Management of Radial and Brachial Artery Perforations during Transradial Procedures — A Practical Approach

ABSTRACT: We present a practical approach to the management of iatrogenic radial and brachial artery perforations during transradial catheterization and interventions. These perforations were treated successfully without abandoning the procedure in 15 patients. J INVASIVE CARDIOL 2009;21:544–547 Key words: radial artery perforation, PCI, guidewire, coronary catheter, transradial approach Transradial access to percutaneous diagnostic procedures was first reported by Campeau.1 Kiemeneij et al performed the first interventional procedure using this route.2 A negligible access-site complication rate (despite aggressive use of antiplatelet agents and glycoprotein IIb/IIIa inhibitors), early ambulation, low periprocedural morbidity and cost savings because of early discharge are the proven benefits of the transradial approach (TRA).3 Moreover, TRA has been overwhelmingly preferred and appreciated by patients as well as hospital staff.4 However, a new learning curve for an operator, radial artery spasm, anatomical challenges at radial, brachial and subclavian regions and iatrogenic perforations in the radio-brachial segment (RBS) could be the reasons for failure or crossover to femoral access.3,10 Perforation in the RBS can occur as a result of injury caused by the tip of a guidewire, a diagnostic catheter or a guide catheter more commonly in a small-caliber arterial segment, a tortuous segment or in an anatomical variation such as a loop.10 It has been managed in the past by external manual compression or inflation of a PTCA catheter across a perforated segment, or by negotiating a long arterial sheath across an affected segment.5,6 We encountered this complication in 15 patients (out of a total of 34,000 procedures via the TRA) who developed perforation in the RBS and were managed successfully by a simple and practical approach without abandoning the procedure. Case No. 1. A 60-year-old male patient underwent coronary angiography via the right radial route. Radial puncture was performed and a 5 French (Fr) sheath (Terumo Corp., Tokyo, Japan) was deployed using the standard technique.10 While negotiating a standard 0.035 inch guidewire along with a 5 Fr TIG diagnostic catheter (Terumo), we encountered resistance and difficulty with wire movement. As a part of our routine protocol, the catheter and guidewire were immediately removed and diluted contrast was injected through the side port of the sheath to define the problem in the RBS. It revealed a loop and a perforation just proximal to it with extravasation of contrast in the surrounding tissue (Figure 1A). The culprit segment and the loop were crossed with a 0.014 inch Whisper PTCA guidewire (Abbott Vascular, Santa Clara, California) (Figure 1B). The TIG diagnostic catheter was negotiated over the PTCA guidewire using a gentle cork-screw movement, and the perforated segment and loop were crossed (Figure 1C). The coronary angiogram was completed successfully. While removing the catheter, we took a pull-back angiogram in the affected segment which revealed a sealed perforation and no contrast extravasation (Figure 1D). The patient did not develop a local hematoma and was discharged the next day with patent radial pulsation. Follow-up vascular Doppler examination 1 month later revealed a patent RBS. Case No. 2. A 54-year-old male underwent stenting of a discrete right coronary artery (RCA) mid-segment stenosis via the right radial route. His coronary angiogram was performed in the other hospital via the transfemoral route. After radial puncture, a 6 Fr sheath (Terumo) was deployed using the standard technique.10 No difficulty or resistance was encountered while negotiating the 6 Fr sheath. As soon we tried to negotiate a 6 Fr JR4 Launcher guide catheter (Medtronic, Inc., Minneapolis, Minnesota) over a 0.035 inch standard guidewire, we encountered resistance and the patient began complaining of significant pain and discomfort in the forearm. As per our standard protocol, we removed the assembly and injected diluted contrast, which revealed a large perforation with extravasation of contrast in the surrounding tissue. We crossed the culprit segment with a 0.014 inch BMW PTCA guidewire (Abbott Vascular). In light of the small caliber of the radial artery, we chose a 5 Fr Launcher JR4 guide catheter (Medtronic) and crossed the perforated segment over the 0.014 BMW PTCA guidewire with a gentle cork-screw maneuver. There was no difficulty in cannulating the RCA and the intervention was successfully completed. While removing the guide catheter, we performed pull-back angiography in the RBS, which revealed a sealed perforation and no extravasation of contrast. The patient was discharged after 48 hours with patent radial pulsation and no local hematoma. Vascular Doppler examination at 1-month follow up revealed a patent RBS. Case No. 3. A 70-year-old diabetic female underwent coronary angiography through the right radial route. After radial puncture, a 5 Fr radial sheath (Terumo Interventional Systems, Somerset, New Jersey) was deployed. We were able to negotiate a 0.035 inch standard guidewire, but encountered significant resistance while negotiating a 5 Fr TIG catheter (Terumo) over the same wire. The patient complained of significant pain and discomfort in the right forearm. As per our routine protocol, we removed the catheter and injected diluted contrast through the side port of the sheath, which revealed a large perforation with extravasation of contrast in the surrounding tissue. We downsized the diagnostic catheter to a 4 Fr JL4 and then a 4 Fr JR4 diagnostic catheter (Cordis Corp., Miami Lakes, Florida) and negotiated them over the 0.035 inch standard guidewire. After successful completion of a diagnostic coronary angiogram, we performed a pull-back angiogram which revealed a sealed perforated segment. The patient was discharged the next day with patent radial pulsation and a mild forearm hematoma. Follow-up vascular Doppler examination after 1 month revealed a patent RBS. Discussion The TRA for diagnostic and interventional procedures is gaining popularity in view of data supporting its superior safety in terms of access-site complications.2,3,5,9,10 Perforation of the RBS is a rare complication, with the reported incidence of From *Total Cardiovascular Solutions Private Limited, Ahmedabad, India, the §Department of Cardiology, St. Vincents Catholic Medical Center of New York, New York, and the £Department of Cardiology, Mercy Hospital and Community Medical Center, Scranton, Pennsylvania. The authors report no conflicts of interest regarding the content herein. Manuscript submitted June 19, 2009, provisional acceptance given July 6, 2009, final version accepted July 28, 2009. Address for correspondence: Tejas Patel, MD, FACC, FSCAI, FESC, Professor and Head, Department of Cardiology, Sheth V.S. General Hospital, Ahmedabad-380 006, India. E-mail: tejaspatel@tcvsgroup.org

1. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3–7.

2. Kiemeneij F. Laarman GJ, Odekerken D, et al. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: The ACCESS study. J Am Coll Cardiol 1997;29:1269–1275.

3. 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;44:349–356.

4. Cooper CJ, EI-Shiekh RA, Blaesng LD, et al. Patient preference for cardiac catheterization via the transfemoral approach. J Am Coll Cardiol 1997;29(Suppl A):310A.

5. Hilldick-Smith D, Lowe MD, Walsh JT, et al. Coronary angiography from the radial artery: Experience, complications and limitations. Int J Cardiol 1998;6:233–239.

6. Calvino Santos RA, Vazquez-Rodriguez JM, Salgado-Fernandez J, et al. Management of iatrogenic radial artery perforation. Catheter Cardiovasc Interv 2004;61:74–78.

7. Sanmartin M, Cuevas D, Goicolea J, et al. Vascular complications associated with radial artery access for cardiac catheterization. Revista Espanola de Cardiologia 2004:57:581–584.

8. Yoo BS, Lee HH, Yoon J, et al. The study of branching anomaly and tortuosity of radial artery for transradial coronary procedure. Korean Circ J 2000;30:82–89.

9. Bazemore E, Mann JT. Problems and complications of the transradial approach for coronary intervention: A review. J Invasive Cardiol 2005;17:156–159.

10. Patel T, Shah S, Ranjan A. Radial region: Addressing the issues. In: Patel’s Atlas of Transradial Interventions: The Basics. Seattle: Sea Script Company, 2007, pp.61–102.