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.
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
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)
Verapamil has substantially reduced the vasospasm problem Before After
Verapamil 3mg in 10 ml saline
Radial artery IVUS
EFFECT OF SL NTG & IA VERAPAMIL On Mean Arterial Pressure (MAP) and HR 100 95 90 85 80 * 75 70 65 60 55 50 MAP HR * p < 0.01 Control NTG1 NTG3 NTG5 V1 V3 V5
Spasm: Repeat verapamil dose
Pseudospasm(kinking) d/t guidewire
Radial occlusion
Radial occlusion is usually silent
Plesmography: Reverse Allen Test
2mo radial occlusion 100 Heparin must be administered for all transradial procedures 80 71% 60 40 20 0 24% 4% No Heparin UFH 2000-3000 UFH 5000 Spaulding et al CCVD 39:365 (1996)
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
Nonocclusive compression: Patent hemostasis
Pancholy et al, CCVI 73:205, 2008
Pneumatic Compression guided by MAP Cubero et al, CCVI 73:467, 2009
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 ± 18 185 ± 21 0.0001 cc of Air 9 ± 2 15 ± 0 0.0001 Compression time (min) 208 203 NS Radial occlusion (%) 2 (1) 21(12) 0.0001 Cubero et al, CCVI 73:467, 2009
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
Nonocclusive radial artery injury
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
OCT: Acute RA injury after TRI Yonetsu et al, European Heart Journal, 2010
Incidence of radial failure directly related to the number of previous procedures Sakai et al CCVI 54:204 208 (2001)
Radial artery ultrasound: RA diameter is smaller in repeat procedures Yoo et al CCVI 58:301, 2003
Intravascular Ultrasound Distal radial artery REPEAT TRI (n=52) FIRST TRI (n=48) p value Minimal lumen diameter,mm 2.23±0.26 2.43±0.32 <0.01 Intima-media thickness,mm 0.46±0.10 0.31±0.07 <0.01 Adapted from WAYKEYAMA ET AL
Repeat procedure: intimal hyperplasia from previous sheath
./ 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
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
Midforearm hematoma
Radial artery sidebranches
Perforation of sidebranch
Radial Loop: RADIAL RECURRENT ARTERY
Avulsion of radial recurrent artey
Dissection of Radial Artery artery
Midforearm Hematoma: recognize, BP cuff, elastic bandage
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
With recognition and early management of these unique problems, major transradial complications are rare
Radial perforation: complete the procedure! Patel et al. JCI 21:544, 2009
Vascular Dysfunction Depends on Number of Catheters and Smoking Status Heiss, C. et al. J Am Coll Cardiol Intv 2009;2:1067-1073 Copyright 2009 American College of Cardiology Foundation. Restrictions may apply.
Radial artery spasm: note high brachial a bifurcation
TRANSRADIAL COMPLICATIONS Tift Mann, MD Raleigh, NC
YOUR FIRST CATH LAB LESSON: DON T FORCE IT!!! Also, use a short, hydrophlic-coated sheath and repeat verapamil doses
Radial Pseudoaneurysm
Doppler Ultrasound of right upper extremity:0.25*0.25 cm pseudo aneurysm with a 0.25 cm neck width.
Symptomatic Radial occlusion
PTCA using antegrade brachial access