Acute compartment syndrome: A rare but important complication of transradial cardiac catheterization

Abstract

The transradial approach has become the gold-standard for coronary angiography. It is better tolerated by patients, associated with less bleeding, earlier post-procedure mobilization, and reduced mortality in patients with myocardial infarction. Given the hand’s dual arterial supply and extensive collateral circulation, the risk of serious functional injury after radial catheterization is essentially reduced to zero. However, even a small amount of bleeding in the volar compartment can lead to compartment syndrome (CS) and permanent neurovascular injury. The purpose of this paper is to describe our experience with an unusual case of late-onset acute CS following transradial coronary angiography, and to summarize the available literature on this topic.

<Learning objective: The transradial approach has become the gold-standard for coronary angiography. However, in rare cases, this approach may be associated with bleeding and acute compartment syndrome. Patients on anticoagulants, and those who have severe atherosclerosis appear to be at increased risk of this complication. The diagnosis relies upon clinician awareness and vigilance, and affected patients require early decompressive fasciotomy to prevent permanent neurovascular injury.>

Introduction

The radial artery has become the favored route of access for diagnostic coronary angiography and percutaneous coronary intervention [1], [2], [3]. When compared with a transfemoral approach, it is associated with improved patient tolerance, earlier mobilization, less bleeding and, in a selected subset of patients with myocardial infarction, increased survival. The dual arterial supply of the hand is considered to largely remove the threat of acute ischemia in cases of radial artery thrombosis or vascular injury. However, given its small volume, small amounts of bleeding in the volar compartment may lead to neurovascular compromise and permanent functional impairment of the hand. This can develop quickly, and may only be associated with subtle clinical features.

Although compartment syndrome (CS) is a rare complication of transradial angiography, it’s significant consequences mandate that it be more widely recognized among interventionalists. Here we report an unusual case of CS with subsequent neuropraxia and severe functional impairment of the hand following transradial coronary angiography. We also review the existing literature relating to CS following transradial and transbrachial coronary access.

Case report

A 64-year-old man with a background of severe peripheral vascular disease and peritoneal dialysis for end-stage renal failure, was transferred to our institution with a non-ST-elevation myocardial infarction and Wellens syndrome on his electrocardiogram. He was given loading doses of aspirin, clopidogrel, and heparin, and prepared for angiography.

A coronary angiogram was carried out via an uncomplicated right radial artery puncture using a 6-Fr sheath. Intraoperative anticoagulation was achieved with 2000 international units of heparin, given as an intra-arterial bolus at the beginning of the case. The angiogram revealed severe triple-vessel disease with an acute thrombus overlying critical calcific stenosis of the left anterior descending artery. He was referred for coronary artery bypass surgery and his clopidogrel was ceased in preparation for this. The puncture site did not demonstrate any active bleeding following two hours of compression with a TR band^® (Terumo, Tokyo, Japan), which was then deflated by 1–2 ml every 10 min prior to being removed, as per our hospital protocol. Given intermittent episodes of angina, a heparin infusion was initiated at six-hours post sheath removal for perioperative anticoagulation.

Over the following twenty-four hours, there was mild discomfort with only minimal superficial bruising at the arterial puncture site. This was associated with a four to six hour period of supratherapeutic anticoagulation (activated partial thromboplastin time 127 s). On days two and three, he had increasing discomfort at the puncture site and was found to have a mildly swollen wrist. His hand remained warm, with a strong radial pulse and brisk capillary refill time distally. He was diagnosed as having a post-operative hematoma, which was managed with a compression garment and elevation.

On the morning of day four, he reported paresthesia in a median nerve distribution with a positive Phalen’s sign and significant tenderness associated with passive movement of the wrist. This prompted concern about acute CS and an urgent ultrasound scan was arranged. Sonography revealed a hematoma of heterogeneous density deep to the radial artery and flexor tendons (Fig. 1A–C). Although atherosclerotic, the radial artery remained patent, with normal Doppler flow and no evidence of pseudoaneurysm (Fig. 1D).

Fig. 1.

(A) Longitudinal view of the patent radial artery overlying a collection of hyperacute blood. (B) Transverse view of the radial artery with underlying mass of two densities. This represents hyperacute hemorrhage sitting above an organizing clot. (C) Longitudinal view of the hematoma with irregular border observed at the junction between acute and hyperacute blood. The flexor tendons and radial artery can be seen to lie above this collection. (D) Longitudinal view of the radial artery demonstrating normal Doppler flow.

