Treatment of Recurrent Radial Artery Pseudoaneurysms by Prolonged Mechanical Compression

Abstract: As radial artery pseudoaneurysm (PA) is a rare complication of transradial catheterization, data on their management are sparse. Here, we report the case of a 77-year-old woman who underwent right transradial diagnostic cardiac catheterization, and subsequently developed a symptomatic PA. She underwent initial treatment with 20 minutes of mechanical compression with a Hemoband (Hemoband Corporation) with initial success. Three weeks later, she developed recurrence of her PA, and was treated with 24 hours of mechanical compression, wearing the Hemoband as an outpatient, with sustained resolution of the PA confirmed by ultrasound 1 month later, and no neurologic or further vascular complications. In addition to demonstrating that an initial PA as well as its recurrence can be treated with prolonged mechanical compression, we review the literature regarding radial artery PAs and their treatment.

J INVASIVE CARDIOL 2013;25(7):358-359

Key words: radial artery, transradial catheterization, pseudoaneurysm

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The patient is a 77-year-old woman with a history of rheumatic heart disease status post mechanical mitral valve replacement 10 years prior, who underwent a diagnostic cardiac catheterization as part of an evaluation for dyspnea on exertion. The patient was admitted for unfractionated heparin infusion while her warfarin was held prior to her catheterization. On the morning of the procedure, her international normalized rate (INR) was 1.8, and platelets and partial thromboplastin time were normal. Intravenous heparin was held for 2 hours prior to the procedure. Arterial access was obtained with a 5 Fr hydrophilic Terumo Glidesheath in the right radial artery. A 50 U/kg bolus of intravenous heparin was administered per our institutional transradial access protocol. After the procedure, the sheath was removed with no complications, and a HemoBand (HemoBand Corporation) was applied to the right radial artery for 4 hours, achieving hemostasis. Intravenous heparin infusion was restarted without bolus immediately after the procedure. Four days after the procedure, she noticed a painful, pulsatile mass in her right wrist without evidence of compromised distal flow. An ultrasound demonstrated a 1.4 x 0.7 x 1.7 cm right radial artery pseudoaneurysm (PA) (Figure 1A). This was treated with manual compression for 20 minutes, and repeat ultrasound the next day demonstrated thrombosis of the PA, with no further communication between the vessel lumen and the PA (Figure 1B).

Three weeks later, the patient presented to clinic with recurrence of the pulsatile mass. Her INR (4.6) was supratherapeutic, and ultrasound demonstrated recurrent 1.6 x 0.7 cm right radial PA (Figure 1C). Warfarin was held, and 24-hour compression with a HemoBand was performed as an outpatient, but the mass remained unchanged. Three days later, after her INR had decreased to 1.8, the HemoBand was reapplied for a second 24-hour period. She did not develop any pale, cold, or painful digits during either of these compression periods. One week later, the size of her wrist mass had decreased, and it was no longer pulsatile or painful. Ultrasound showed thrombosis of the PA with a patent artery lumen and no flow into the PA (Figure 1D). Ultrasound 1 month later showed a normal right radial artery with no remaining PA (Figure 1E).

PA is a rare complication of radial artery catheterization. In the RIVAL trial comparing transradial and transfemoral access catheterization in patients with acute coronary syndromes, PAs requiring ultrasound compression, thrombin injection, or surgical repair occurred in 0.2% of transradial and 0.7% of transfemoral patients (P=.006). While the risk factors for radial artery PAs have not been systematically analyzed, they are presumably similar to many of those for femoral artery PAs, which include larger sheaths, periprocedural antiplatelet agents and anticoagulants, inadequate compression/closure, and hypertension.¹ In a case series of 5 patients with radial PAs, 4 had been anticoagulated prior to and after the procedure, while 4 had used 6 Fr sheaths (the other used a 5 Fr sheath).²

Treatment options for radial PAs include mechanical compression,^2,4 ultrasound-guided thrombin injection,³ or surgical repair.¹ Here, we report the successful treatment of a recurrent, late (over 3 weeks postprocedure) PA with prolonged compression, which resulted in total resolution of the PA, and no evidence of distal perfusion compromise. 

As use of transradial catheterization expands, so will the incidence of PAs. This is the first report of treatment of recurrent PA with prolonged (up to 24 hours) mechanical compression, supporting the existing literature to show that this appears to be a safe, non-invasive means of treating PAs. In addition, the fact that the PA was not successfully treated with prolonged compression at the first attempt does not preclude subsequent successful attempts. Since comparative trials of treatment methods for PAs will be difficult given their low incidence, it is reasonable to attempt this non-invasive treatment (while closely monitoring for evidence of distal perfusion compromise) prior to thrombin injection or surgical repair.

References

1. Webber GW, Jang J, Gustavson S, Olin JW. Contemporary management of postcatheterization pseudoaneurysms. Circulation. 2007;115(20):2666-2674.
2. Collins N, Wainstein R, Ward M, Bhagwandeen R, Dzavik V. Pseudoaneurysm after transradial cardiac catheterization: case series and review of the literature.Catheter Cardiovasc Interv. 2012;80(2):283-287.
3. Herold J, Brucks S, Boenigk H, Said SM, Braun-Dullaeus RC. Ultrasound-guided thrombin injection of pseudoaneurysm of the radial artery after percutaneous coronary intervention.Vasa. 2011;40(1):78-81.
4. Liou M, Tung F, Kanei Y, Kwan T. Treatment of radial artery pseudoaneurysm using a novel compression device.J Invasive Cardiol. 2010;22(6):293-295.

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From the Division of Cardiology, Department of Internal Medicine, University of California, San Francisco, California.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted October 9, 2012, provisional acceptance given November 16, 2012, final version accepted January 9, 2013.

Address for correspondence: Babak Nazer, MD, University of California, San Francisco, Division of Cardiology, 505 Parnassus Avenue, M1184, San Francisco, CA 94143-0124. Email: babak.nazer@ucsf.edu