Treatment of Radial Artery Pseudoaneurysm Using a Novel Compression Device

   ABSTRACT: Radial artery pseudoaneurysm is an extremely rare complication associated with transradial catheterization. We report 2 cases of pseudoaneurysm of the radial artery that were successfully treated using the Terumo TR band. We believe that the safety, efficiency, speed and minimal invasiveness of this method make it feasible for use as a treatment for peripheral pseudoaneurysm in such patients. J INVASIVE CARDIOL 2010;22:293–295    The transradial approach for coronary angiography and interventions has become increasingly popular as an attractive alternative to the femoral approach because of its clinical benefits. Pseudoaneurysm (PA) of the radial artery is an extremely rare complication associated with this procedure and is most often localized in the area of penetrating vascular trauma. Current methods of treatment for radial artery PA are adopted from those of femoral artery PA, including ultrasound-guided compression, percutaneous thrombin injection and surgical repair.¹ We propose the use of a novel compression device specifically designed for radial artery hemostasis called the TR Band (Terumo^®, Tokyo, Japan) as a safe and effective modality for the treatment of radial artery PA. We present 2 cases of radial artery PA after transradial catheterization, both resolved by using the TR Band. To our knowledge, this has not been previously reported among conservative treatment approaches to the management of radial artery PA.    Case 1. A 62-year-old male underwent a cardiac catheterization via the right radial access for chest pain. He had a history of rheumatic heart disease, status post mechanical mitral valve replacement and was on warfarin therapy for atrial fibrillation. Over the subsequent 3 weeks, he developed pulsatile and painful swelling over the right wrist without circulatory or neurological compromise. The patient was already restarted on warfarin with a quantitative international normalized ratio (INR) of 2.5. Physical examination revealed an erythematous prominence over the volar aspect of his right distal wrist measuring 2 x 2 cm (Figure 1A). A duplex ultrasound examination was performed which demonstrated a PA with to-and- fro laminar flow at the neck region (Figure 2A). Spectral Doppler imaging at the inflow tract revealed a high-velocity flow of > 1.2 m/sec with aliasing, which is decreased with compression using the ultra- sound probe. A TR Band was placed over the patient’s right wrist above the PA and instilled with 10 cc of air (Figure 1B), with a palpable distal radial pulse. The patient wore this compression device for approximately 8 hours. Upon removal of the TR Band and inspection of his wrist, the prominence appeared to be smaller in size and felt firm on palpation. A repeat ultrasound scan of the right wrist showed persistent presence of the PA, however there was no flow at the neck of the PA. A light pressure bandage was applied to the wrist thereafter. The patient was instructed to temporarily hold his warfarin therapy and instead take aspirin. At 2-week follow up, the PA appeared to have tremendously reduced in size by physical and ultrasound examinations. On this visit, the patient was told to restart his warfarin therapy. At 4-week follow up, there was complete resolution of the PA by duplex ultrasound and only a superficial cutaneous discoloration remained where the prominence was prior (Figures 1C and 2B).    Case 2. An 83-year-old female developed a painless, pulsatile bulge on her right wrist 2 weeks after transradial catheterization. She had a history of hypertension and was on warfarin therapy for permanent atrial fibrillation. The patient denied any weakness or paresthesia of her right hand. The INR was measured to be subtherapeutic at 1.8. On physical examination, there was a small circular mass with erythema located on the dorsal aspect of the right carpal wrist (Figure 3A). Distal to the mass, the radial artery pulse was strong and palpable, with a negative Allen’s test for arterial insufficiency to the palm. Color Doppler imaging showed an approximately 1 x 1 cm PA with laminar flow entering and exiting the PA via a small radial artery communication. Spectral Doppler imaging revealed a classic to-and-fro waveform within the neck, which is considered pathognomonic for a PA (Figure 4A). A TR Band that was distilled with 12 cc of air for approximately 6 hours was applied to the right wrist. Afterwards, the mass diminished in size and felt rigid on palpation. The patient was advised to hold warfarin and to take aspirin in the interim. Serial ultrasound scans of the right wrist at 2-week and 4- week follow up showed gradual resolution of the PA (Figure 4B). The patient was initiated back on warfarin and her wrist returned to its baseline appearance (Figure 3B).

