TransRadial Coronary Intervention (TRI)–related complications: How to prevent?

Sang-Yong Yoo, M.D.Department of CardiologyUlsan college of MedicineGangneung Asan Hospital

Incidence of Radial artery complications Meta-analysis of 12 randomized trials (1989 ~ 2003)

◦0.3% vs. 2.8% (transradial vs. transfemoral)◦ 1 arteriovenous fistula◦ 1 perforation of brachial artery requiring surgery ◦ 1 hematoma >3cm◦ 2 others

Agostoni P, et al. JACC 2004;44:349-56

Incidence of Radial artery complications Randomized trial (2006 ~ 2008)

◦ First randomized trials (n=1,124) comparing access site complications after coronary procedures via transradial versus transfemoral access with a closure devices.

◦0.58% (3 patients in 512) vs. 3.71% (transradial vs. transfemoral) No beating radial artery pulse without forearm ischemia

Brueck M, et al. JACC 2009;2:1047-54

Transradial complications Vagal reactions Radial artery spasm Radial artery occlusion Bleeding/Dissection/Perforation Radial artery fistula Pseudoaneurysm Chronic pain/neuralgia Cerebral embolism Others

Pain/Vagal reactions During sheath insertion, procedural

hypotension requiring treatment with atropine occurs frequently.

Hildick-Smith DJ, et al. Int J Cardiol 1998;64:231.

May be exacerbated by verapamil.

Decreasing pain and anxiety

Kim JY J Invasive Cardiol 2007;19:6-9.

Between 1 to 3 hours before the start of a proce-dure

A eutectic mixture of local anesthetic

(EMLA) cream (lidocaine 2.5% and prilocaine

2.5%)

가격 : 수가 6,000 원 , 보험상한 3,960 원

Incidence of Radial artery spasm (RAS)22% (8% on med.) - Kiemeneij F,

et al(N=100)

(CCI 2003;58:281–284)

22.2% - The SPAMS study(N=1,219)

(CCI 2006;68:231-235)

Fukuda, et al diagnosed RAS through radial artery angiography and found that RAS occurred in most patients through transradial approach. (Jpn Heart J 2004; 45: 723-731)

Incidence of Radial artery spasm

Risk factors for Radial artery spasmThe SPASM study found that young and

female were the independent predictors of RAS.

(Catheter Cardiovasc Interv 2006; 68: 231)Saito et al found that the inner diameter of

radial artery was an independent predictor of RAS.

(Catheter Cardiovasc Interv 1999; 46: 173)In vitro studies showed that patients with

diabetes had serious endothelial dysfunction and the radial artery was prone to spasm.

(J Am Coll Cardiol 2007; 50:1047)

Risk factors for Radial artery spasm

Prevention of RASSingle punctureKiemeneij F pointed out, a

straightforward, accurate, single puncture will lower the risk of spasm.

(J Invasive Cardiol 2006;18:159.)In the introduction of Turkey

experience, Vefali and Arslan deemed that the best measure to prevent RAS was the least number of access attempts.

(Turk Kardiyol Dern Ars 2008;36:163.)

Prevention of RASAntispasmodics

Nitroglycerin+Verapamil

Nitroglycerin None0%

5%

10%

15%

20%

25%

3.8% 4.4%

20.4%

Radial artery spasm

p=0.804

p=0.003

p=0.001

Chen CW Cardiology 2006;105:43-47.

Prevention of RAS”Cocktail”

Cocktail No cocktail0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.53

0.76000000000000

1

“Cocktail”= 200ug Nitroglycerin+ 5mg Verapamil

Kiemeneij F CCI 2003;58:281-284.

Max

imal

pul

lbac

k fo

rce

(Kg)

Prevention of RASVerapamil, Molsidomine

Catheter Cardivasc Interv 2006;68:231-235.

Prevention of RASHydrophilic-coated sheath

n=783

Short sheath (13cm)

Hy-drophilic coated

Uncoated

Long sheath (23cm)

Hy-drophilic coated

Uncoated

Hydrophilic-coated

Uncoated0%5%

10%15%20%25%30%35%40%45%

19.0%

39.9%

Radial artery spasm

Rathore JACC Cardiovasc interv 2010;3:475-83.

OR 2.87; 95% CI 2.07-3.97, p<0.001)

Prevention of RASOthersSmaller catheterRestricting catheter maneuvers

and exchangesUse an exchange length

hydrophilic guidewire that is maintained in a stable position in the ascending aorta to prevent spasm at radial or brachial artery.

