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Singh VP 201111


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Radial Artery Angiography and Intervention: Complications

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Singh VP 201111

  1. 1. Radial Artery Angiography and Intervention: Complications Varinder P Singh, MD Director, Coronary Intervention and Cath Lab Operations Columbia University NY,NY
  2. 2. Disclosure Statement of Financial Interest• I, V. Singh DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation
  3. 3. Complications• Relatively common Radial artery spasm/occlusion Vasovagal reaction Radial artery dissection Ensconced catheter• Very uncommon Perforation/forearm hematoma/ Axillary Hematoma Hand ischemia (where there is co-existent ulnar artery flow compromise) Granuloma formation at access site (has been associated with hydrophilic sheath use) AV Fistula Compartment Syndrome
  4. 4. Radial Artery Occlusionvs Hemostasis Technique Pancholy S. Catheter Cardiovasc Interv 2008; 72: 335-340
  5. 5. Radial Occlusion vs Sheath Size Spaulding, et al. Cathet Cardiovasc Diag 1996; 39: 365-370
  6. 6. Radial Artery Occlusion vs HeparinSpaulding, et al. Cathet Cardiovasc Diag 1996;39:365-370
  7. 7. Radial Artery Occlusion vs Time to Sheath removalN=234. Saito, et al. Catheter and Cardiovasc Interv 1999;46: 37-41
  8. 8. Reducing Radial Artery Occlusion Summary• Patent Hemostasis• Avoid Spasm• Smallest Sheath Size Necessary• Heparin- ? timing of admistration• Remove Sheath As Soon As Possible• Can reduce rate to 1% from 5-8%
  9. 9. Perforation
  10. 10. Perforation
  11. 11. Perforation• Tejas Patel, et al reported 15 perforations out of 34,000 Transradial procedures (0.04%)• The Key is to recognize the perforation early, as unrecognized perforations can lead to compartment syndrome.• Angiography was performed pre procedure, post procedure, and anytime a complication was suspected.• Of these 15, all completed their procedures successfully.• The perforation was sealed by tamponade with the sheath or a catheter Patel, et al J Invasive Cardiol 2009; 21: 544-547
  12. 12. Perforation• If you have encountered a perforation or are concerned, wrap the arm with ace bandage, elastoplast, etc.• Monitor hand for perfusion/ischemia: color, oximetry, pain/parathesias, capillary refill, pulse, venous congestion• Vascular surgery consultation earlier rather than later
  13. 13. Hematoma or Swelling ? your best friendsExternal Compression Intravascular Tamponade LONG Hydrophilic sheath NOT the Destination Sheath
  14. 14. Compartment Syndrome Compartment syndrome is the most dangerous transradial complication• A large hematoma causes hand ischemia due to pressure- induced occlusion of both the radial and ulnar arteries• Know the signs and symptoms Acute pain and tumefaction Disturbances in sensitivity Pallor of the distal limb, with preserved radial and ulnar pulses. Pain on movement of the fingers Decreased sensation (touch) Pallor and lack of capillary refill• Emergency surgical consult Fasciotomy with hematoma evacuation must be performed as an emergency procedure
  15. 15. Complications• Ensconced catheter  Hydrophilic sheath avoids this • Destination sheath is semi hydrophilic  Treatment • Sedation and time • Anesthesia for general sedation • Supraclavicluar block
  16. 16. Pseudoaneurysm •Complication of Compression •Higher with certain closure bands •Thrombin Injection or compressionAfshar & Nasiri, J Teh Univ Heart Center 3 (2009) 193-196
  17. 17. Sterile Abscess • Granuloma associated with Hydrophilic sheaths • Vascular surgery consult • Conservative management vs surgical removalIan Gilchrist MD,
  18. 18. A-V Fistula • Rare complication • Self Limited Clinical courseSanmartin et al, Rev Esp Cardiol. 2004; 57: 581-4
  19. 19. Complications These other complications occur very infrequently• Infraclavicular hematoma Results from perforation of a small branch of the axillary artery• Scarring Depigmented scar at puncture site due to undue compression
  20. 20. Anatomic Limitations Anatomic variations• Retroesophageal origin of subclavian artery  0.45 %  60 % success rate
  21. 21. Retroesphageal Insertion
  22. 22. Strategies to Manage Potential Procedural Complications During the Transradial ApproachComplication Management StrategyLocal access Compression of RA both proximally and distally to the puncture site usingbleeding manual pressure (or compression devices) Perform an RA arteriogram when any resistance to guidewire or catheterForearm insertion occurshematoma ACE™ bandage to forearm Ensure that occlusion of both the RA and UA does not occur during theCompartment proceduresyndrome Fasciotomy with hematoma evacuation The puncture site should not be too distalAccess failure If radial loop is present, transverse with hydrophilic guidewires If RAs are smaller than 2 mm in diameter, use 5F guidewirePseudoaneury Thrombin injection and or mechanical compressionsm formationRadial artery Caused by intense spasm, prevent RA spasmavulsionRadial Cross perforation site using guidewire with extreme caution and seal theperforation perforation with the guiding catheter
  23. 23. Summary• Radial complications do occur although rare• Early recognition is key• Low threshold for angiography• Allmost all can be managed in the lab