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This document discusses complications related to transradial catheterization. It begins by covering some anatomical considerations for complications, such as congenital variants of the arteries in the arm and forearm and arterial tortuosity. It then classifies and provides incidence rates for various complications including asymptomatic radial artery occlusion, radial artery spasm, and hand ischemia. Risk factors for different complications are also outlined. The bulk of the document focuses on prevention strategies such as careful case selection, use of small catheters and sheaths, spasmolytic cocktails, anticoagulation, and patent hemostasis techniques. Early detection and management of complications like perforation, pseudoaneurysm, and critical hand ischemia are also discussed.
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Halkin A
- 1. Complications of Transradial Catheterization: What to Look For and How to Avoid Them Amir Halkin Tel Aviv Medical Center Tel Aviv, Israel
- 2. Conflicts of interest None to declare
- 3. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009 âThe complications from radial artery access are trivial compared to femoral, with <4% loss of radial artery pulse as the worst of itâ http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
- 4. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009 âThe complications from radial artery access are trivial compared to femoral, with <4% loss of radial artery pulse as the worst of itâ âWhy do I persist with femoral artery access when complications from radial access are so much lower?â http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
- 5. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009 âThe complications from radial artery access are trivial compared to femoral, with <4% loss of radial artery pulse as the worst of itâ âWhy do I persist with femoral artery access when complications from radial access are so much lower?â âI left Quebec with the enthusiasm of a converted sinner, returning to UCI to begin our radial program âŚ.â http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
- 6. Transradial Catheterization Complications Radial Artery Catheterization: The way to go MORTON KERN, 2009 âThe complications from radial artery access are trivial compared to femoral, with <4% loss of radial artery pulse as the worst of itâ âWhy do I persist with femoral artery access when complications from radial access are so much lower?â âI left Quebec with the enthusiasm of a converted sinner, returning to UCI to begin our radial program âŚ.â http://www.cathlabdigest.com/articles/Radial-Artery-Catheterization-The-way-go
- 7. Transradial Catheterization Complications: What to Look for and How to Avoid Them Anatomical Considerations Classification and Incidence Prevention and Management
- 8. Transradial Catheterization Complications: What to Look for and How to Avoid Them Anatomical Considerations Classification and Incidence Prevention and Management
- 9. Transradial Catheterization Complications: Anatomical Considerations Congenital variants Arterial tortuosity Lo et al. Heart 2009 Rodriguez-Niedenfuhr et al. J Anatomy 2001
- 10. Transradial Catheterization Complications: Anatomical Considerations Congenital anatomical variants Location Variant Arm Superficial brachial Accessory brachial Arm and Forearm Brachio-radial Brachio-ulnar Brachio-interosseous Brachio-median Superficial brachio-radial Superficial brachio-ulnar Superficial brachio-ulnoradial Forearm Superficial radial Absent radial Absent ulnar Rodriguez-Niedenfuhr et al. J Anatomy 2001
- 11. Transradial Catheterization Complications: Anatomical Considerations Congenital anatomical variants Location Variant Arm Superficial brachial Accessory brachial â 2-3:1,000 Arm and Forearm Brachio-radial â 15:100 Brachio-ulnar Brachio-interosseous Brachio-median Superficial brachio-radial Superficial brachio-ulnar Superficial brachio-ulnoradial Forearm Superficial radial Absent radial Absent ulnar Rodriguez-Niedenfuhr et al. J Anatomy 2001
