Radial Artery Perforation During Transradial Catheterization Managed with a Coronary Polytetrafluoroethylene-Covered Stent Graft

Abstract: A 69-year-old man underwent transradial catheterization (TRC) with successful percutaneous coronary intervention (PCI), but developed a radial artery perforation. Guiding catheter re-positioning and prolonged balloon inflation were unable to provide hemostasis. Successful reconstruction of the perforated vessel required the unconventional and novel use of a coronary polytetrafluoroethylene-covered stent graft. 

J INVASIVE CARDIOL 2012;24(4):185-187

Key words: radial artery perforation, radial artery complications, radial artery access

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Case Report

A 69-year-old man with a history of hypertension, type 2 diabetes mellitus, hyperlipidemia, former tobacco use, and known coronary artery disease treated with multiple percutaneous coronary interventions (PCI) with drug-eluting stents (DES) presented with Canadian Class III anginal symptoms. He underwent elective coronary angiography. Right radial access (RRA) was obtained uneventfully using angiocath access with a 6 Fr sheath. Immediately after sheath insertion, a standard regimen of verapamil, nitroglycerin, and heparin was begun, and a 6 Fr radial-specific diagnostic catheter (Tiger catheter, 6 Fr, 100 cm length; Terumo Medical Corporation) was guided to the ascending aorta by an angled tip hydrophilic wire (Stiff Angled Glidewire, 0.35 cm diameter, 145 cm length; Terumo Medical Corporation). Left coronary artery injection revealed in-segment restenoses of the proximal and mid portions of the left anterior descending artery (LAD), as well as severe obstructive disease  at the origin of the first obtuse marginal branch (OM1) of the left circumflex artery (LCX) and ramus intermedius artery (RI) (Figure 1). The right coronary artery demonstrated mild diffuse disease throughout. He underwent PCI of the mid LAD, RI, and OM1 vessels. The diagnostic catheter was exchanged for a guiding catheter (Mach 1 FCL 3.5, 6 Fr; Boston Scientific) over a 300-cm long, 0.035-cm diameter J-tip wire. Adjunctive anticoagulation therapy was administered with a standard, weight-based bivalirudin bolus and infusion, and  prasugrel was given orally. Activated clotting time was 352 seconds at 5 minutes after bivalirudin injection. Successful PCI was performed with deployment of a DES in the RI and percutaneous transluminal coronary angioplasty (PTCA) of the OM1 and LAD lesions.    

The patient developed pain in the volar aspect of his right arm soon after the guiding catheter was advanced over the J-tip wire. Progressive expansion of a hematoma was noted, and after successful PCI, a peripheral angiogram was performed of the right radial artery, demonstrating a perforation with persistent contrast dye extravasation and soft tissue staining (Figure 2). The bivalirudin infusion was immediately stopped and prolonged balloon inflation using a semi-compliant coronary balloon (Trek, 4.00 mm diameter, 15 mm length; Abbott Vascular) was undertaken at 8 atm of pressure for 500 seconds (Figure 3). Despite these measures, persistent extravasation of dye was noted, along with arm pain and hematoma expansion. A coronary polytetrafluoroethylene (PTFE)-covered stent graft (JoStent Graftmaster, 4.00 mm diameter, 19 mm length; Abbott Vascular) was placed at the site of the radial artery perforation to obtain hemostasis (Figure 4). Following successful deployment of the covered stent graft at the site of the radial artery perforation, no extravasation of contrast dye was noted. The patient was admitted to the coronary care unit and monitored for the development of compartment syndrome. At 2 week follow-up, the hematoma had resolved. 

