TransRadial Coronary Intervention (TRI)–related complications: How to prevent? Sang-Yong Yoo, M.D. Department of Cardiology Ulsan college of Medicine Gangneung Asan Hospital

Incidence of Radial artery complications Meta-analysis of 12 randomized trials (1989 ~ 2003) 0.3% vs. 2.8% (transradial vs. transfemoral) 1 arteriovenous fistula 1 perforation of brachial artery requiring surgery 1 hematoma >3cm 2 others Agostoni P, et al. JACC 2004;44:349-56

Incidence of Radial artery complications Randomized trial (2006 ~ 2008) First randomized trials (n=1,124) comparing access site complications after coronary procedures via transradial versus transfemoral access with a closure devices. 0.58% (3 patients in 512) vs. 3.71% (transradial vs. transfemoral) No beating radial artery pulse without forearm ischemia Brueck M, et al. JACC 2009;2:1047-54

Transradial complications Vagal reactions Radial artery spasm Radial artery occlusion Bleeding/Dissection/Perforation Radial artery fistula Pseudoaneurysm Chronic pain/neuralgia Cerebral embolism Others

Pain/Vagal reactions Decreasing pain and anxiety During sheath insertion, procedural hypotension requiring treatment with atropine occurs frequently. Hildick-Smith DJ, et al. Int J Cardiol 1998;64:231. May be exacerbated by verapamil. Decreasing pain and anxiety Between 1 to 3 hours before the start of a procedure A eutectic mixture of local anesthetic (EMLA) cream (lidocaine 2.5% and prilocaine 2.5%) 가격: 수가 6,000원, 보험상한 3,960원 Kim JY J Invasive Cardiol 2007;19:6-9.

Incidence of Radial artery spasm (RAS) 22% (8% on med.) - Kiemeneij F, et al (N=100) (CCI 2003;58:281–284) 22.2% - The SPAMS study (N=1,219) (CCI 2006;68:231-235) Fukuda, et al diagnosed RAS through radial artery angiography and found that RAS occurred in most patients through transradial approach. (Jpn Heart J 2004; 45: 723-731)

Incidence of Radial artery spasm

Risk factors for Radial artery spasm The SPASM study found that young and female were the independent predictors of RAS. (Catheter Cardiovasc Interv 2006; 68: 231) Saito et al found that the inner diameter of radial artery was an independent predictor of RAS. (Catheter Cardiovasc Interv 1999; 46: 173) In vitro studies showed that patients with diabetes had serious endothelial dysfunction and the radial artery was prone to spasm. (J Am Coll Cardiol 2007; 50:1047)

Risk factors for Radial artery spasm

Prevention of RAS Single puncture Kiemeneij F pointed out, a straightforward, accurate, single puncture will lower the risk of spasm. (J Invasive Cardiol 2006;18:159.) In the introduction of Turkey experience, Vefali and Arslan deemed that the best measure to prevent RAS was the least number of access attempts. (Turk Kardiyol Dern Ars 2008;36:163.)

Prevention of RAS Antispasmodics Chen CW Cardiology 2006;105:43-47.

Prevention of RAS ”Cocktail” “Cocktail”= 200ug Nitroglycerin+ 5mg Verapamil Maximal pullback force (Kg) Kiemeneij F CCI 2003;58:281-284.

Prevention of RAS Verapamil, Molsidomine Catheter Cardivasc Interv 2006;68:231-235.

Prevention of RAS Hydrophilic-coated sheath Short sheath (13cm) Hydrophilic coated Uncoated Long sheath (23cm) OR 2.87; 95% CI 2.07-3.97, p<0.001) Rathore JACC Cardiovasc interv 2010;3:475-83.

Prevention of RAS Others Smaller catheter Restricting catheter maneuvers and exchanges Use an exchange length hydrophilic guidewire that is maintained in a stable position in the ascending aorta to prevent spasm at radial or brachial artery.

Extraction of the radial artery 6 Fr sheath 500 ug nitroglycerin

Resistant radial artery spasm Even after the use of a vasodilator, RAS has been reported in up to 20% of the patients (Kim Sh et al. Int J Cardiol 2007; 120: 325). Ana do lu Kar di yol Derg 2010;10:90

Incidence and Risk factors for Radial artery occlusion 2~10% Prolonged cannulation Sheath size Anticoagulation Hemostasis Youakim S. Occupational Medicine 2006;56:507

Prevention of acute radial occlusion Heparin less than 3,000 U female radial artery diameter (<2.7mm) No predictive factor of radial occlusion in patients receiving 5,000 U of heparin. p<0.05 p<0.05 Spaulding C, et al. Cathet Cardiovasc Diag 1996;36:365

Acute radial artery occlusion Sheath size Saito, et al. CCVI 1999;46:173/Nagai et al, AJC 1999;83:180

Late (95 days) radial artery occlusion Risk factors Radial artery diameter Difference in radial artery diameter and sheath size Diabetes mellitus 38% vs. 14% (p=0.0006) Nagai et al. AJC 1999;83:180

Radial artery occlusion Repeat procedure a = Cross-over to femoral artery b = p<0.05 Distal radial artery (5~25mm) First TRI Repeat PCI P Lumen area (mm2) 5.27 ± 1.21 4.5 ± 0.99 <0.01 Intima-media thickness (mm) 0.31 ± 0.07 0.46 ± 0.10 MLD (mm) 2.43 ± 0.32 2.23 ± 0.26 Yoo BS, et al. CCVI 2003;58:301 Wakeyama et al. JACC 2003;42:1109