Extraction of the radial artery

58/F 6 Fr sheath 500 ug nitroglycerin

Resistant radial artery spasmEven after the

use of a vasodilator, RAS has been reported in up to 20% of the patients (Kim Sh et al. Int J Cardiol 2007; 120: 325).

Ana do lu Kar di yol Derg 2010;10:90

Incidence and Risk factors for Radial artery occlusionIncidence

◦2~10%

Prolonged cannulation

Sheath size Anticoagulation Hemostasis

Youakim S. Occupational Medicine 2006;56:507

Prevention of acute radial occlusionHeparinless than 3,000

U◦ female◦ radial artery

diameter (<2.7mm)

No predictive factor of radial occlusion in patients receiving 5,000 U of heparin.

0 2~3,000 5,0000%

10%20%30%40%50%60%70%80% 71%

24%

4%

Post-procedural radial artery oc-clusion (2 months)

Dose of heparin (U)

Spaulding C, et al. Cathet Cardiovasc Diag 1996;36:365

p<0.05

p<0.05

Acute radial artery occlusionSheath size

4, 5Fr 6 Fr 7, 8Fr0%

1%

2%

3%

4%

5%

6%

7%

8%

3.5%

4.9%

7.5%

OcclusionSaito, et al. CCVI 1999;46:173/Nagai et al, AJC 1999;83:180

Late (95 days) radial artery occlusionRisk factors

◦ Radial artery diameter

◦ Difference in radial artery diameter and sheath size

◦ Diabetes mellitus

Nagai et al. AJC 1999;83:180

38% vs. 14% (p=0.0006)

Radial artery occlusionRepeat procedure

First TRI Repeat PCI P

Lumen area (mm2)

5.27 ± 1.21 4.5 ± 0.99 <0.0

1Intima-media thickness (mm)

0.31 ± 0.07

0.46 ± 0.10 <0.0

1

MLD (mm) 2.43 ± 0.32

2.23 ± 0.26

<0.01

Yoo BS, et al. CCVI 2003;58:301

a = Cross-over to femoral arteryb = p<0.05

Distal radial artery (5~25mm)

Wakeyama et al. JACC 2003;42:1109

Treatment of symptomatic radial artery thrombosisSmall pilot study

◦ not randomized, double-blinded design

◦ symptomatic occlusion – LMWH 4 weeks

◦ asymptomatic occlusion – no treatment

LMWH None0%

10%20%30%40%50%60%70%80%90%

100%86.7%

19.1%

Zankl AR et al. Clin Res Cardiol 2010;99:841Modified from Kim KS, et al. J Cardiovasc Ultrasound 2010;18:31

Pa-

tenc

y

Allen’s testShows Intact Palmar Arch

On the basis of the modified Allen’s test ≤ 9 seconds criteria, 6.3% of patients were excluded from TRI

PL and OX type A,B, and C, only

1.5% of patients were excluded.

Barbeau GR, et al. Am Heart J 2004;147:489

Edgar V. N. Allen (1900-1961)Professor of Medicine at the Mayor Clinic.

But, an abnormal Allen’s test has never been predictive of ischemic injury from an arterial line. (J Trauma 2006;206:468.)

Wallach SG. Am J Critical Care 2004;13:315

Hemostasis technique

EarlyPersistent (30

days)

0%2%4%6%8%

10%12%

5.0%

1.8%

12.0%

7.0%

Incidence of Radial Occlusion

Perfused HemostasisTraditional Hemostasis

Pancholy S, et al. CCI 2008;72:335

Preserve long term radial function by maintaining distal perfusion during hemostasis

p<0.05p<0.05

Root of Most Problems Abundant forearm

branches Anatomical variations

Luz A, et al. Eurointervention 2009;5:1

Radial artery anomaly and procedural outcome

Types of radial anomaly and their rates of procedural failure7% 2.3% 2.0% 2.5%

Lo TS, et al. Heart 2009;95:410

Radial loop andRadial recurrent artery

Avulsion of radial recurrent artery

Causes of bleeding/perforationOverzealous advancement of a

wireHydrophilic wires

◦useful in overcoming tortuous segment or radial loops

◦increase the risk of perforation→Wire should never be advanced

against resistance

Classification ofLocal bleedingType I: ≤ 5 cmType II: ≤ 10 cmType III: > 10 cm, but not above

elbowType IV: extending above elbowType V: anywhere with ischemic

threat of the hand (compartment syndrome)

Bertrand OF et al. 2009;157:164-9.