- 12. Transradial Catheterization Complications: Anatomical Considerations Congenital anatomical variants Location Variant Arm Superficial brachial Accessory brachial â 2-3:1,000 Arm and Forearm Brachio-radial â 15:100 Brachio-ulnar Brachio-interosseous Brachio-median Superficial brachio-radial Superficial brachio-ulnar Superficial brachio-ulnoradial Forearm Superficial radial Absent radial â 3:10,000 Absent ulnar â 1-2:10,000 Rodriguez-Niedenfuhr et al. J Anatomy 2001
- 13. Transradial Catheterization Complications: Anatomical Considerations Arterial tortuosity Location Variant Radial Loops Tortuosity Lo et al. Heart 2009
- 14. Transradial Catheterization Complications: Anatomical Considerations Arterial tortuosity Location Variant Radial Loops â 2.5:100 Tortuosity â 2:100 Lo et al. Heart 2009
- 15. Transradial Catheterization Complications: Anatomical Considerations Arterial tortuosity Location Variant Radial Loops â 2.5:100 Tortuosity â 2:100 n=1,560 4.6% 37% 13% 23% Lo et al. Heart 2009
- 16. Transradial complications Anatomical Considerations Classification and Incidence Prevention and Management
- 17. Transradial Catheterization Complications: Classification and Incidence Kanei al. CCI 2011 Event Rate Asymptomatic radial artery occlusion 2-18% Nonocclusive radial artery injury common Radial artery spasm 5-10% Sterile granuloma 2.8% Hand ischemia rare Perforation rare Pseudoaneurysm rare AV fistula rare Nerve damage rare Hemorrhge/transfusion rare
- 18. Transradial Catheterization Complications: Classification and Incidence Kanei al. CCI 2011 Event Rate Asymptomatic radial artery occlusion 2-18% Nonocclusive radial artery injury common Radial artery spasm 5-10% Sterile granuloma 2.8% Hand ischemia rare Perforation rare Pseudoaneurysm rare AV fistula rare Nerve damage rare Hemorrhge/transfusion rare
- 19. Transradial Catheterization Complications: Risk Factors Event Risk factors â˘Prolongedhigh pressure compression Asymptomatic radial artery occlusion â˘âSheath/Artery diameter â˘Multiplepuncture attempts Nonocclusive radial artery injury â˘Tortuous anatomy â˘Radialartery occlusion Hand ischemia â˘Negligent evaluation of palmar arch circulation Radial artery spasm â˘Small caliber vessel/large sheaths â˘Multiple catheter exchange â˘Inadequate premedication Perforation â˘Tortuous anatomy â˘Aggressive wiring Pseudoaneurysm â˘Multiple punctures â˘Excessive anticoagulation â˘Large sheaths AV fistula â˘Multiple punctures Sterile granuloma â˘Cook sheaths Nerve damage â˘Multiple punctures
- 20. Transradial Catheterization Complications: Risk Factors Event Risk factors â˘Prolongedhigh pressure compression Asymptomatic radial artery occlusion â˘âSheath/Artery diameter â˘Multiplepuncture attempts Nonocclusive radial artery injury â˘Tortuous anatomy Operator-related factors: â˘Radial artery occlusion Hand ischemia â˘multiple punctures â˘Negligent evaluation of palmar arch circulation â˘inadequate âspasmolysisâ/anticoagulation Radial artery spasm â˘Small caliber vessel/large sheaths â˘large caliber cathetersâ˘Multiple catheter exchange â˘multiple catheter exchanges premedication â˘Inadequate â˘Tortuous anatomy â˘aggressive wiring Perforation â˘Aggressive wiring â˘occlusive hemostasis â˘Multiple punctures Pseudoaneurysm â˘Excessive anticoagulation â˘Large sheaths AV fistula â˘Multiple punctures Sterile granuloma â˘Cook sheaths Nerve damage â˘Multiple punctures
- 21. Transradial Catheterization Complications: Radial Occlusion and Critical Hand Ischemia Case Report (I) Kanei et al. CCI 2011
- 22. Transradial Catheterization Complications: Critical Hand Ischemia
- 23. Transradial Catheterization Complications: Critical Hand Ischemia âHand ischemia with necrosis has never been reported during TRC with thorough pre-examination of intact collateral circulationâŚâ
- 24. Transradial Catheterization Complications: Case Report (II) 56 y.o. â Suspected troponin positive ACS Urgent TRC cath (negative Allen test) â NCA Severe âhand painâ Physical exam reportedly normal, palpable radial pulse â required opiates Doppler study â radial artery occlusion
- 25. Transradial Catheterization Complications: Case Report (II) Vascular surgery consult: heparin, analgesia
- 26. Transradial Catheterization Complications: Case Report (II) RAO can result in critical hand ischemia (i.e., tissue loss) despite dual palmar arch supply !!!
