Radial artery perforation: when a friend turns against you
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Radial artery approach is currently the most common access site for coronary angiography and percutaneous coronary intervention. It rarely results in complications, improves patient comfort, and reduces the duration of hospitalization.
A 91-year-old woman presented to our institution with ST-segment elevation myocardial infarction (STEMI). The right radial access was chosen for the performance of percutaneous coronary intervention. After the introduction of 6 F sheath, there was difficulty in the advancement of 0.035 J wire that was exchanged with a Terumo hydrophilic wire. After the procedure and before sheath removal, radial arteriography was done and revealed perforation. Protamine sulfate was administered and prolonged balloon inflation was attempted but failed to seal the perforation, so a 7-F-long vascular sheath was inserted to internally tamponade the vessel, and the patient was sent to the coronary care unit for monitoring. Over the next 3 days, serial radial angiographies were done revealing the persistence of the perforation, and on the fourth day, angiography revealed multiple thrombi. Thrombus aspiration was done using Pronto V4 extraction catheter (Vascular Solutions, USA) and was followed by the deployment of a covered stent. The stent was dislodged and successfully snared. Finally, the perforation was sealed spontaneously and there were no signs of intra-arterial thrombi.
Despite the very low complication rate of radial approach, the interventional cardiologist should be aware of any possible complication, and how to avoid or, eventually, manage it.
KeywordsRadial artery perforation
Percutaneous coronary intervention
ST-segment elevation myocardial infarction
Activated partial thromboplastin time
Radial artery approach is currently the most common access site for coronary angiography and percutaneous coronary intervention (PCI) since it results in fewer local vascular complications than transfemoral approach. This approach rarely results in complications, improves patient comfort, and reduces the duration of hospitalization .
Radial artery perforation is a rare complication (< 1%) and often leads to forearm hematoma . Conservative management including neutralization of heparin, crossing with a wire, and deployment of either a long sheath or guide catheter across and external compression by sphygmomanometer cuff may help in sealing the perforation . In some rare cases, in case of persistance of the perforation, balloon angioplasty or use of covered stent has been described . This case is unusual in that the perforation did not seal conservatively at first together with the heavy thrombus burden that was managed by thrombus aspiration, which is rarely used in the management of such cases.
Despite the very low complication rate of radial approach, the interventional cardiologist should be aware of any possible complication, and how to avoid or, eventually, manage it .
ME was the cooperator and drafted the manuscript. GD was in charge of the patient in the ICU. RL revised the manuscript. BC was the primary operator. All authors have read and approved the final manuscript.
The authors did not receive any funds.
Ethics approval and consent to participate
The case report did not require ethics committee approval as no new treatment modality was used or drug was tested. In addition, no patient’s data information was revealed.
Consent for publication
Verbal consent was obtained as the patient was right-handed and the procedure was done via right radial approach. The consent was an informed consent, and the patient agreed based on the fact that this case report will help other patients. I consent on behalf of the other authors to publish this case report.
The authors declare that they have no competing interest.
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