complications compared to the traditional transfemoral approach.^1-3 Moreover, it has also been suggested that TR approach may favorably impact mortality in patients undergoing percutaneous coronary intervention.^4,5 Besides, the TR approach is associated with an increasing grading of patient’s comfort, early deambulation, and reduced hospital stay.

Radial artery occlusion is the most common complication following TR catheterization and is usually asymptomatic due to the dual blood supply to the hand. Hand ischemia with necrosis is a known complication in critically ill patients after prolonged artery cannulation for blood pressure monitoring,⁶ while symptomatic radial artery occlusion after TR cardiac catheterization has been described in only 2 cases.^7,8 In the first, Rhyne et al⁷ described the case of a patient complaining of numbness, loss of sensitivity, and paresthesias 2 weeks after the procedure. Radial artery occlusion was documented by arteriography performed 4 months later because of persistent symptoms, and successfully treated with radial artery angioplasty.

Notably, in this case, hand ischemia occurred in the presence of ulnar artery patency according to the modified Allen’s test based on plethysmography.⁹ In the second case, Kaney et al⁸ reported on acute hand ischemia in a patient with a suspicious history of Raynaud’s disease. The patient had prolonged pain and ischemia of the 5th digit of her right hand. Angiogram of the upper right extremity showed a radial artery occlusion and a small ulnar artery with diffuse spasm. No further interventions have been described by the authors. 

Compared to the above-reported cases, ours offers some insights into possible mechanisms leading to radial occlusion since we clearly observed the presence of fresh red thrombus, confirming previous observations.¹⁰ We also reported for the first time that manual thromboaspiration by means of devices usually used in the context of ST-segment elevation myocardial infarction may result in a successful flow restoration, provided that the procedure is performed within the early hours after symptom onset (<12 hours in the present case). 

On the other hand, the present case gives us the opportunity to underline the importance of some rules for radial intervention. Although the need to evaluate the ulnar artery patency by means of modified Allen’s test is controversial (we routinely perform transradial cardiac catheterization without evaluating ulnar artery patency with an outstanding safety profile), radial access must be avoided in patients with small-vessel inflammatory disease who are at increased risk of distal artery obstruction. Indeed, in the present case, we observed a very small ulnar and inter-osseous arteries with no evidence of vasculature of the hand stemming from the ulnar system. Second heparin should be administered to reduce the risk of radial artery occlusion. In our case, an INR value of 1.8 was not able to prevent this phenomenon. Finally, postprocedure occlusive compression should be as short as possible since it has been shown that prolonged compression is associated with an increased risk of radial artery occlusion.^11,12 In the present case, the 6-hour compression period may have contributed to artery occlusion. Besides, due to the hemostasis device we used, excessive force of the compression as a contributing factor to the radial occlusion may not be ruled out.^11,12 Accordingly, we also suggest that a careful nonocclusive compression able to avoid the bleeding should be adopted.

Conclusion

The present case shows that in patients with small-vessel inflammatory disease, radial artery occlusion, one of the most common and usually asymptomatic complications following TR cardiac catheterization, may cause severe hand ischemia. Thus, in this kind of patient the TR approach should be avoided. In cases of this severe complication, patients may be treated with manual thromboaspiration provided it is performed in a timely fashion.

References

1. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures: systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44(2):349-356.
2. Brueck M, Bandorski D, Kramer W, et al. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv. 2009;2(11):1047-1054.
3. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409-1420.
4. Chase AJ, Fretz EB, Warburton WP, et al. Association of the arterial access site at angioplasty with transfusion and mortality: the MORTAL study (Mortality benefit Of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg). Heart. 2008;94(8):1019-1025.
5. Mamas MA, Ratib K, Routledge H, et al. Influence of access site selection on PCI-related adverse events in patients with STEMI: meta-analysis of randomised controlled trials. Heart. 2011;98(4):303-311.
6. Valentine RJ, Modrall JG, Clagett GP. Hand ischemia after radial artery cannulation. J Am Coll Surg. 2005;201(1):18-22.
7. Rhyne D, Mann T. Hand ischemia resulting from a transradial intervention: successful management with radial artery angioplasty. Catheter Cardiovasc Interv. 2010;76(3):383-386.
8. Kanei Y, Kwan T, Nakra NC, et al. Transradial cardiac catheterization: a review of access site complications. Catheter Cardiovasc Interv. 2011;78(6):840-846.
9. Barbeau GR, Arsenault F, Dugas L, et al. Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the Allen’s test in 1010 patients. Am Heart J. 2004;147(3):489-493.
10. Pancholy SB. Transradial access in an occluded radial artery: new technique. J Invasive Cardiol. 2007;19(12):541-544.
11. Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv. 2008;72(3):335-340.
12. Sanmartin M, Gomez M, Rumoroso JR, et al. Interruption of blood flow during compression and radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv. 2007;70(2):185-189.

________________________________________

From the Istituto di Cardiologia, Azienda Ospedaliero-Universitaria Policlinico St Orsola/Malpighi Bologna, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted May 29, 2012 and accepted June 19, 2012.

Address for correspondence: Nevio Taglieri,  MD, Institute of Cardiology, Bologna University, St Orsola/Malpighi Hospital, Via Massarenti 9, 40138, Bologna, Italy. Email: neviotaglieri@hotmail.it