An orthopedic consultation was sought, and the anterior compartment pressure was found to be 50 mm Hg. The diagnosis of acute CS was made and the patient underwent urgent volar fasciotomy, using a modified Henry approach with extension into carpal tunnel release, under general anesthesia. A hematoma was evacuated from beneath the flexor pollicis longus tendon.

Post-operatively, the patient went on to have bypass surgery, with five grafts. This was complicated by recurrent episodes of ventricular tachycardia, requiring cardioversion in the intensive care unit. He had mild neuropraxia of the right hand at discharge from hospital on day 16, although this had completely resolved by his two-month follow-up.

Discussion

Acute CS is a rare, yet hand-threatening, complication of transradial coronary angiography. We conducted an audit of transradial coronary angiograms that were complicated by CS at our institution between 01/01/2001 and 12/31/2015. Of the 1157 transradial procedures performed, only a single patient experienced CS, representing an incidence of 0.086%. Another case series has estimated this complication to arise in 0.004% of patients [4] and a systematic literature search revealed only four previously reported cases [4], [5], [6], [7]. These cases, and those resulting from transbrachial approaches, are summarized in Table 1.

Table 1.

Characteristics of patients with compartment syndrome following transradial and transbrachial coronary angiography.

	Author(s)	Year	Artery	Sheath size (Fr)	Time of onset (hours)	Source of bleeding	Closure delay (days)	Duration of follow-up (months)	Outcome
Arm	Tatli et al. [8]	2015	Brachial	6	4	Brachial art. perforation	NR	NR	NR
	Omori et al. [5]	2013	Brachial	7	0.5	Puncture site	8	31	Complex regional pain syndrome without associated neurological impairment
			Brachial	5	1	Perforation of branch of brachial art.	7	NR	Complete neurovascular recovery
	Segal and Adair [10]	1990	Brachial	NR	NR	NR	7	6	Ongoing radial nerve palsy, resolution of ulnar nerve palsy
Forearm	Omori et al. [5]	2013	Radial	5	0.5	Perforation of branch of brachial art.	10	NR	Complete neurovascular recovery
	Tizon-Marcos and Barbeau [4]	2008	Radial	NR	<1	Radial art. laceration	10	72	Complete neurovascular recovery
			Radial	4	72	Radial art. laceration	NR	36	Volkmann’s contracture with reduced mobility, pain and paresthesia
	Lin et al. [6]	2004	Radial	NR	∼12	Radial art. laceration	NR	NR	NR
	Lotan et al. [7]	1997	Radial	6	NR	NR	NR	NR	NR

NR, not reported; Fr, French; Art, artery.

The first reported case of CS following transradial angiography was reported in 1997. Three-quarters of reported cases emerged within 12 h of intervention with 4- or 5-French catheters, and all involved laceration of the radial or brachial arteries. All patients were managed with early decompressive fasciotomy under general anesthesia. At least three of the four patients had delayed primary closure of their wound. Outcome data were available in two of the four reports. One of these patients experienced complete neurovascular recovery, while the other had a Volkman contracture with reduced mobility.

The subject of the present report developed unusually delayed symptoms, with only one previously documented case arising after 24 h [5]. However, this nerve injury was secondary to a delayed bleed from the radial puncture site, rather than from an acute arterial laceration. Fortunately, despite a brief period of neuropraxia, he experienced a complete neurovascular recovery.

CS has also been reported to follow transbrachial coronary angiography. In one case, when a 7-French catheter was employed, bleeding occurred from the puncture site [5]. The remaining patients bled from perforation of the brachial artery or one of its tributaries [5], [8]. Among those patients with available outcome data, one experienced complete neurovascular recovery, while the other had persistent pain without associated neurologic impairment.

In cases of CS after both transradial or transbrachial approaches, unsuccessful hemostasis at the puncture site, or arterial laceration associated with sheath insertion or removal, seem to be the most common sources of bleeding [5]. Given their fragility, heavily atherosclerotic arteries would appear to be at greatest risk of significant bleeding following cannulation [9]. Anticoagulation, particularly if supratherapeutic, is likely to increase this risk.

CS is an uncommon, yet important, potential complication of transradial coronary intervention. Its diagnosis relies upon clinician awareness and vigilance, and affected patients require early decompressive fasciotomy to prevent permanent neurovascular injury.

Conflict of interest

The authors declare that there are no conflict of interest.