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Pseudoaneurysm of the Radial Artery Complicating Transradial Catheterization in a Lupus Patient

Pseudoaneurysm of the Radial Artery Complicating Transradial Catheterization in a Lupus Patient

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  • 1. Sa’ar  Minha  M.D,  Chen  David  M.D,  Alex  Blatt  M.D,   Ricardo  Krakover  M.D  and  Alberto  Hendler  M.D   FESC   Dept.  of  Cardiology  &  Dept.  of  Vascular  Surgery   ,  Assaf  Harofeh  Medical  Center.  Zerifin
  • 2. Background —  Patient  characteristics:     —  30-­‐year-­‐old  male   —  Hx  of  systemic  lupus  erythematosus  (SLE)  since  the  age   of  15.   —  Diagnosed  as  APLA  syndrome  at  the  age  of  19  after  an   embolic  event  involving  the  spleen.   —  On  chronic  warfarin  therapy,  corticoesteroids  and  anti-­‐ inflammatory  drugs  (plaquanil).   —  Positive  family  history  of  CAD.  
  • 3. Clinical  Characteris3cs —  Effort  dyspnea  and  non-­‐specific  chest  pain  —  Echo-­‐Doppler  demonstrated  LVEF  of  50%    &  regional   wall  motion  abnormalities  (apico-­‐inferior  hypokinesis)  —  Referred  to  an  elective  coronary  angiography.  
  • 4. Procedural  Characteris3cs —  5  days  prior  to  the  procedure  the  oral  anticoagulation   therapy  was  replaced  by  LMWH  (60  mg  bid),  while   continuing  the  steroids  and  the  anti-­‐inflammatory   medication.  —  The  last  dose  of  LMWH  was  given  the  morning  of  the   procedure,  about  8  hours  before.  —  ASA  100  mg  was  added  at  admission.      
  • 5. Procedural  Characteris3cs  cont’ —  Coronary  Angiography   —  Right  radial  approach   —  6F  radial  vascular  sheath.     —  Prior  to  angiography  we  routinely  inject  through  the  vascular   sheath:  UFH  2500  units  and  2  cc  of  5  mg  of  Verapamil  diluted   to  10  cc  with  NS  0.9%.   —  Coronary  angiography  was  performed  utilizing  a  Judkin’s   technique  and  demonstrated  normal  coronary  arteries.     —  No  additional  UFH  or  Verapamil  was  administered.     —  The  vascular  sheath  was  immediately  removed  and  local   hemostasis  performed  manually.     —  The  patient  was  discharged  4  hrs.  after  the  procedure.      
  • 6. Procedural  Outcome —  3  days  after  parallel  therapy  with  warfarin  and  LMWH,   when  a  therapeutic  INR  was  achieved,  the  LMWH  was   interrupted.  —  Two  weeks  after  the  procedure,  a  2x2  cm  pulsatile  bulge   appeared  at  the  puncture  site  and  the  patient  was   referred  to  a  Dupplex-­‐US  of  the  puncture  site.
  • 7. at  the  puncture  site US-­‐Doppler
  • 8. at  the  puncture  site US-­‐Doppler
  • 9. Treatment —  After  local  thrombin  injection  under  ultrasound   guidance,  the  pseudoaneurysm  was  resolved
  • 10. US-­‐Doppler-­‐  post  injec3on
  • 11. Discussion —  Late  appearance  of  pseudoaneurysm  is  rare  with  few  reported   cases  in  the  literature.  —  pseudoaneurysms  are  caused  by  trauma,  vasculitis,  infections   and  iatrogenic  causes-­‐all  promoting  weakness  of  the  vessel   wall  supporting  structures.  —  Pseudoaneurysm  rupture  and  bleeding  to  the  forearm  can  have   devastating  outcome.  —  We  speculate  that  patients  presenting  with  chronic  inflammatory   diseases  (SLE,  APLA,  vasculitis),  treated  by  both  anticoagulation   and  steroids  all  may  predispose  to  aforementioned  complication.    
  • 12. Discussion —  Recommendation:   —  Considering  alternatives  to  diagnostic  angiography   —  MSCT/SPECT/CMR   —  Close  follow-­‐up  is  warranted  in  patients  predisposed  to  this   complication.   —  Issues  of  controversy   —  Anticoagulation   —  Option  I:  Due  to  its  short  half-­‐life,  a  continuation  of   LMWH  for  one  week  before  re-­‐initiation  of  warfarin  is   suggested.   —  Option  II:  Performing  the  procedure  on  warfarin  with  low   initial  INR   —  Sheath  removal  and  compression  (manual  vs.  mechanical)