Diagnosis and management of local complications

1. Diagnosis And Management Of Local
Complications
Eltigani Abdelaal, MD
University Hospital of South Manchester
UK
AIM-RADIAL 2014
Chicago, October 23rd-25th 2014

2. Disclosures
• None

3. Outline
• RAO
• Hand ischaemia
• Radial Artery Spasm
• Forearm Haematoma; Perforation
• Compartment Syndrome
• Catheter entrapment and arterial eversion
• Pseudoaneurysm
• A-V Fistula

4. versus 3.71%; OR 0.15, 95% Superficial palmar
Palmar carpal branches
at the expense of longer arch
of the radial
Superficial branch
and ulnar arteries
of the radial nerve
radiation exposure.49
Radial
The RIVAL trial50 has, artery
randomized dataset with merits of the radial and femoral seminal multicentre, multinational enrolled 7,021 patients who were undergoing with or without PCI. The Median nerve
outcome measure of death, stroke, or major bleeding Ulnar
Ulnar
occurred with similar incidence Deep palmar arch
artery
nerve
femoral access groups (HR incidence of the secondary not related to CABG surgery—groups (HR 0.73, 95% CI 0.43–occurred in sites other incidence of access-site complications reduced with radial access P <0.0001). A quarter of patients received a VCD. Cross-over significantly higher with radial (HR 3.82, 95% CI 2.93–4.97, time and contrast groups, although median with radial access (9.3 min The results of the RIVAL problems associated with femoral arterial access are could not show a difference such as MI and death, or indeed of major bleeding events. vascular access-site bleeding femoral approach does not Figure 4 | Anatomy of the radial artery. The radial artery is the smaller of the two
terminal branches of the brachial artery, continuing the direct line of this vessel.
Just proximal to the wrist joint, the radial artery superficially overlies the distal end
and styloid process of the radius bone. This feature facilitates arterial puncture and
compression haemostasis. At this point, the artery has a diameter of 2–3 mm
and is not immediately adjacent to other neurovascular structures. Here, the radial
artery gives off the superficial palmar branch, which anastomoses with the distal
end of the ulnar artery to form the superficial palmar arch. The main vessel passes
to the dorsum of the hand, via the floor of the anatomical snuffbox, and re-emerges
on the palmar surface of the hand to anastomoses with the end branches of the
ulnar artery giving rise to the deep palmar arches. These anastomoses facilitate
full perfusion of the hand in cases of radial artery occlusion.
Inferior
epigastric
artery
Adapted from Byrne, R. A. et al. Nat. Rev. Cardiol.-2013
External iliac artery
Common femoral
artery
REVIEWS
!
TRA- Collateral Circulation, Favourable Anatomy
Easily compressible, Low risk
Adapted Barbeau Test- Barbeau et al, AHJ, 2004 from Rao, S; Euro Heart J 2012

5. TFA: Unfavourable Anatomy
Femoral access Complications
Hematoma (1-12%)
Pseudo-aneurysm (1-6%)
AV Fistula (1%)
Vessel Laceration and free bleeding <1%
Intimal Dissection (Ante- or retrograde)
Acute Vessel Closure (Thrombosis)
Retroperitoneal Hge (0.2-0.9%)
Thickening of Perivascular Tissue
Neural Damage
Infection
Peri-catheter Clot
Death

6. Major Femoral Bleeding Complications After
!
Incidence of Major
Femoral Bleeding
Complications
From 1994 - 2005
Doyle et al. J Am Coll Cardiol Intv 2008;1:202–9
PCI
N=17,901 Patients - Mayo Clinic 1994-2005

7. TFA: > 50 years on- Still No Consensus on Optimal Technique!
Higher Risk of Vascular Complications

8. Impact of Bleeding on Mortality After PCI
Pooled analysis of 17,034 patients in REPLACE-2, ACUITY, and HORIZONS-AMI
Independent Hazard of the Occurrence of TIMI Non-CABG–Related Major Bleed and
of MI Within 30 Days on Subsequent Mortality Within 1 Year
Major Bleeding:
•Independently associated with MI, Stroke and Death
•2-8 fold increase in Mortality in ACS and PCI
•Hazard of Death associated with Bleeding is = or >
that in those who develop MI
Mehran, R, et al. J Am Coll Cardiol Intv 2011;4:654–64