- 27. Transradial complications Anatomical Considerations Classification and Incidence Prevention and Management
- 28. Transradial Catheterization Complications: Prevention Case selection Access Negotiation of upper extremity vasculature Hemostasis
- 29. Transradial Catheterization Complications: Prevention Case selection â˘Age, gender â˘Co-operative patient â˘Palmar arch circulation Access Negotiation of upper extremity vasculature Hemostasis
- 30. Transradial Catheterization Complications: Prevention Case selection â˘Age, gender â˘Co-operative patient â˘Palmar arch circulation Access Negotiation of upper extremity vasculature Hemostasis
- 31. Transradial Catheterization Complications: Prevention Case selection â˘Age, gender â˘Co-operative patient â˘Palmar arch circulation Access â˘Liberal anesthesia, analgesia & sedation â˘Small caliber catheters â˘Spasmolytic cocktail â˘Hydrophilic sheaths â˘Anticoagulation (i.v.=i.a., weight adjusted dose) Negotiation of upper extremity vasculature Hemostasis
- 32. Transradial Catheterization Complications: Prevention Case selection â˘Age, gender â˘Co-operative patient â˘Palmar arch circulation Access â˘Liberal anesthesia, analgesia & sedation â˘Small caliber catheters â˘Spasmolytic cocktail â˘Hydrophilic sheaths â˘Anticoagulation (i.v.=i.a., weight adjusted dose) Negotiation of upper extremity vasculature â˘Avoid non-J-tipped 0.035â wires >> 0.014â â˘Liberal fluoroscopic guidance â˘Anticipate spasm and adverse anatomic features Hemostasis
- 33. Transradial Catheterization Complications: Prevention Case selection â˘Age, gender â˘Co-operative patient â˘Palmar arch circulation Access â˘Liberal anesthesia, analgesia & sedation â˘Small caliber catheters â˘Spasmolytic cocktail â˘Hydrophilic sheaths â˘Anticoagulation (i.v.=i.a., weight adjusted dose) Negotiation of upper extremity vasculature â˘Avoid non-J-tipped 0.035â wires >> 0.014â â˘Liberal fluoroscopic guidance â˘Anticipate spasm and adverse anatomic features Hemostasis â˘âPatent hemostasisâ
- 34. Transradial Catheterization Complications: Prevention: Palmar arch circulation â˘absent ulnar 0.01-0.03% â˘radial/ulnar atherosclerosis 1% Not every routine practice is supported by a RCT: e.g., Antibiotics for pneumococcal pneumonia, Jumping out of an aeroplane with a parachute Just Test It!!!
- 35. Transradial Catheterization Complications: Prevention: Palmar arch circulation Barbeau Test Barbeau et al. AHJ 2004 2 separate series: n=1,010 n=7,049 No cases of acute hand ischemia
- 36. Transradial Catheterization Complications: Prevention: Patent hemostasis Pancholy et al. PROPHET. CCI 2008 n=436 conventional patent 12% hemostasis âBarbeau testâ 7% radial artery patency @ 24-hr, 30-d 5% 1.8% 1.8%
- 37. Transradial Catheterization Complications: Prevention: Patent hemostasis Pancholy et al. PROPHET. CCI 2008 n=436 conventional patent 12% hemostasis âBarbeau testâ 7% radial artery patency @ 24-hr, 30-d 5% 1.8% 1.8% âPatent hemostasisâ reduces risk of radial occlusion
- 38. Transradial Catheterization Complications: Prevention and Management Event Prevention/Management â˘Anticoagulation Radial artery occlusion â˘Patent hemostasis Nonocclusive radian artery injury â˘Careful evaluation prior to harvesting for CABG Hand ischemia â˘Careful examination of palmar circulation â˘Smallcaliber sheaths/catheters Radial artery spasm â˘Hydrophilic catheters â˘Premedication â˘Avoid 0.035â hydrophilic wires/fluoroscopy guidance Perforation â˘Early detection Pseudoaneurysm â˘Compression â˘Thrombin injection AV fistula â˘Surgery Sterile granuloma â˘Removal of hydrophillic coating Nerve damage â˘Supportive care
