Hematomas, Compartment Syndrome, and Boney Infarcts: Potential Melancholy for Dorsal Radial Access?

The internet, specifically the world of Twitter and Facebook, has shown what might be considered irrational exuberance for dorsal radial access by many early adopters. This access has been known since the 1970s for arterial access, but never played a dominant role in the critical care unit. The concept that this access can now provide a near risk-free approach to the arterial tree is a bit prattish. All arterial puncture has a cost. Every artery runs near an accompanying vein and nerve, raising a potential litany of misadventures from collateral structural damage. After the frisson of excitement over dorsal radial access runs its course, we will probably hear of a series of complications analogous to those seen at every other access site also reported for the dorsal radial.

In this month’s Journal of Invasive Cardiology, Koutouzis et al¹ offer one of the first reports in a journal of hematoma encountered after dorsal radial access, although several other reports of hematoma and even pseudoaneurysm² have already appeared on social media. There is a variety of unique anatomical components to the hand that add new dimensions to hematomas and their potential for spread. As noted in this report, the hand hematoma spread distally on the dorsal hand and was impeded from proximal spread by the reflections of subcutaneous tissue at the wrist. How to quantitate the bleeding was difficult, as the traditional EASY scale³ for quantitating common radial artery hematoma is not applicable to the dorsal radial since they do not share common anatomical routes for hematoma expansion. In addition, the potential for compartment syndrome is different. A common radial hematoma may result in compartment syndrome in the surrounding forearm muscles. Dorsal radial hemorrhage, on the other hand, endangers the thenar eminence and other small muscles of the thumb and neighboring fingers. While these muscles may not be as large as those in the forearm, the treatment with fasciotomy is similarly disfiguring and morbidity can be severe. To date, pictures of a hand fasciotomy associated with dorsal access have not yet been published, but it is probably only a matter of time before this complication is demonstrated. 

Interventional cardiology has evolved from a femoral-centric field to a general vascular one where a variety of potential vascular access sites exist, each with its benefits, risks, and best approach for the interventionist to consider. Many of the complications across all potential access sites have common themes of hematoma, pseudoaneurysm, arteriovenous fistula, and compartment syndromes. The dorsal radial artery is also a source of small feeder arteries to the wrist bones. Damage to these arteries from trauma is known to cause disabling avascular necrosis. Whether similar vascular damage can be caused by instrumentation of the dorsal radial is yet to be seen. The report by Koutouzis et al¹ is a reminder that these complications can occur in even the more distal access points used by cardiologists. It also signals the start of reports describing what can go wrong in the world of dorsal radial access as many around the globe explore its potential and limitations. 

References

1.    Koutouzis M, Kontopodis E, Tassopoulos A, Tsiafoutis I, Lazaris E. Hand hematoma after cardiac catheterization via distal radial artery. J Invasive Cardiol. 2018;30:428. Epub 2018 Jun 19.

2.    Fauzi YA [@uziyaha46]. Pseudoaneurysm, 3 months after coronary angiography via #ldTRA. A 64 yo/F with AF had history PCI of LM-LAD. She is on aspirin and rivaroxaban – what is your plan? [Tweet]. https://twitter.com/uziyahya46/status/1042329525080584198. Posted September 19, 2018.

3.    Bertrand OF. Acute forearm muscle swelling post-transradial catheterization and compartment syndrome: prevention is better than treatment! Catheter Cardiovasc Interv. 2010;75:366-368.

From the Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, Pennsylvania.

Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The author reports no conflicts of interest regarding the content herein.

Address for correspondence: Ian Gilchrist, MD, Heart and Vascular Institute, College of Medicine, Penn State University, Hershey, PA  17033. Twitter: @Radial_icg  Email: Icg1@psu.edu