Transradial cardiac catheterization: A Review of Access Site Complications

Abstract

Transradial catheterization (TRC) has been associated with a lower incidence of major access site related complications as compared to the transfemoral approach. With the increased adoption of transradial access, it is essential to understand the potential major and minor complications of TRC. The most common complication is asymptomatic radial artery occlusion, which rarely leads to clinical events, owing to the dual collateral perfusion of the hand. Adequate anticoagulation, appropriate compression techniques, and smaller sheath size can minimize the risk of radial artery occlusion. Hand ischemia with necrosis has never been reported during TRC with thorough pre-examination of intact collateral circulation. Radial artery spasm is relatively common, and can result in access and procedural failure. It can be prevented by the use of vasodilator cocktails and hydrophilic sheaths. Radial artery perforation can lead to severe forearm hematoma and compartment syndrome if not managed promptly. Careful observation, prompt detection of the hematoma, and management with a pressure bandage dressing are critical to avoid serious complications. Pseudoaneurym and arteriovenous fistula are rare complications, which can likely be managed conservatively without surgical intervention. Nerve injury occurring during access has been reported. Close observation for improvement is necessary, although symptoms usually improve over time. In summary, to prevent access site complications, avoidance of multiple punctures, gentle catheter manipulation, use of guided compression, coupled with careful observation for adverse warning signs such as hematoma, loss of pulse, pain, are critical for safe and effective TRC.

Quantification of the distal radial artery for improved vascular access

“…In addition to the frequent use of the RA for drawing arterial blood gases and intra-arterial pressure monitoring, studies have demonstrated that there are many potential benefits of achieving arterial access through a transradial approach when compared to traditional transfemoral or transbrachial procedures [1,3,9,10,18,19,20,26,28]. However, some researchers have shown that the transradial approach is associated with increased rates of procedural failure overall [8].…”

“…Thus arterial access via the RA offers the advantage of increased ease of vascular access, increased ability to provide haemostasis, and decreased rates of access site complications including bleeding and haematoma development, arteriovenous fistula formation, aneurysm, limb ischaemia and nerve damage when compared to transbrachial or transfemoral approaches [1,3,9,10,14,18,19,26,28]. RA cannulation for PCI also touts improved patient tolerance, decreased length of patient hospital stay, decreased medical expenses [1,3,5,18,20,21], decreased nursing work-load [14,18] and decreased time to ambulation post procedurally [1,3,14,15,19,20,21,26,27] when compared to transbrachial or transfemoral approaches. Despite the rising use of the RA for vascular access, there is little consensus in the literature as to which point of the RA is the most appropriate site for cannulation.…”

“…The literature recommends cannulation anywhere from just proximal to the radial styloid [9], to 2 cm proximal to the radial styloid process [6,10] and 2-3 cm proximal from the flexural crease of the wrist [12,20] with little or no objective justification as to why these are the preferred sites. The presence of anatomic variations in the radial artery such as hypoplastic RAs, tortuosity greater than 35-45 degrees or abnormal branching patterns have all been associated with failure to puncture the RA, vasospasm and increased negative outcomes during attempted transradial-PCI including procedure failure [1,6,11,13,14,18,24,28] but the literature fails to objectively take these factors into account when making suggestions for appropriate vascular entry sites. The goal of our research is thus to quantify the anatomy of the distal RA in hopes of elucidating the most appropriate location to attempt to vascular access.…”

Arteriovenous Fistula as a Rare Early Complication of Transradial Coronary Angiography: With Literature Review on Management Strategies

“…The low incidence of AV fistula formation complicating transradial coronary angiography is illustrated in a recent large case series of 10,324 patients by Tatli et al, where only four cases of AV fistula were documented [1]. Patients with iatrogenic radial AV fistula are usually asymptomatic and typically present with a pulsatile mass, thrill, or bruit over the wrist [6,7]. The time to diagnosis can be variable from weeks up to a year from the angiography procedure.…”

Critical hand ischaemia after transradial cardiac catheterisation: an uncommon complication of a common procedure

“…Although postprocedure radial artery occlusion is a common complication, which occurs in 2-18 % of patients, it seldom leads to clinical events because of the protecting dual collateral perfusion of the hand [10]. Even though hand ischaemia with necrosis after transradial interventions is rare, its devastating nature underscores the importance of this complication.…”