9. Bayesian Meta-analysis
15 RCT + 61 observational: 761,919 Patients
Effects of TRA vs. TFA in clinical outcomes.
TRA Superior:
➡ 78% reduction
➡ 80% reduction
➡ 44% reduction
Bertrand et al. Am Heart J 2012;163:632-48

10. Radial Artery Occlusion
• Incidence varies depending on:
• Population studied
• Procedure type
• Size and length of sheaths
• Adjuvant pharmacotherapy
• Haemostatic technique
• Method and time of assessment for RAO

11. Incidence of RAO according to Time and Method of
Detection
D= Doppler
Oxi= Oximetry
P= Palpation
X= Angiography
Abdelaal et al; Best practice in transradial angiography and interventions. Rao & Bertrand- In Press

12. 12
10
8
6
4
2
0
Pre Patent Hemostasis Post Patent Hemostasis
Early Late
0.8
1.8
5.3
6.9
1.1
5.0
9.0
10.5
Sanmartin Rathore Plante Pancholy Cubero Bernat
UFH 70-100 u/kg UFH 70 u/kg UFH 70 u/kg or
Bivalirudin
UFH 50 u/kg UFH 70-100 u/kg UFH 5000 u
+ Ulnar
Compression
RAO Rates
2007 2010 2010 2008 2009 2011
% RAO
Rao et al. JACC Interv 2012

13. Pathophysiology Of R A O
• Multifactorial:
• Shear stress due to sheath insertion:
• Endothelial injury
• inflammation and thrombus formation
• Peri-arterial tissue or fat necrosis,
adventitial inflammation
• Intimal hyperplasia
• Incidence: 0.8 -30%- depending on time
and method of assessment
Vascular Health and Risk Management 2009:5 submit your manuscript | www.dovepress.com
529
Dovepress
for atherosclerosis, clinical presentation, and severity of
coronary artery disease (Table 1).
The histological findings of the distal ends of RA’s (in
the proximity of the puncture site) are shown in Table 2.
The distal ends of the TRA group had significantly more
with atherosclerosis of the RA unrelated to the catheterization
procedure.
Transradial catheterization has gained increasing
popularity in the last decade and is considered safer than the
transfemoral approach.8,9 However, there has been concern
Normal Intimal proliferation Calcification
Adventitial
Inflammation Tissue necrosis neovascularization
Figure 2 Representative sections of the radial artery showing different histopathological findings encountered in the study.
Abbreviations: IH, intimal hyperplasia; M, media.
!
Staniloae et al. Vasc health risk Mang 2009
Wakeyama et al. JACC 2003

14. Radial Artery Occlusion
• Diagnosis:
• USS Dulpex is gold standard:
• Visible obstruction in 2-D USS and absence of integrate
Doppler flow signal distal to puncture site
• Modified oxymetry-plethysmography (Cheng, Brbeau et al)
• Pulse: insensitive and inaccurate- collateral supply
• Timeline: spontaneous recannalization frequent finding

15. Predictors
Predictors of RAO
Patient-related
Female gender Zhou et al
Uhleman et al
DM Zhou et al
Younger age Uhleman et al
PVD Uhleman et al
Low BMI Rathore et al
Procedural
Sheath size
Saito et al, Dham et al
Zhou et al
Uhleman et al
Anticoagulation
Lefevre et al,
Bernat et al,
Plante et al
Zhou et al
Occlusive hold
Pancholy et al
Sanmartin et al
Cubero et al
Successive cannulation Abdelaal et al
Abdelaal et al; Best practice in transradial angiography and interventions. Rao & Bertrand- In Press

16. Radial Artery Occlusion- Clinical Sequelae
• Usually quiescent - protective dual hand blood supply
• No evidence to date that “RAO per se” causes hand ischaemia!
• Reports of digital gangrene after prolonged radial cannulation:
• In anaesthetic + ITU practice
• Patients often systemically unwell
• HD instability, vasopressor use, lack of A/C

17. Hand Ischaemia Due To R A O
• 3 case reports following TRA for CA/PCI
• Variable period and mode of presentations
• Often: hand numbness, parasaethsia, sensitivity to touch
• Diagnosis: USS Duplex gold +/- angiography
• Treatment:
• 1- Amputation; 2- Re-cannalization; 3- lysis + open
embolectomy

