How Should We Approach a Radial Artery Perforation?

Disclosures: Orlando Marrero reports he works for Mercator MedSystems and is a consultant for Boston Scientific. Dr. Zaheed Tai reports the following: Terumo (proctor for transradial course), Spectranetics (proctor for laser course, speaker, advisory board member), The Medicines Company (speakers bureau). 

Orlando Marrero, RCIS, MBA, can be contacted at orlm8597@icloud.com. 

Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.

Question: What do you do when you have a radial artery perforation? Do you abort the case or go to the contralateral side or femoral approach?

Answer: Hopefully, neither. Typically, we will try and salvage the radial artery access and complete the case. The presence of the catheter/sheath will address the perforation. Following is a case example.

This is a 75-year-old male with history of diabetes and hyperglycemia. He presented to the hospital 1/28/2015 with unstable angina and subsequent positive troponins resulting in a non-ST-elevation myocardial infarction (NSTEMI). He underwent diagnostic angiography at that time, demonstrating multi-vessel disease, but with no involvement of the left anterior descending coronary artery (LAD). He was staged for percutaneous revascularization of the RCA CTO first. Planned access involved one femoral and one radial access. 

The right radial was prepped and draped in sterile fashion. The right radial artery was accessed with a 6 French Glidesheath Slender (Terumo). There was difficulty advancing the wire by the technologist and subsequent angiography revealed a perforation of the radial artery. A 0.014-inch Runthrough wire (Terumo) was used to negotiate the radial artery and advanced into the axillary artery. A 0.035-inch QuickCross catheter (Spectranetics) was used to exchange the Runthrough for a standard 0.035-inch J wire and an AR Mod (Amplatz right modified) was used to engage the RCA (an AL1 [Amplatz left] did not engage well). From the right groin, we accessed with a micro puncture kit and advanced a 6 French Q 3.5 guide (Boston Scientific) for contralateral injection.

We initially approached with an antegrade attempt. Heparin was administered to an activated clotting time (ACT) of 300 and a Runthrough wire was advanced into the mid RCA to the occluded segment. We tried to advance a CenterCross catheter (Roxwood Medical) for more back up; however, it would not advance secondary to poor guide support and vessel tortuosity. Therefore, we went with a 150cm Corsair catheter (Asahi Intecc) and initially, a Fielder XT (Abbott Vascular) and a Pilot 200 wire (Abbott Vascular), both of which failed to cross. We changed to a retrograde attempt, advancing a Runthrough wire into the first septal of the LAD, and exchanged out to a Corsair catheter for a Fielder FC wire, and then a Pilot 50 for surfing the collaterals. We were not able to get good retrograde crossing into the distal posterior descending artery (PDA) and therefore, after multiple attempts, reverted to the antegrade approach. Advancing the Pilot wire, we entered a different antegrade dissection plane, into which we were able to advance a wire; clearly the wire was sub-intimal at the reconstitution point. We advanced the Corsair behind the knuckled Pilot wire to switch for a stiffer wire and use a CrossBoss (Boston Scientific) and a Stingray catheter (Boston Scientific) to complete antegrade dissection reentry. However, when we advanced the Corsair behind the wire, the wire entered the true lumen just distal to the cap, which was confirmed by contralateral injection. Initial attempts to advance the Corsair distally and exchange the wire resulted in the guide backing up, and we actually lost wire position transiently, but were able to rewire. However, once the Corsair was down deep enough, the wire was able to advance. The catheter was removed with a trapping balloon, a 2.5x20mm Emerge (Boston Scientific), and we used a 0.9mm excimer laser coronary angioplasty (ELCA) catheter (Spectranetics) to create a channel to allow for advancement of a balloon. Laser atherectomy was performed for approximately 90 seconds in total. We were able to advance a 2.5x30mm Emerge balloon and predilate the lesion, and then advance and deploy a 2.5x38mm Promus Premier stent (Boston Scientific). There was poor flow in the PLV, possibly secondary to a subintimal hematoma. A second stent, a 2.5x28mm Promus Premier, was overlapped proximally with the initial stent. We advanced a second wire, placing one wire in the PDA and 1 wire in the posterior left ventricular artery (PLV), a Runthrough and an Asahi Prowater (Abbott Vascular), respectively. We placed a 2.5x30mm Emerge into the PDA and a 2.0x20mm Emerge into the PLV, going up to 6 atmospheres (atm) on the PLV and 4atm on the PDA, for one minute. We were then able to administer intracoronary nitroglycerin and angiography revealed good runoff in both vessels. Intravascular ultrasound (IVUS) showed some negative remolding. The vessel was >3mm, although angiographically, appeared adequately sized by stent. However, given the IVUS findings, we post-dilated the stent with a 3.25mm Quantum balloon (Boston Scientific) at high pressure. Angiography revealed TIMI-3 flow without dissection, perforation, or embolization. The wires were removed and orthogonal views were obtained, revealing brisk flow. The patient tolerated the procedure well. A Perclose (Abbott Vascular) of the right groin was performed and a final angiogram through the radial sheath demonstrated resolution of the perforation and no contrast extravasation. A TR Band (Terumo) was placed over the right radial artery.

