Extraction of the Radial Artery During Transradial Coronary Angiography: An Unusual Complication

The transradial technique is a currently accepted alternative to the femoral site for vascular access during coronary percutaneous interventions. While in some laboratories it is only used when the femoral entry site proves troublesome or impossible, in others it is routinely used as the access site of choice. The procedure can be performed safely, with few access-site complications, better patient comfort and earlier ambulation.1,2 We describe a patient in whom the radial artery was inadvertently extracted during sheath removal. Case Report. A 58-year-old, hypertensive, dyslipidemic, overweight woman was catheterized for unstable angina. The catheterization was performed via the right radial artery using a 6 French (Fr) diameter radial catheterization kit (Cordis Corporation, Miami, Florida). Following sheath insertion, 0.5 mg diluted nitroglycerine was administered via the sheath. Diagnostic angiography was successfully performed, with an uneventful course. Insignificantly narrowed coronary artery disease was demonstrated, and conservative medical therapy was contemplated. Another 0.5 mg diluted nitroglycerine was injected via the sheath with each catheter exchange. During sheath removal, the patient experienced great pain and an additional 0.5 mg nitroglycerine was injected via the sheath. After a 3-minute delay, a second attempt was made to remove the sheath. This was again accompanied with pain (albeit less than before) and there was some resistance to the withdrawal, although no more than is usually felt. The sheath was finally withdrawn, and to our surprise, a tubular structure was adherent to the distal end of the sheath. No local hematoma or ischemia were observed. The extracted portion of the artery was incised, and the dissected edges of the artery were sutured. The patient recovered from the procedure with an uneventful clinical course. The tubular structure that was extracted with the sheath was sent for pathological analysis. On macroscopic examination, it was 4 mm long and 2 mm wide. Microscopic examination, which included an elastica histochemical staining, confirmed that it consisted of a muscular artery. However, the localization of the different layers of the vessel was inverted, with residual intima and elastica interna at the periphery and the adventitia in the center of the structure (Figure 1). Our interpretation of the findings is that during sheath extraction, an invagination occurred with inversion of the vessel. Discussion. Previously reported access-site complications include mild hematomas, hematic effusions, nerve injuries, arteriovenous fistulas, pseudoaneurysms and reduced or absent radial pulse. The latter have been reported to occur at a frequency of 5–20%, probably as a result of local vasospasm and/or thrombosis, and rarely lead to ischemic manifestations.3–5 Although total extraction of the radial artery appears dramatic and frightening, its consequences are essentially similar to those of the more common causes of absent pulse. Small radial arteries, which are more frequent in women, are more liable to undergo spasm and may be at higher risk for such complications.4 The number and duration of coronary manipulations may also increase this risk. The occurrence of this embarrassing and frightening complication emphasizes the need for meticulous attention and prudence when a patient complains of local pain during sheath extraction. Although not found to be helpful in our patient, the use of local anesthesia during sheath insertion and intra-arterial nitroglycerine between catheter exchanges and before sheath extraction might prevent arterial spasm. When severe pain and resistance are encountered during sheath extraction, additional vasodilators such as nitroglycerine and/or papaverin should be injected intra-arterially, and the extraction should be performed slowly and prudently.

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