18. Critical Hand Ischaemia Due Thrombus Embolization
• Rademaker & Laarman.
• 44 yr old lady, Smoker, +ve FH, ACS, +ve ETT
• TRA, 6Fr radiofocus. Pain due to spasm, 5000 UFH
• TR Band 18 ml!
• 5-days post TRA:
• Pain, parasethesia, sensitivity to touch, absent RRA pulse
• Doppler: RAO
Rademakers & Laarman. Neth Heart J. 2012. DOI 10.1007/s12471-012-0276-8

19. Selective angiography via RFA, 2.5Fr Renegade micro-catheter
Distal embolization RAO
Rademakers & Laarman. Neth Heart J. 2012. DOI 10.1007/s12471-012-0276-8

20. Critical Hand Ischaemia Due Thrombus Embolization
• Treatment:
• LMWH + Urokinase : bolus 100,00 IU+ continuous infusion of
400,000 IU at 100,000 IU/Hr
• Further 2,500,000 IU; still no symptomatic or angio
improvement
• Emergency embolectomy and patch repair
• Others: thrombectomy, IA verapamil, prilocaine, and
phentolamines successful if reversing symptoms- 60%

21. Outline
• RAO
• Hand ischaemia
• Radial Artery Spasm
• Forearm Haematoma; Perforation
• Compartment Syndrome
• Catheter entrapment and arterial eversion
• Pseudoaneurysm
• A-V Fistula

22. Radial Artery Spasm
Definition
• Subjective: friction accompanied by subjective feeling of pain
• Objective: direct force measurement using pullback
• Maximal pullback force (MPF) >1.0 kg = clinical RAS (Kiemeneij)
Predictors
• Female
• Young age
• DM
• Low BMI
Pathophysiology
• Type III artery- Alpha-adrenoceptor dominant vessel
• Functional post junctional alpha-2 adrenoceptros
• Exaggerated vasospatic response to circulating catecholamines
Incidence • 5.0-30%
Adapted from: Abdelaal et al. J Anesth Clin Res 2012

23. Radial Artery Spasm
• Prevention:
• Anti-spasmodic medications
• Adequate analgesia and sedation
• Sheath selection: hydrophilic coating
• Treatment:
• Severe spasm: repeated IA vasodilators, sedation, analgesia
• Extreme: axillary nerve block, deep sedation, GA!

24. Comparison Of Antispasmodic Cocktails
Study Medication, dose RAS Vs. med dose RAS Result
Adapted from: Dandekar & Shroff; Cardiovasc Rev Med 2012
Kiemeneij et al ; CCI
2003
Verapamil 5mg + NTG
200mcg 8% Placebo 22%
Verapamil & NTG
superior
Ruiz-Salmeron; CCI
2005 Verapamil 2.5mg 13.2% Phentolamine 2.5 mg 23.2%
Verapamil superior-p0.004
Copoola; JIC 2006
NTG 200 mcg +
Na Nitropruside 100
mcg
9.5% NTG 100 mcg 12.2% No difference p0.58
Copoola; JIC 2006
NTG 200 mcg +
Na Nitropruside 100
mcg
9.5%
Na Nitropruside 100
mcg- 13.4% 13.4% No difference
Chen; Cardiology 2006
NTG 100 mcg+
Verapamil 1.25mg 3.8% NTG 100 mcg 4.4%
No difference both
superior to placebo
Kim et al, IJC 2007 Nicorandil 4mg 50.7%
Verapamil 0.1mg +
NTG 200 mcg 52% No difference

25. Outline
• RAO
• Hand ischaemia
• Radial Artery Spasm
• Forearm Haematoma; Perforation
• Compartment Syndrome
• Catheter entrapment and arterial eversion
• Pseudoaneurysm
• A-V Fistula

26. Forearm Haematoma
• 9.5% “EASY”
• Usually immediately clinically apparent- superficial
• RA perforation, small vessel dissection
• Rarely a cause for concern, but!
• Higher risk in females: 4.4 fold increase (95%CI
2.49-7.81-“EASY”)
• Classification: Grade I: local superficial
• Grade I1-IV: muscular infiltration

27. Transradial Haematoma Classification System
Bertrand et al. Circulation 2006
Bertrand et al. Catheter Cardiovasc Interv (2012) 75, 366-368