Discussion

In the current era of patient-oriented outcomes, there is emphasis on improving the safety and efficacy of percutaneous coronary intervention (PCI). Femoral access remains the most frequent vascular access for performing PCI, in part because of familiarity, use of larger devices, increased guide support, need for hemodynamic support, and operator inexperience with radial access and some of its associated nuances. Femoral access has inherent challenges secondary to anatomical variability and inability to visualize the artery. Ultrasound-guided access has been used to facilitate femoral access; however, femoral access bleeding complications are associated with increased morbidity and mortality.^1-3 The potential risk of an access complication is increased if bilateral access is obtained. When performing chronic total occlusion (CTO) revascularization, dual access is recommended in order to adequately assess collaterals, estimate the length of the occlusion, and allow for alternating between retrograde and antegrade techniques. Although there are no randomized trial data comparing transradial vs transfemoral access for CTOs, the current data is promising, with very little cross-over, especially with an experienced radialist.^4-6 Radial access has the potential for earlier ambulation, improved patient comfort, and lower risk of vascular complications. One of the most common reasons for aborting the radial approach is iatrogenic dissection or perforation. An obvious alternative is to abort the access and switch to either the contralateral radial or femoral access. This may not be feasible if vascular access is limited or the contralateral approach is proven hostile (radial loop, spasm, anatomical variation, etc.) and therefore one needs to be able to manage the complication.^7,8

Radial artery perforation is a rare complication, occurring <1% of the time, and often leads to forearm hematoma.⁹ The first step, obviously, is to avoid this complication altogether. Selective angiography if the wire meets resistance when advancing in the forearm will help define the anatomy and potentially avoid inadvertent vessel dissection or perforation. In the event a perforation occurs, passing a wire distal to the perforation in the lumen and then completing the procedure (with a guide or diagnostic catheter), placing a long sheath, or balloon angioplasty have demonstrated safety without incidence of long-term vascular issues.^9-11 There has been one case of using a covered stent to resolve a perforation.¹² Typically, this complication responds to more the more conservative measures described. Without proper recognition, perforation can potentially result in compartment syndrome; fortunately, this is a rarity.¹³ Therefore, in the event of radial artery perforation, the following steps are recommended:

• Image the vessel to assess the perforation site and extent (we use digital subtraction angiography (DSA), as this allows good visualization and road mapping for wire passage;
• Maintain the wire in the vessel. An 0.014-inch wire, in our experience, has always been able to navigate the vessel and pass distally (then exchange for an 0.035-inch wire via an exchange catheter);
• Advance the guide or catheter to complete the procedure. It is also possible to change to a long sheath;
• Frequently check the forearm and monitor for swelling, etc. External pressure will also help achieve hemostasis (the external pressure should not be so tight to prevent catheter advancement or exchange);
• Repeat the angiogram upon completion of the procedure to confirm resolution of the perforation (if not resolved, then consider percutaneous transluminal angioplasty [PTA]).

As an individual radial operator’s volume increases, he or she is likely to encounter this complication. Prompt recognition and treatment will often allow completion of the procedure without the need to abandon the access site. 

References

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2. Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006; 114(8): 774-782.
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