Discussion

Transradial catheterization (TRC) has demonstrated  a lower incidence of major access-site related complications when compared to the traditional transfemoral approach.¹ While a meta-analysis recently showed a decrease in major bleeding with TRC,¹ randomized controlled trials have individually demonstrated discrepancies regarding outcomes^3,4 and the preferred access site for angiography remains unsettled. Transradial catheterization does, however, allow for early ambulation and may potentially shorten hospital length of stay.¹

Radial artery perforation is an uncommon complication of TRC, occurring in between 0.1%-1% of all patients undergoing radial access-site procedures.^5,6 While rare, radial artery perforation can lead to compartment syndrome, with severe neurovascular compromise. Calvino-Santos et al reported female gender, height, and vessel tortuosity as risk factors for perforation.⁵ When faced with perforation, operators often use a bail-out strategy, abandoning the radial approach and converting to the transfemoral approach. However, continuing the procedure either with the use of a long sheath,⁵ prolonged balloon inflation,⁷ or a guiding catheter^8,9 can often salvage the radial access site, and lead to successful completion of PCI. Local tamponade by external compression or internal hemostasis using a catheter is frequently successful in sealing the perforation. In our case, neither use of the guiding catheter nor prolonged balloon inflation led to successful hemostasis. Unconventional use of a PTFE-covered stent graft led to successful reconstruction of the radial artery, though attempts at prolonged internal tamponade may have proven to be successful. To our knowledge, this represents the second time in the literature whereby a coronary PTFE-covered stent graft was used successfully in treating radial perforation in the setting of TRC or PCI.¹⁰ Given the success of this treatment approach, TRC operators should consider the use of a covered stent in the treatment algorithm of patients with radial artery perforation not responsive to the more conventional techniques of catheter tamponade or prolonged balloon occlusion (Figure 5).

Conclusion

While uncommon, radial artery perforation can occur during transradial catheterization. While conservative management with a long sheath, guide catheter repositioning, and prolonged balloon inflation may be helpful in the treatment of radial perforation, use of a PTFE-covered stent graft is a novel and effective therapeutic option and should be considered in cases refractory to conservative therapy.

References

1. Agostoni P, Biondi-Zoccai GL, Benedictis LD, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures. J Am Coll Cardiol. 2004;44(2):349-354.
2. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157(2):132-140.
3. Brueck M, Bandorski D, Kramer W, Wieczorek M, Holtgen R, Tillmanns H. A randomized comparison of transradial versus transfemoral approach for coronary angiography and angioplasty. JACC Cardiovasc Interv. 2009;2(11):1047-1054.
4. Jolly SS, Yusuf S, Cairns J, et al; the RIVAL trial group. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;307:1409-1420. Epub 2011 Apr 4.
5. Calvino-Santos RA, Vasquez-Rodriguez JM, Salgado-Fernandez J, et al. Management of iatrogenic radial artery perforation. Catheter Cardiovasc Interv. 2004;61(1):74-78.
6. Sanmartin M, Cuevas D, Goicolea J, Ruiz-Salmeron R, Gomez M, Argibay V. Vascular complications associated with radial artery access for cardiac cathterization. Rev Esp Cardiol. 2004;57(6):581-584.
7. Rigatelli G, Dell’Avvocata F, Ronco F, Doganov A. Successful coronary angioplasty via the radial approach after sealing a radial perforation. JACC Cardiovasc Interv. 2009;2(11):1158-1159.
8. Gunasekaran S, Cherukupalli R. Radial artery perforation and its management during PCI. J Invasive Cardiol. 2009;21(2):E24-E26.
9. 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;10(10):544-547.
10. Sallam MM, Ali M, Al-Sekaiti R. Management of radial artery perforation complicating coronary intervention: a stepwise approach. J Interv Cardiol. 2011 May 3 [Epub ahead of print].

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From Mount Sinai Heart, Mount Sinai Hospital, New York, New York.
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 November 29, 2011, provisional acceptance given December 13, 2011, final version accepted January 16, 2012.
Address for correspondence: Rajeev L. Narayan, MD, Mount Sinai Heart, Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY 10029. Email: Rajeev.Narayan@mountsinai.org