TRANSRADIAL COMPLICATIONS Tift Mann, MD, FSCAI

Transcription

1 Disclosure Information TRANSRADIAL COMPLICATIONS Tift Mann, MD, FSCAI The following relationships exist related to this presentation: Terumo Boston Scientific Abbott Medicines Co consultant research support research support consultant Off label use of products will not be discussed in this presentation.

2 TRANSRADIAL ACCESS SITE COMPLICATIONS ACCESS Radial artery spasm Radial artery occlusion Nonocclusive arterial injury Pseudoaneurysm AV malformation Aseptic granulom Radial a eversion/avulsion ARM/FOREARM Midforearm hematoma Persistent pain sx Compartment sx SHOULDER Vascular hematoma RLN palsy

3 Radial vasospasm is by far the most common complication It is usually preventable or certainly minimized by Adequate sedation/analgesia Conscious decision re catheter size IA vasodilator(s)

4 Verapamil has substantially reduced the vasospasm problem Before After

5 Verapamil 3mg in 10 ml saline

6 Radial artery IVUS

7 EFFECT OF SL NTG & IA VERAPAMIL On Mean Arterial Pressure (MAP) and HR * MAP HR * p < 0.01 Control NTG1 NTG3 NTG5 V1 V3 V5

8 Spasm: Repeat verapamil dose

9 Pseudospasm(kinking) d/t guidewire

10 Radial occlusion

11 Radial occlusion is usually silent

12 Plesmography: Reverse Allen Test

13 2mo radial occlusion 100 Heparin must be administered for all transradial procedures 80 71% % 4% No Heparin UFH UFH 5000 Spaulding et al CCVD 39:365 (1996)

14 Factors in Radial Occlusion 1. Vasopasm 2. Inadequate anticoagulation 3. Prolonged occlusive pressure 4. Radial Artery damage Access Prolonged cannulation Sheath-to-artery ratio > 1 Excessive compression pressure

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16 Nonocclusive compression: Patent hemostasis

17 Pancholy et al, CCVI 73:205, 2008

18 Pneumatic Compression guided by MAP Cubero et al, CCVI 73:467, 2009

19 Force of Compression TR Band Group A Group B (n=176) (n=175) P MAP (mm Hg) 98 ± 15 95± 18 NS Pressure exerted (mm Hg) 102 ± ± cc of Air 9 ± 2 15 ± Compression time (min) NS Radial occlusion (%) 2 (1) 21(12) Cubero et al, CCVI 73:467, 2009

20 Radial occlusion Transradial procedures should be performed with smallest possible catheter Sheath Size Saito et al, CCVI 46: 173, 1999 Nagai et al, AJC 83: 180, 1999

21 Nonocclusive radial artery injury

22 Postprocedure radial vasoreactivity % change in doppler arterial diameter before and after 0.4 mg NTG and 4min ischemia(edv) * Sanmartin et al J Invas Card 2004; 16:635 *Heiss et al JACC Intv 2009; 2; 1067

23 OCT: Acute RA injury after TRI Yonetsu et al, European Heart Journal, 2010

24 Incidence of radial failure directly related to the number of previous procedures Sakai et al CCVI 54: (2001)

25 Radial artery ultrasound: RA diameter is smaller in repeat procedures Yoo et al CCVI 58:301, 2003

26 Intravascular Ultrasound Distal radial artery REPEAT TRI (n=52) FIRST TRI (n=48) p value Minimal lumen diameter,mm 2.23± ±0.32 <0.01 Intima-media thickness,mm 0.46± ±0.07 <0.01 Adapted from WAYKEYAMA ET AL

27 Repeat procedure: intimal hyperplasia from previous sheath

28 ./ Bilateral OCT: Right and Left RA from the same patient Right radial artery (Repeat TRI) Left radial artery (First TRI) 5 cm from the puncture site 5 cm from the puncture site Yonetsu et al, European Heart Journal, 2010

29 Focus: Prevention of Radial A injury Liberal use of IA verapamil to prevent spasm Shorter sheaths 5F(?4F) catheters for all dx procedures Conscious decision re guide catheter diameter based on PCI complexity and RA diameter 5F guide for straightforward PCI, esp women Sheathless guide technique

30 Midforearm hematoma

31 Radial artery sidebranches

32 Perforation of sidebranch

33 Radial Loop: RADIAL RECURRENT ARTERY

34 Avulsion of radial recurrent artey

35 Dissection of Radial Artery artery

36 Midforearm Hematoma: recognize, BP cuff, elastic bandage

37 Persistent forearm pain syndrome Radial a may be patent or occluded but hand not ischemic? Arteritis- nonoccl thrombus? Myositis- sidebranch hemorrhage/thrombosis Responds to warm compresses, NSAID, time, steroids infreqently required

38 With recognition and early management of these unique problems, major transradial complications are rare

39 Radial perforation: complete the procedure! Patel et al. JCI 21:544, 2009

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41 Vascular Dysfunction Depends on Number of Catheters and Smoking Status Heiss, C. et al. J Am Coll Cardiol Intv 2009;2: Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.

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43 Radial artery spasm: note high brachial a bifurcation

44 TRANSRADIAL COMPLICATIONS Tift Mann, MD Raleigh, NC

45 YOUR FIRST CATH LAB LESSON: DON T FORCE IT!!! Also, use a short, hydrophlic-coated sheath and repeat verapamil doses

46 Radial Pseudoaneurysm

47 Doppler Ultrasound of right upper extremity:0.25*0.25 cm pseudo aneurysm with a 0.25 cm neck width.

48 Symptomatic Radial occlusion

49 PTCA using antegrade brachial access

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