Compartment syndrome 0.4% (overestimated) Unrecognized perforation Unsuccessful compression Radial artery laceration during sheath insertion or

removal

Compartment syndromenot due to bleeding or hematoma

Araki T, et al. CCI 2010;75:362-365

The forearm muscles are swollen.No bleeding or hematoma is noted.

The patient’s forearm 1 hr after the transra-dial intervention. The right forearm is stiffer and more swollen than the left forearm.

The tissue pressure exceeded 100 mm Hg.

The forearm muscles are greatly swollen and partially necrosed, but hematoma or signs of hemorrhage are not noted.

we suspect that an arterial spasm in-duced by the radial sheath or catheter

resulted in ischemia of the forearm mus-

cles.

Prevention/SolutionLook under fluoroscopy during

wiring.Don’t push – push and

perforation will happen.If in doubt take a picture.Early detection!

PseudoaneurysmRare

complicationUsually the

result of inadvertent perforation of an anomalous radial artery.

Arteriovenous fistula

87/F2004 diagnostic CAG via Rt. radial artery (6 Fr.)2008 single vessel PCI via Rt. radial artery (6 Fr.)2010 Pulsatile mass

•0.3% in femoral access (Kent KC et al. J Vasc Surg 1993;17:125), N=1,838.•Radial artery AV fistula after catheterization procedures (4 cases were reported)

Case 1. 64/M Pulikal et al. Circulation 2005 Case 2. 59/M Spence et al. Can J Cardiol 2007 Case 3. 61/M Spence et al. Can J Cardiol 2007 Case 4. 67/M Kwac MS et al. Korean Cir J 2010

Sheath-related complicationsSterile abscess

with use of hydrophilic-coated sheath◦ 5% foreign body

reaction◦ 2~3 weeks after

procedure◦ Remnant of

silicone Several weeks after radial cardiac catheterization with a 6-F Cook hydrophilic sheath, a sterile abscess formed be-tween the skin and radial artery. The patient had local pain without systemic symptoms. This was treated with surgical drainage and local skin care with resolution over several weeks.

Hemostasis ComplicationsHandcuff Injuries

Tighter is not better

Chronic pain(Complex Regional Pain Syndrome: CRPS 1)

46-year old anesthesiologist

Allen’s test (-) 6 Fr, 23 cm sheath 10,000 U heparin 6 Fr pigtail catheter, 6

Fr JL4 20 hr hemostasis

(Hemaband) Over several months,

cold intolerance, burning sensation, parasthesias, and loss of pulse

Retire

Papadimos TJ, et al. Cathet Cardiovasc Interv 2002;57:537.

Dissection of arteria lusoriaSuccess rate only 60% by transradial approach

(Valsecchi O, et al.Catheter Cardiovasc Interv 2006;67:870–8.)

….the guide wire (0.035 inch; Terumo Corp., Tokyo, Japan) was

prone to advance into the descending aorta. After several attempts, the guide wire passed

into the ascending aorta. However, resistance was

encountered while advancing a pigtail catheter (5-Fr; Bard Inc., Murray Hill, NJ, USA). Stasis of

contrast medium was noted after test injection of 5 mL of contrast

medium……. J Chin Med Assoc 2009;72(7):379–381

Cerebral embolism

TransradialTransfemoral0.0%2.0%4.0%6.0%8.0%

10.0%12.0%14.0%16.0% 0.152

0

New cerebral lesion (MRI)

TCD (transcranial Doppler)◦ 92.1% gaseous◦ 7.9% solid◦ more solid microemboli

in transradial 57 vs. 36, p=0.012) in right MCA

◦ During catheter flushing, ventriculography

Lund C, et al. Eur Heart J 2009;26:1269

p=0.567

• Cautious manipulation and gentle advancement of guidewire and catheters especially aortic arch and aorto-subclavian junction• Exchange of catheters over the guidewires while leaving them in the ascending aorta.

ConclusionMeticulous technique,

appropriate preventive measures, and early recognition of problems are fundamental in avoiding unnecessary morbidity and mortality associated with these risk.

Complications arising from radial arterial access are infrequent and are usually avoidable.