Hemorrhagic Epidermal Bullae Following Transradial Percutaneous Coronary Intervention

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00302. Epub November 15, 2024.

A 77-year-old man presented with a non-ST segment elevation myocardial infarction (NSTEMI) and underwent successful percutaneous coronary intervention (PCI) of the mid-left anterior descending artery via right radial access with placement of a drug-eluting stent. Patent hemostasis was achieved using a TR Band (Terumo), but mild distal forearm swelling developed shortly after (Figure A). Upon removal of the TR Band, diffuse ecchymosis and hemorrhagic bullae were observed on the volar forearm (Figure B, C). Ultrasound of the radial artery showed no evidence of vessel occlusion, hematoma or pseudoaneurysm. The vascular surgery team was promptly consulted and ruled out compartment syndrome or hand ischemia. In the absence of indications for urgent surgical intervention, conservative management with serial examinations was advised. The dermatology team was subsequently consulted and concurred with continued conservative management.  The patient was treated with compression wraps, arm elevation, and ice packs, with gradual improvement in both swelling and bullae (Figure D, E). He was discharged home on dual antiplatelet therapy the following day and complete resolution was noted on outpatient follow-up 4 weeks later (Figure F).

While access-related complications from transradial PCI are not infrequent, they typically involve a spectrum of vascular issues ranging from bleeding, perforation, and compartment syndrome to radial artery spasm, occlusion, pseudoaneurysm, and arterio-venous fistula formation.The development of hemorrhagic epidermal bullae following transradial PCI is an extremely rare phenomenon. These blood-filled blisters may result from prolonged radial compression device use, acantholysis from epidermis adhesions to the TR Band on deflation, or an allergic reaction to the TR Band's polyvinyl chloride material. In our case, we suspect that pre-existing vascular congestion likely increased the local pressure causing tissue damage, separation of the skin layers, and vessel rupture with resultant hemorrhagic bullae formation. As described, conservative management typically yields excellent results, but early surgical consultation is crucial to rule out complications like infection or dermal necrosis.

Affiliations and Disclosures

Ammar A. Hasnie, MD; Nakeya Dewaswala, MD; Amartya Kundu, MD

From The Gill Heart & Vascular Institute, Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.

Disclosures: There are no relevant disclosures or conflicts of interest in relation to this work.

Consent statement: The authors confirm that informed consent was obtained from the patient for the study and/or interventions described in the manuscript and to the publication of their data.

Address for correspondence: Amartya Kundu, MD, Division of Cardiovascular Medicine, University of Kentucky, 900 S. Limestone Avenue, 326F Wethington Building, Lexington, KY 40536-0200, USA. Email: amartya.kundu@uky.edu; X: @AmartyaKundu_MD