Discussion

   Transradial artery catheterization remains underutilized in the United States despite globally lower rates of complications compared to the standard transfemoral approach. According to a recent meta-analysis, major access-site complications occur in 0.3% of radial cases compared to 2.8% of femoral cases.² One type of complication associated with the transradial approach is radial artery occlusion, which has an incidence of 3–10% and usually has no clinical sequelae due to collateral circulation from the ulnar artery.    A relatively rare occurrence is the formation of radial artery PA which is caused by disruption and injury of the arterial wall during cannulation with resultant hemorrhage and hematoma. These vascular lesions are associated with multiple puncture attempts, catheter infection and the use of larger sheath sizes. Anticoagulation therapy may also be a predisposing factor, since there is literature noting a significant number of patients on anticoagulation who develop a PA, and both of our index patients were on warfarin therapy.³ The development of such PA occurs in a matter of hours after the catheterization, but is only observed days to months (7–40 days) later. Early diagnosis and treatment of the false aneurysm is essential to maintain adequate circulation of the hand and to minimize any further complications such as spontaneous rupture, hand ischemia (especially if the radial artery is dominant) and compartment syndrome. Preventive measures should always be employed to reduce the occurrence of PA formation as well as other vascular complications including meticulous sterile preparation, avoidance of multiple punctures at the same site, use of Seldinger technique, gentle manipulation of equipment in the artery and use of guided compression for hemostasis post procedure.⁴    The traditional management of PA includes ultrasound- guided compression, percutaneous thrombin injection and surgical repair. Currently, there is no endovascular therapeutic option for PA treatment. Ultrasound-guided compression gained widespread acceptance when it was first introduced in 1991 for the treatment of femoral PA due to its safety and efficacy. Direct compression at the neck of the PA using a transducer probe causes stasis of blood and promotes coagulation and occlusion internally within the PA. Unfortunately, this procedure needs to be repeated if flow is still present at the inflow tract after 10-minute intervals, during which time the patient may experience extreme discomfort from prolonged compression. Furthermore, the failure rate is extremely high and ultra-sound guided compression is costly in terms of workload for medical staff, use of sophisticated technical equipment and total procedure time.⁵    An alternative method for the treatment of PA with a higher success rate and immediate response is percutaneous thrombin injection, which entails the injection of thrombin percutaneously into the sac of the PA under direct sonographic visualization.    There is a risk involved with this procedure where thrombin can escape from the PA and embolize to the distal vasculature causing thrombosis of branch vessels, extremity paresthesia or pain and skin necrosis. The combined maneuver of pressurizing the PA and releasing at the time of thrombin injection may raise the margin of safety, as reported by Pozniak et al.⁶    The usual surgical approach involves excision of the PA and/or ligation of the radial artery. The radial artery can be safely sacrificed, as this has been shown in studies on lacerations of the wrist arteries and radial artery harvesting for coronary artery bypass graft surgery (CABG).^7,8 Vascular reconstruction should be reserved for complicated or ruptured PA, failed conservative management or critical hand ischemia with potential limb loss.    Our review of the literature did not reveal any prior cases of radial artery PA successfully treated with the TR Band, which was originally developed as a compression device to assist hemostasis of the radial artery after a transradial procedure. The device has a transparentplate that is positioned over the PA and secured via a Velcro strap. The inflator syringe permits accurate pressure adjustment as air is injected into the side port which inflates the compression balloon overlaying the PA. The application of an occlusive bandage such as a TR Band and waiting for spontaneous healing during a wait-and-see period was a successful treatment strategy for our 2 patients with small-to-moderate-sized PAs. Therefore, we believe that this would be of great interest as a promising nonoperative approach due to its simplicity and effectiveness.

Conclusion

   The transradial approach is considered a safe and effective alternative to transfemoral catheterization despite the possible rare complication of PA. Nonoperative management of uncomplicated PA of the radial artery is a safe and valuable treatment strategy that may be useful, especially in patients who are on anticoagulation therapy. The TR Band provides a simple, minimally invasive and cost-effective method that may be the first line of treatment for patients with small-to-moderate-sized radial artery PAs.

_________________________________________________ From the Division of Cardiology, Department of Medicine, Beth Israel Medical Center, New York, New York. The authors report no conflicts of interest regarding the content herein. Manuscript submitted December 23, 2009, provisional acceptance given January 18, 2010, final version accepted January 25, 2010. Address for correspondence: Michael Liou, MD, Chinatown Cardiology, P.C., 41 Elizabeth Street, Suite 601, New York, NY 10016. E-mail: mclv66@yahoo.com

1. Morgan R, Belli AM. Current treatment methods for postcatheterization pseudoa- neurysms. J Vasc Interv Radiol 2003;14:697–710.
2. AgostoniP,Biondi-ZoccaiGG,deBenedictisML,etal.Radialversusfemoralapproach for percutaneous coronary diagnostic and interventional procedures: Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–356.
3. Kang SS, Labropoulos N, Mansour MA, et al. Expanded indications for ultra- sound-guided thrombin injection of pseudoaneurysms. J Vasc Surg 2000;31:289–298.
4. Pancholy D, Coppola J, Patel T, Roke-Thomas M. PROPHET trial: A randomized comparison of traditional versus patency documented hemostasis after transradial catheteriztion. Catheter Cardiovasc Interv 2008;72:335–340.
5. Schaub F, Theiss W, Busch R, et al. Management of 219 consecutive cases of post- catheterization pseudoaneurysm. J Am Coll Cardiol 1997;30:670–675.
6. Pozniak M, Mitchell C, Ledwidge M. Radial artery pseudoaneurysm: A maneuver to decrease the risk of thrombin therapy. J Ultrasound Medicine 2005;24:119–122.
7. Johnson M, Ford M, Johansen K. Radial or ulnar artery laceration. Repair or ligate? Arch Surg 1993;128:971–975.
8. Starnes SL, Wolk SW, Lampman RM, et al. Noninvasive evaluation of hand cir- culation before radial artery harvest for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1999;117:261–266.