A Safe, Novel, and Non-Invasive Method of Treating Long Radial Artery Pseudoaneurysm

Transradial (TR) access compared to transfemoral (TF) access in percutaneous coronary interventions results in overall lower access site complications.¹ Furthermore, in patients with acute coronary syndrome undergoing percutaneous coronary intervention, TR access compared to TF access reduces net adverse clinical events, including all-cause mortality.² However, TR access is not without risks for serious complications, which include radial artery occlusion and pseudoaneurysm.³ Risk factors for pseudoaneurysm increase with multiple puncture attempts, aggressive manipulation of the catheters and wires, larger sheath size, inadequate hemostasis, catheter-related infection, and aggressive systemic anticoagulation.³ Reducing the number of multiple puncture attempts with ultrasound guidance⁴ could potentially lead to a lower rate of pseudoaneurysm formation. Recommended treatment options for pseudoaneurysm include ultrasound-guided compression, direct thrombin injection, or surgical intervention.⁵ Treatment with a pneumatic compression device such as the TR Band (Terumo) has been previously described^6,7,8; however, we report a modified pneumatic compression technique to safely treat a long radial artery pseudoaneurysm.  

Case Report 

A 62-year-old female who was admitted for unstable angina and underwent cardiac catheterization via right radial artery access was found to have a significant mid left anterior descending (LAD) artery stenosis. One drug-eluting stent was deployed in the mid LAD, reducing the 95% stenosis to a 0% stenosis without dissection or immediate complications. Hemostasis of the right radial artery access site was achieved with a TR Band. One hour post bivalirudin infusion, the TR Band was removed by an intensive care unit nurse following the standard protocol, without any bleeding or immediate complications. On the following morning, the patient complained of distal forearm swelling and pain. Bedside ultrasound revealed a long 0.5 x 0.5 x 7.0 cm pulsatile radial artery pseudoaneurysm. Treatment with ultrasound-guided compression for over one hour was unsuccessful. While waiting for an interventional radiologist to inject thrombin into the pseudoaneurysm, we tried a non-invasive treatment method with TR Band compression. However, due to the long length of the pseudoaneurysm, we had to place two TR Bands side by side to cover the full length of the pseudoaneurysm (Figure 1). To attempt to avoid causing radial artery occlusion, we first inflated the TR Bands to high pressure with a full 18 ml of air, and then released the air until a normal pulse oximetry waveform was obtained from the right index finger. Furthermore, ultrasound confirmed patency of the distal radial artery during the time of compression. After 60 minutes of TR Band compression, the neck of the pseudoaneurysm was occluded and color Doppler showed a patent radial artery with no blood flow to the pseudoaneurysm (Figure 2). The patient was observed for 3 hours and discharged home on the same day without delay in discharge. A follow-up ultrasound 3 days later showed complete resolution of the pseudoaneurysm.

Discussion 

Pseudoaneurysm is a rare complication from TR access in cardiac catheterization and its incidence is estimated at 0.08%.⁹ Elimination of hemorrhage or leak from the radial artery into the pseudoaneurysm should be achieved in a timely manner, as delay in treatment could lead to the development of a fibrous wall and become difficult for treatment.⁵ 

There are different treatment strategies to help resolve radial artery pseudoaneurysm, but each treatment modality has its own challenges and potential complications. Ultrasound-guided compression may cause pain, which occurred with the patient in this case presentation. Furthermore, it is a time-consuming procedure performed at bedside. Thrombin injection is often resorted to in treating pseudoaneurysms. However, the unintended entry of thrombin into the adjacent artery can result in an embolism to an extremity, resulting in paresthesia, pain, or frank necrosis, with cases of limb loss being reported.⁵ Surgical intervention has potential downfalls as well, including bleeding, infection, nerve damage, and anesthesia complications, in addition to a prolonged length of stay.

With the goal of minimizing risk in treating radial artery pseudoaneurysm, a non-invasive pneumatic compression device method has been demonstrated to be safe and effective. Furthermore, by paying attention to detail in order to ensure radial artery patency during the compression period, risk for radial artery occlusion is essentially eliminated. When encountering a long pseudoaneurysm, as seen in this reported case, the application of two TR Bands side by side was authenticated to be effective. Thus far, we have applied this technique successfully in treating two different patients. 

In addition to treatment, patient education regarding radial artery pseudoaneurym is equally important in health care. Patients should be educated about the nature of the complication, treatment options and plans, and expected recovery. Patients should be advised that as with any hematoma, the pseudoaneurysm will leave a trace of blue-colored ecchymosis in the surrounding area which should slowly resolve into a rainbow of colors, until it is yellow and fades away over periods of days to weeks. They should also be cautioned that if they experience sudden pain or swelling in the area, they should seek medical attention immediately.

Summary

When encountering a pseudoaneurysm complication from TR access in cardiac catheterization, non-invasive intervention with pneumatic compression device should be the initial treatment option prior to more technically challenging (ultrasound-guided compression) or invasive means (thrombin injection or surgery). Furthermore, when the length of the pseudoaneurysm is longer than the width of a TR Band, placement of two TR Bands side by side, as presented in this case, could also be effective in treating a long pseudoaneurysm. The end result is a safe, effective, efficient, and cost-conscious way of treating radial artery pseudoaneurysm.

References

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2. Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, et al; MATRIX Investigators. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015 Jun 20; 385(9986): 2465-2476. doi: 10.1016/S0140-6736(15)60292-6. 
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7. Nazer B, Boyle A. Treatment of recurrent radial artery pseudoaneurysms by prolonged mechanical compression. J Invasive Cardiol. 2013 Jul; 25(7): 358-359.
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Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Howard Lan, DO, at hwlan@llu.edu.