Radial Artery Pseudoaneurysm Rupture After Cardiac Catheterization

A 73-year-old man with history significant for paroxysmal atrial fibrillation on apixaban underwent percutaneous coronary intervention (PCI) of the left anterior descending artery via transradial access.  The patient was discharged on clopidogrel, atorvastatin, carvedilol, isosorbide mononitrate, losartan, and apixaban. Ten days later, the patient presented with swelling in the right hand, wrist, and forearm (Figure 1). Doppler arterial ultrasound (US) showed an outpouching measuring 3.9 cm x 2.8 cm in the distal radial artery with a neck measuring 2 mm (Video). A radial artery pseudoaneurysm (PSA) was diagnosed. Before the surgical team could intervene, the PSA ruptured (Figure 2). Computed tomographic angiogram (CTA) with contrast showed 1.5 cm x 1.5 cm PSA with contrast extravasation laterally and into the dorsal soft tissues of the wrist/distal forearm consistent with hematoma and PSA rupture (Figure 3A, B). The patient underwent successful evacuation of hematoma and reconstruction of the radial artery.

The incidence of radial artery PSA is less than 0.1%. When present, the radial PSA is generally pulsatile and surrounded by a fibrous sac. In most cases, this complication can be prevented by applying firm and prolonged compression of the puncture site with a TR Band (Terumo), especially in patients taking oral anticoagulants. No standard management guidelines exist. Manual or US-guided compression is prone to failure in the presence of anticoagulation. US-guided thrombin injection increases the risk of arterial embolization and peripheral thrombosis of the affected limb. Surgical management is recommended for large (>3 cm), symptomatic, expanding, infected, or subacute pseudoaneurysms after initial conservative management has failed. Endoluminal management, including embolization and covered stents, has been used for repair, but research is limited to case reports.

Affiliations and Disclosures

From the ¹Department of Internal Medicine, LSU Health Shreveport, Louisiana, USA; ²Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA; ³Banner Desert Medical Center, Mesa, Arizona, USA.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Pramod Kumar Ponna, MD, Department of Internal Medicine, LSU Health Shreveport, LA, USA. Email: Pramodponna4@gmail.com