Treatment of symptomatic radial artery thrombosis Small pilot study not randomized, double- blinded design symptomatic occlusion – LMWH 4 weeks asymptomatic occlusion – no treatment Patency Modified from Kim KS, et al. J Cardiovasc Ultrasound 2010;18:31 Zankl AR et al. Clin Res Cardiol 2010;99:841

Allen’s test Shows Intact Palmar Arch Edgar V. N. Allen (1900-1961) Professor of Medicine at the Mayor Clinic. But, an abnormal Allen’s test has never been predictive of ischemic injury from an arterial line. (J Trauma 2006;206:468.) Wallach SG. Am J Critical Care 2004;13:315 On the basis of the modified Allen’s test ≤ 9 seconds criteria, 6.3% of patients were excluded from TRI PL and OX type A,B, and C, only 1.5% of patients were excluded. Barbeau GR, et al. Am Heart J 2004;147:489

Hemostasis technique p<0.05 p<0.05 Preserve long term radial function by maintaining distal perfusion during hemostasis Pancholy S, et al. CCI 2008;72:335

Root of Most Problems Abundant forearm branches Anatomical variations Luz A, et al. Eurointervention 2009;5:1

Radial artery anomaly and procedural outcome 7% 2.3% 2.0% 2.5% Types of radial anomaly and their rates of procedural failure Lo TS, et al. Heart 2009;95:410

Radial loop and Radial recurrent artery Avulsion of radial recurrent artery

Causes of bleeding/perforation Overzealous advancement of a wire Hydrophilic wires useful in overcoming tortuous segment or radial loops increase the risk of perforation Wire should never be advanced against resistance

Classification of Local bleeding Type I: ≤ 5 cm Type II: ≤ 10 cm Type III: > 10 cm, but not above elbow Type IV: extending above elbow Type V: anywhere with ischemic threat of the hand (compartment syndrome) Bertrand OF et al. 2009;157:164-9.

Compartment syndrome 0.4% (overestimated) Unrecognized perforation Unsuccessful compression Radial artery laceration during sheath insertion or removal

Compartment syndrome not due to bleeding or hematoma The tissue pressure exceeded 100 mm Hg. The forearm muscles are swollen. No bleeding or hematoma is noted. The patient’s forearm 1 hr after the transradial intervention. The right forearm is stiffer and more swollen than the left forearm. we suspect that an arterial spasm induced by the radial sheath or catheter resulted in ischemia of the forearm muscles. The forearm muscles are greatly swollen and partially necrosed, but hematoma or signs of hemorrhage are not noted. Araki T, et al. CCI 2010;75:362-365

Prevention/Solution Look under fluoroscopy during wiring. Don’t push – push and perforation will happen. If in doubt take a picture. Early detection!

Pseudoaneurysm Rare complication Usually the result of inadvertent perforation of an anomalous radial artery.

Arteriovenous fistula 2004 diagnostic CAG via Rt. radial artery (6 Fr.) 2008 single vessel PCI via Rt. radial artery (6 Fr.) 2010 Pulsatile mass 0.3% in femoral access (Kent KC et al. J Vasc Surg 1993;17:125), N=1,838. Radial artery AV fistula after catheterization procedures (4 cases were reported) Case 1. 64/M Pulikal et al. Circulation 2005 Case 2. 59/M Spence et al. Can J Cardiol 2007 Case 3. 61/M Spence et al. Can J Cardiol 2007 Case 4. 67/M Kwac MS et al. Korean Cir J 2010

Sheath-related complications Sterile abscess with use of hydrophilic-coated sheath 5% foreign body reaction 2~3 weeks after procedure Remnant of silicone Several weeks after radial cardiac catheterization with a 6-F Cook hydrophilic sheath, a sterile abscess formed between the skin and radial artery. The patient had local pain without systemic symptoms. This was treated with surgical drainage and local skin care with resolution over several weeks.

Hemostasis Complications Handcuff Injuries Tighter is not better

Chronic pain (Complex Regional Pain Syndrome: CRPS 1) 46-year old anesthesiologist Allen’s test (-) 6 Fr, 23 cm sheath 10,000 U heparin 6 Fr pigtail catheter, 6 Fr JL4 20 hr hemostasis (Hemaband) Over several months, cold intolerance, burning sensation, parasthesias, and loss of pulse Retire Papadimos TJ, et al. Cathet Cardiovasc Interv 2002;57:537.

Dissection of arteria lusoria Success rate only 60% by transradial approach (Valsecchi O, et al.Catheter Cardiovasc Interv 2006;67:870–8.) ….the guide wire (0.035 inch; Terumo Corp., Tokyo, Japan) was prone to advance into the descending aorta. After several attempts, the guide wire passed into the ascending aorta. However, resistance was encountered while advancing a pigtail catheter (5- Fr; Bard Inc., Murray Hill, NJ, USA). Stasis of contrast medium was noted after test injection of 5 mL of contrast medium……. J Chin Med Assoc 2009;72(7):379–381

Cerebral embolism TCD (transcranial Doppler) 92.1% gaseous 7.9% solid more solid microemboli in transradial 57 vs. 36, p=0.012) in right MCA During catheter flushing, ventriculography p=0.567 Cautious manipulation and gentle advancement of guidewire and catheters especially aortic arch and aorto-subclavian junction Exchange of catheters over the guidewires while leaving them in the ascending aorta. Lund C, et al. Eur Heart J 2009;26:1269

Conclusion Meticulous technique, appropriate preventive measures, and early recognition of problems are fundamental in avoiding unnecessary morbidity and mortality associated with these risk. Complications arising from radial arterial access are infrequent and are usually avoidable.