28. Forearm Haematoma- Management
• Prompt recognition!!
• Control BP and pain management
• Consider interruption of A/C or GPI
• Additional bracelet(s) alongside arterial course
• Inflated BP cuff (20mmHg < systolic)- deflate every 15 mins
• Pulse oxymetry
• Ice cubes

29. Radial Artery Perforation
Incidence • 0.1-1%
Predictors
• Female
• Elderly
• Hypertensives
• Calcified arteries
• Anatomic variants: Loops, high bifurcation, accessory radial
Procedural
• Excessive anticoagulation
• Aggressive wire mannipulation
• Advancement against resistance
Suspect if • Pain + difficulty advancing kit
Adapted from: Abdelaal et al. J Anesth Clin Res 2012

30. • Index of suspicion
• Consider sheath insertion and judicious contrast
injection!
• Extravasation- usually limited
• Angioplasty wire to cannulate beyond
perforation
• Long sheath/catheter insertion: often seals
perforation and allows ipsilateral TRA procedure
• Conservative management
Perforation - Management
Dandekar & Shroff; Cardiovasc Rev Med 2012

31. Outline
• RAO
• Hand ischaemia
• Radial Artery Spasm
• Forearm Haematoma; Perforation
• Compartment Syndrome
• Catheter entrapment and arterial eversion
• Pseudoaneurysm
• A-V Fistula

32. Compartment Syndrome
• PREVENTION

33. Compartment Syndrome
• Rare but very serious, requiring emergent fasciotomy
• Incidence: 0.004% (Tizon-Marcos et al; CCI 2008)
• Forearm 3 compartments:
• Volar, dorsal and radial
• Bound by non-distensible fascia
• Rising pressure = capillary obstruction and ischaemia

34. Compartment Syndrome
• Aetiologies:
• Mal-application of HS device !
• Unrecognized perforation
• Symptom evolution:
• Pain & swelling
• If untreated: pallor, parasaethesia, loss of contraction, then loss
of pulse

35. Compartment Syndrome
• Diagnosis:
• Clinical- high index of suspicion
• Management:
• Arm elevation, cuff pressure, ice application
• Liaison with vascular surgeons

36. Compartment Syndrome
Direct compartment pressure measurement & Fasciotomy
Measurement of forearm tissue pressure
Araki et al. Cathter Cardiovasc Interv. (2010); 75: 362-365

37. Outline
• RAO
• Hand ischaemia
• Radial Artery Spasm
• Forearm Haematoma; Perforation
• Compartment Syndrome
• Catheter entrapment and arterial eversion
• Pseudoaneurysm
• A-V Fistula

38. Catheter Entrapment & Arterial Eversion
• Due to severe spasm
• Exacerbated by excessive torquing of catheters, kinking!
• Treatment: adequate analgesia, deep sedation, GA, removal
under fluoroscopy
• Eversion of RA: reported with severe RAS
• Surgical ligation.. often no sequelae
Dieter et al. Cathter Cardiovasc Interv. (2003); 58: 478-480

39. • Rare: 0.1%
Radial Artery Pseudoaneurysm
• Factors: multiple punctures, systemic A/C,
infection, large sheath
• Often subclinical when very small
• Pain and swelling, several days/weeks after
• Diagnosis: Angiography; USS Doppler
• Treatment:
• Compression, surgical ligation (in rare cases)
Dandekar & Shroff; Cardiovasc Rev Med 2012

40. Arterio-Venous Fistula
• Very rare; isolated cases reports
• 0.% in TRA vs. 0.14% TFA- RIVAL
• Persistant pain
• Swelling, palpable thrill
• Surgical ligation if large

41. Arterio-Venous Fistula
Abdelaal et al; In Press
Enlarged viens, pulsatile,
Palpable Thrill
Complex fistula connections
with cephalic vein
Turbulent flow
Velocity 1m/sec

42. Extemely Rare- But Reported!
• Brachial artery dissection. Campu. Cathet Cardiovasc Diagn 1989;16:3–7.
• Ischaemic contracture. Wu et al Cath Cardiovasc Diagn 1997;40:159 –163
• Neural damage.
• Brachial artery perforation. Spaulding. Cath Cardiovasc Diagn 1996;39:365–370
• Complex regional pain syndrome: Papadimos. CCI 2002;57:537–540.
• Pain, swelling, reduced ROM, vasomotor instability
• Sympathetic block

43. Thank You