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

2. 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

3. 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:

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

5. 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.

6. 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: )
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: )

7. Incidence of Radial artery spasm

8. 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)

9. Risk factors for Radial artery spasm

10. 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.)

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

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

13. Prevention of RAS Verapamil, Molsidomine
Catheter Cardivasc Interv 2006;68:

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

15. 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.

16. Extraction of the radial artery
6 Fr sheath
500 ug nitroglycerin

17. 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

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

19. 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

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

21. 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

22. 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

23. 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

24. Allen’s test Shows Intact Palmar Arch
Edgar V. N. Allen ( )
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

25. 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

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

27. Radial artery anomaly and procedural outcome7%
2.3%
2.0%
2.5%
Types of radial anomaly and their rates of procedural failure
Lo TS, et al. Heart 2009;95:410

28. Radial loop and Radial recurrent artery
Avulsion of radial recurrent artery

29. 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

30. 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.

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

32. 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:

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

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

35. 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

36. 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.

37. Hemostasis Complications Handcuff Injuries
Tighter is not better

38. 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.

39. 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

40. 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

41. 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.