Complications of the transradial approach by Alejandro Travieso-González and Pablo Salinas Sanguino. Cardiología Intervencionista. Hospital Universitario Clínico San Carlos

1. Complications
of the transradial approach
Alejandro Travieso-González
Pablo Salinas Sanguino
Cardiología Intervencionista
Hospital Universitario Clínico San Carlos

2. I. Transradial approach: overview
• First transradial coronary angiography in 1989 (Compeau).
• First transradial PCI in 1993 (Kiemeneij and Laarman).
• Longer learning curve for (new) operators.
• Many clinical trials have demonstrated superiority over
femoral access, including lower mortality in some
subsets.
• Most used access nowadays, especially in Europe.

3. II. Transradial approach complications:
• Less frequent than other vascular accesses.
• Almost never life-threatening.
• Operator-dependent: less common in radial-first centers.
Arterial spasm
Bleeding and perforation
Occlusion
AV fistulae
Pseudo-aneurysm
Puncture site infection
Compartment syndrome
Rare (<5%) Very rare (<1%)

4. III. Arterial spasm:
• Most frequent complication in transradial approach (10-15%)
• Patient discomfort, decreased success rate.
• Risk factors for spasm:
• Patient: anxiety, age, female sex, tortuosity.
• Operator: repeated puncture, procedure duration.
• Equipment: sheath diameter, sheath/lumen ratio,
hydrophilic/non hydrophilic sheaths.

5. III. Arterial spasm:
Spasm prevention
Analgesia.
Adequate atmosphere.
Optimal sheath diameter.
Hydrophilic sheath.
Vasodilators.
Sedation.
Garg N. Indian Heart J. 2016

6. IV. Perforation and bleeding:
• Incidence:
• Hematoma 14%.
• Perforation 1%.
• Frequently caused by
manipulation of sheath, wire or
catheter.
• Risk factors: tortuosity,
atherosclerosis, loops (or
combination: calcified loops).

7. IV. Perforation and bleeding:
• Management:
• If catheter is not in true lumen: remove sheath/wire and
compression.
• If catheter is in true lumen (or true lumen is accesible):
• Advance sheath/catheter and continue the procedure: in
most cases (due to wire manipulation), this will solve the
perforation.
• Contrast injections after catheter removal to detect
persistent bleeding.

8. IV. Perforation and bleeding:
• Management: if bleeding persist after catheter removal
External compression: sometimes difficult in forearm
Long sheath for prolonged time (12-24 h)
Vascular surgery: if previous measures don’t work
Ballooon occlusion / covered stents

9. V. AV Fistulae
• Very rare.
• Frequently due to inadequate
hemostasis.
• Management: nearly always
conservative. Very rarely
requires surgery.
Pascual I. JACC Cardiovasc Interv. 2017

10. VI. Pseudo-Aneurysm
• Nearly always due to inefficient
hemostasis.
• Incidence: 0.1%.
• Risk factors: repeated
punctions, large sheaths,
ineffective compression, heparin
dosage.
• Generally of little dimensions.
• Conservative managenemt:
compression.
Korabathina R. New York University Shool of
Medicine

11. VII. Radial artery occlusion:
• Can appear in 3-5% of patients
• Nearly always asymptomatic. Rarely: loss of grip
strength. Almost never signs of distal ischemia.
• 50% present spontaneous recanalization over time.
• Risk factors: procedure duration, sheath/artery ratio,
sheath length, heparin dosage, prolonged compression
times.
• Consider using non-dominant arm in hand professionals.

12. VII. Radial artery occlusion:
• Management:
• Asymptomatic: observation.
• Symptomatic:
• Acute occlusion: ulnar artery compression (1 hour) promotes
radial artery re-opening, and has shown to be successful.
• Anticoagulation.
• If symptoms persist: theoretically, revascularization
(percutaneous or surgical) is indicated.

13. VII. Others:
Compartment syndrome:
very rare (0.1-0.4%), ofter secondary to uncontrolled
perforation. Requires urgent surgery.
Puncture site infection:
very rare, generally only local infection.

14. Conclusions:
• Transradial approach: safe, widely used
• Complications less frequent than other approaches, but
still can appear.
• Preventive strategies can diminish their incidence.
• Rapid identification and management can control almost
all situations.
• Every time you suspect problems, use fluoroscopy and
gentle contrast injections.

15. To learn more:
• Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and
risk factors of peripheral arterial catheters used for
haemodynamic monitoring in anaesthesia and intensive care
medicine. Crit Care. 2002; 6(3): 199–204.
• George S, Mamas M, Nolan J, Ratib K. Radial artery perforation
treated with balloon tracking and guide catheter tamponade –
A case series. Cardiovasc Revascularization Med. 2016; 17(7):
480–6.
• Chatterjee A, White JS, Leesar MA. Management of radial artery
perforation during transradial catheterization using a
polytetrafluoroethylene-covered coronary stent. Cardiovasc
Revascularization Med. 2017; 18(2): 133–5.