- 39. Transradial Catheterization Complications: Prevention and Management Event Prevention/Management â˘Anticoagulation Radial artery occlusion â˘Patent hemostasis Nonocclusive radian artery injury â˘Careful evaluation prior to harvesting for CABG Prevention: Hand ischemia â˘Verify functionality of â˘dual examination arch supply Careful palmar of palmar circulation (Allen, Barbeau tests) â˘Small caliber sheaths/catheters Radial â˘Technique and dedicated devices artery spasm â˘Hydrophilic catheters â˘Patent hemostasis â˘Premedication â˘Avoid 0.035â hydrophilic wires/fluoroscopy guidance Perforation â˘Early detection Pseudoaneurysm â˘Compression â˘Thrombin injection AV fistula â˘Surgery Sterile granuloma â˘Removal of hydrophillic coating Nerve damage â˘Supportive care
- 40. Transradial Catheterization Complications: Prevention and Management of Critical Hand Ischemia What should be done when radial occlusion is detected? Recognize the potential consequences Avoid nihilism Ulnar artery compression for radial artery occlusions Early angiography and intervention for CHI
- 41. Transradial Catheterization Complications: Prevention of Hand ischemia Ulnar compression can resolve early radial occlusion Berant et al. AJC 2011 n=465 i.v. heparin i.v. heparin 2000u 5000u TR hemostatic band 3-4 hour duplex RAO 1-hr ulnar occlusion
- 42. Transradial Catheterization Complications: Prevention of Hand ischemia Ulnar compression can resolve early radial occlusion Berant et al. AJC 2011 n=465 i.v. heparin i.v. heparin 2000u 5000u TR hemostatic band 3-4 hour duplex RAO 1-hr ulnar occlusion
- 43. Transradial Catheterization Complications: Management of Hand ischemia Early angiography and intervention for critical hand ischemia Kawarada et al. CCI 2010
- 44. Transradial Catheterization Complications: Summary Though generally very safe, serious potential complications of TRC should be recognized Most complications are easily avoided by simple preventive measures (case selection, technique and dedicated devices, patent hemostasis) Early detection and intervention should may prevent permanent radial occlusion and critical hand ischemia
- 45. Transradial Catheterization Complications Radial vs. Femoral Access RIVAL. LANCET 2011 4.0% 3.7% p=0.9 CURRENT sub-study n=7,021 10: death/MI/CVA/non CABG bleed femoral radial 0.5% 3,514 3,507 p=0.23 0.3% 20: non CABG bleed
- 46. Transradial Catheterization Complications Radial vs. Femoral Access RIVAL. LANCET 2011 Radial Femoral p=0.23
- 47. Transradial Catheterization Complications: Anatomical Considerations Radial Anomaly vs. No Radial anomaly Lo et al. Heart 2009
- 48. Transradial Catheterization Complications: Prevention: Access Hydrophilic sheath use reduces radial spasm Rathore et al. JACC CArdiovasc Interv 2010 n=790 hydrophilic no coat 13cm 23cm
- 49. Transradial Catheterization Complications: Prevention: Access Route of heparin administration has no impact on radial occlusion rates Pancholy SB et al. AJC 2009 n=500
- 50. Transradial Catheterization Complications: Prevention: Access â˘Local anesthesia, liberal analgesia & sedation â˘Small caliber catheters â˘Spasmolytic cocktail â˘Hydrophilic sheaths â˘Anticoagulation Hydrophilic sheath use reduces radial spasm Rathore et al. JACC CArdiovasc Interv 2010 Route of heparin administration has no impact on radial occlusion rates Pancholy SB et al. AJC 2009
- 51. Transradial Catheterization Complications: Prevention: Upper Extremity Vessel Negotiation â˘Minimize use of non-âJ-tippedâ 0.035â wires â˘Fluoroscopic guidance/road mapping â˘Anticipate spasm/adverse anatomy
- 52. Transradial Catheterization Complications: Prevention: Upper Extremity Vasculature