Pseudoaneurysm After Distal Transradial Coronary Intervention Successfully Managed by Prolonged Pneumatic Compression: Simple Solution for a Rare and Challenging Problem

J INVASIVE CARDIOL 2021;33(10):E836-E838.

Key words: coronary angiography, distal transradial access, percutaneous coronary intervention, pseudoaneurysm

A 75-year-old woman with hypertension, hypothyroidism, and diabetes was referred to the cath lab due to non-ST segment elevation myocardial infarction. Urgent coronary angiography was uneventfully performed via right distal transradial access (dTRA), despite lusoria subclavian artery. The left anterior descending coronary artery was successfully treated by percutaneous coronary intervention with stenting. A TR band (Terumo) was left in situ for 60 minutes and completely removed after 2 hours without bleeding. Proximal and distal radial pulses were palpable after hemostasis and at hospital discharge 24 hours later, uneventfully.

Six days later, she noticed subtle and rapidly progressive wrist, hand, and finger swelling, with pain, ecchymosis, and movement limitation. Physical examination evidenced pulsatile mass, thrill, and murmur, compatible with pseudoaneurysm (Figure 1). Doppler ultrasound (US) evidenced a huge cavity with whirlwind flow and spontaneous contrast communicating with the right distal radial artery (RA) (Video 1). After continuous 30-minute US-guided pseudoaneurysm’s neck compression (Figure 2), no pulsatile mass, thrill, murmur, whirlwind flow, or Doppler pulses were detected. One-week follow-up evidenced recurrence of pulsatile mass (Video 2), thrill, and murmur, compatible with pseudoaneurysm recidivism (Figure 3), confirmed by Doppler US (Figure 4; Videos 3 and 4). Following pseudoaneurysm neck precise location, a TR band was placed and inflated with 20 mL of air (Figure 5, Video 5). After 4 hours, Doppler US showed proximal and distal RA patency, absent flow, and complete resolution of the initial pulsatile cavity (Figure 6, Video 6). During TR band inflation and after its removal, pulse oximetry in all digits was ≥95% (Figure 7). Physical examination and Doppler US at 30 and at 120 days (Figure 8) after index procedures  corroborated pseudoaneurysm resolution.

Prolonged pneumatic compression appears to be feasible for the management of pseudoaneurysms after dTRA procedures.