“When It Rains, It Pours”: Radial Perforation and Entrapment

History

An 86-year-old female was referred for cardiac catheterization with “rest angina” and elevated troponin I. Coronary angiography was contemplated via right radial access. 

Procedure 

The right radial artery was punctured using counter-puncture technique and a .021-inch micropuncture guide wire was placed in the Teflon cannula. Mild difficulty was encountered at the first attempt to advance the wire. The guide wire was withdrawn and a low-pressure manual injection radial angiogram was performed. A perforation was noted at the distal radial artery (Figure 1). In an attempt to obtain control of the radial artery lumen, a .014-inch guide wire was placed in the access cannula and attempts were made to navigate the lumen, with further resistance. A new area of perforation was noted proximal to the previous site of extravasation (Figure 2). After several attempts, the .014-inch guide wire was placed in the subclavian artery successfully. Tortuosity was noted all along the proximal vessels (Figure 3). 

A 5 French (Fr) hydrophilic introducer sheath was inserted in the radial artery. A 5Fr Tiger catheter was placed in the ascending aorta, and moderate difficulty was encountered while attempting to torque the catheter. After placing the .035-inch guide wire in the catheter, the catheter was successfully placed in left and right coronary ostia, and coronary angiography was performed. Non-obstructive coronaries were found. The Tiger catheter was removed and the guide wire was left in place, in view of previously noted perforations, to maintain lumen access to the radial artery. Manual injection radial angiogram was performed to evaluate the status of perforated segments. No further extravasation was noted (Figure 4). At this point, attempt was made to remove the .035-inch guide wire without any movement of the guide wire, with fairly severe pain along the arm reported by the patient with each attempt to pull the wire. A repeat radial angiogram was performed, with appearance of the lumen contour fairly typical of diffuse, long spasm. 

Multiple doses of intra-arterial nitroglycerin and verapamil were administered via the introducer sheath with no improvement in the ability to remove the guide wire. Systolic blood pressure was now 80mmHg and heart rate was 45 beats/minute. Atropine 0.6mg was injected intravenously. 

A sphygmomanometer cuff was applied at the proximal upper arm and inflated at 120mmHg for 5 minutes. The cuff inflation was very well tolerated by the patient symptomatically, with total absence of plethysmographic signal in the ipsilateral digits. After 5 minutes of occlusion, the cuff was deflated and the guide wire was gently tugged upon. No pain was reported by the patient, and the guide wire was successfully removed from the radial artery introducer sheath. Soon after removal of the guidewire, an inflatable band was applied at the puncture site and the introducer sheath was removed from the radial artery. Patent hemostasis was achieved after 5 minutes of titration of band pressure. 

Hospital course 

The patient was monitored closely in the post-procedure area for forearm symptoms and digital perfusion as well as radial artery patency. After 2 hours of hemostatic compression, the band was removed, and radial artery was patent with no evidence of a forearm hematoma. The next day, after 24 hours of post-procedural stability, the patient was discharged to home. 

Follow-up

At 30-day follow-up, the patient remained asymptomatic, with no abnormality of forearm circulation or symptoms. 

Discussion 

With the increase in adoption of transradial access (TRA), an increase in observed complications of TRA is expected. This case describes two dreaded complications of TRA, radial artery perforation and entrapment. We will discuss the strategies for prevention and management of these complications below. 

The most common etiology of radial artery perforation is guide wire-related trauma. A J-tipped guide wire ‘engaging” a small side branch is frequently presumed to be a cause for “cryptogenic” perforations. In this instance, difficulty in advancing the guide wire with likely side branch trauma or subintimal placement would have resulted in perforation. As recommended, the operators performed a radial angiogram when they encountered resistance to advancement of the guide wire (Figure 1). Appropriately so, instead of abandoning the access site, they elected to gain control of the arterial lumen and succeeded (Figure 3).^1,2 Perforation being the immediate issue at hand, a catheter was placed through the perforated segments and the procedure was completed as recommended. As expected, the catheter placement was successful in resolving the extravasation (Figure 4). But, a good deed never goes unpunished. The next problem at hand was guide wire entrapment. 

Hardware entrapment is a result of severe spasm, with underlying coexisting variant anatomy. Although possible, it is unusual to develop entrapment in a normal anatomic setting. The treatment of entrapment is directed at relieving spasm, as instituted by the operators, although is frequently limited by systemic effects of the vasodilator compounds, causing hypotension and bradycardia. Although measures such as deep conscious sedation or even general anesthesia have been described as adjuncts in these circumstances, a relatively simple non-pharmacologic method exploiting local physiology has been described³, which was used by the operators in this instance with success. An argument can be made to use the non-pharmacologic method first, eliminating the hypotension and bradycardia frequently associated with high-dose spasmolytic pharmacotherapy. Regardless, this case exemplifies the fact that following previously outlined strategies to tackle complications of TRA leads to effective mitigation of potentially major consequences. 

But, more significant is the issue of fully utilizing the information we frequently have in the catheterization suite to potentially prevent some of these complications. When faced with a complication, we frequently fail to notice and utilize some of the details we would normally pay attention to. In this instance, when the operators performed a radial artery angiogram, only the radial and median arteries were visualized (Figures 1 and 4), with no visualization of the ulnar artery. This should have served as a hint that an anatomic variation could exist, and should have led to further delineation of the anatomy, after the lumen was accessed with a guide wire successfully. The other hint that anatomy conducive to severe spasm might exist was the fact the “tortuosity” was deemed severe enough to necessitate using a guide wire to torque the catheter for coronary access. These subtle hints are frequently not attended, and may lead to nerve-wracking complications as in this instance of entrapment. It is evident in the angiogram performed after guide wire removal that this patient did have a “high takeoff” radial artery (Figure 5), known to develop diffuse and severe spasm, creating a perfect environment for entrapment. In the hands of an experienced operator, most of the time severe spasm occurs in the setting of anatomic abnormalities. 

TRA-related complications are infrequent, but need to be treated promptly, using commonly prescribed techniques and treatments. Most importantly, when hardware transit is not optimal, defining local anatomy and using all possible information may help prevent complications. 

References

1. Calviño-Santos RA, Vázquez-Rodríguez JM, Salgado-Fernández J, Vázquez-González N, Pérez-Fernández R, Vázquez-Rey E, Castro-Beiras A. Management of iatrogenic radial artery perforation. Catheter Cardiovasc Interv. 2004 Jan; 61(1): 74-78.

2. Patel T, Shah S, Sanghavi K, Pancholy S. Management of radial and brachial artery perforations during transradial procedures — a practical approach. J Invasive Cardiol. 2009 Oct; 21(10): 544-547.

3. Pancholy SB, Karuparthi PR, Gulati R. A novel nonpharmacologic technique to remove entrapped radial sheath. Catheter Cardiovasc Interv. 2015 Jan 1; 85(1): E35-E38. doi: 10.1002/ccd.25593.