Iatrogenic Radial Recurrent Artery Perforation in Coronary Intervention

Abstract

An 80-year-old man underwent percutaneous coronary intervention of the left anterior descending coronary artery for intractable angina. During catheter advancement, he experienced an iatrogenic perforation of the radial recurrent artery that was successfully managed by covered stent placement in the radial artery, effectively occluding the radial recurrent branch. (Level of Difficulty: Intermediate.)

Graphical abstract

An 80-year-old man underwent percutaneous coronary intervention of left anterior descending coronary artery for intractable angina. During catheter…

History of Presentation

An 80-year-old Caucasian man was referred for elective percutaneous coronary intervention (PCI) for intractable angina. Previous diagnostic coronary angiography had shown severe mid left anterior descending coronary artery (LAD) stenosis. His right radial artery was occluded after his diagnostic procedure, so left radial access was planned.

Learning Objectives

• •Operators should be aware of perforation as a complication of radial access and the importance of early recognition and definitive management to reduce the risk for subsequent compartment syndrome.
• •Operators should understand the management options for radial perforation, including the use of covered stents should conservative management steps fail.

Left radial access was obtained using a 6-F Glidesheath Slender (Terumo, Tokyo, Japan). A 6-F extra backup guide was selected for the intervention and advanced over a 0.035-inch J-tipped guidewire. The guidewire would not advance beyond the (left) radiohumeral joint. However, the guide catheter was accidentally advanced beyond the wire tip. This was recognized early; the guidewire was removed, and a contrast injection was performed (Video 1). This showed diffuse contrast staining. The guide was the pulled back, and repeat angiography was performed with 3 ml of contrast (Figure 1). This showed a perforation of the proximal radial recurrent artery, with the proximal radial artery in secondary spasm.

Online Video 1.

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Contrast Injection After Guidewire Removal Shows Extensive Contrast Extravasation Into an Artery, Which Later Was Shown to Radial Recurrent Branch

Figure 1.

Radial Angiogram Showing Catheter-Induced Perforation of the Radial Recurrent Artery Below the Brachial Bifurcation

See Video 1.

Medical History

The patient was known to have hypertension and hypercholesterolemia, with normal renal function and hemoglobin level. Percutaneous intervention was decided as the best method of revascularization, per American and European guidelines.

Differential Diagnosis

With extensive contrast staining, the differential diagnoses were radial artery perforation, brachial artery perforation, radial artery dissection, or a branch (of the radial) artery perforation.

Investigations

Because dissection of the artery was a possibility, strong antegrade injection was not performed. Gentle injections with 3 ml of contrast showed a perforation at the proximal part of the radial recurrent artery. The radial artery cranial to the radial recurrent branch was in vasospasm secondary to catheter-induced injury (Video 2).

Online Video 2.

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Contrast Injection After Pulling Back the Guidewire Shows Perforation of Proximal Part of Radial Recurrent Branch, With Spasm of the Proximal Main Radial Artery

Management

A floppy tip 0.014-inch angioplasty wire (Versaturn, Abbott Laboratories, Lake Bluff, Illinois) was carefully advanced across the origin of the radial recurrent branch into the proximal radial artery and then into the aortic root. The extra backup guide catheter could not be advanced easily over the wire, so balloon tracking using a 2.5 × 15 mm semicompliant balloon (inflated to 4 atm) was performed to allow guide advancement. PCI to the LAD was then performed without complication (Figures 2A and 2B).

Figure 2.

Stenosis of the Mid LAD

(A) Severe stenosis of the mid left anterior descending coronary artery (LAD). (B) Treated mid LAD stenosis.

The procedure was completed in 40 min. Intra-arterial heparin was used as sole anticoagulant agent, with activated coagulation time guidance (target 250 to 300 s maintained throughout). After completion of the coronary intervention, the guide was withdrawn back into the brachial artery, leaving a Versaturn wire in the left subclavian artery. Brachial angiography was performed with 5 ml of contrast, during which time the catheter was pulled back into the radial artery. This again demonstrated contrast extravasation from the radial recurrent branch (Figure 3).

Figure 3.

Post-PCI Brachioradial Angiogram Showed Persistent Leak Into the Radial Recurrent Branch and Contrast Extravasation

See Video 2. PCI = percutaneous coronary intervention.

Initial attempts to occlude the radial recurrent branch perforation with a 2.5 × 15 mm semicompliant balloon were made, with 2 episodes of 10-min inflations. However, this did not successfully occlude the artery and control the perforation (Figure 4A). A 2.5 × 18 mm pericardium covered stent (Aneugraft, ITGI Medical, Or Akiva, Israel) was then implanted across the radial recurrent branch. There was still flow into the radial recurrent branch after stent implantation (Video 3), which was managed with post-dilatation of the stent, first with a 3-mm and then with a 4-mm noncompliant balloon (Figures 4A and 4B). This successfully occluded the radial recurrent branch and ended contrast extravasation (Figure 4C, Video 4).

Figure 4.

Sealing of the Radial Recurrent Branch

(A) Balloon tamponade failed to occlude the radial recurrent branch. (B) Covered stent reduced the flow but did not stop it completely. See Video 3. (C) After post-dilatation of covered stent with a 4-mm noncompliant balloon, the radial recurrent branch was sealed completely. See Video 4.

Online Video 3.

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A 2.5-mm Covered Stent Did Not Stop Flow Into the Radial Recurrent Artery

Online Video 4.

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A 4-mm Noncompliant Balloon Dilatation Occludes Flow Into the Radial Recurrent Branch

Discussion

Radial artery access is recommended over femoral artery access for coronary interventions by the European Society of Cardiology (1). Compared with femoral access, radial access is shown to reduce major bleeding, vascular complications, and major acute cardiovascular events (2). Analysis of a large American registry of more than 290,000 patients with ST-segment elevation myocardial infarction showed that transradial access resulted in lower risk for bleeding and lower in-hospital mortality (3). The large randomized MATRIX trial, which compared transradial and femoral access in acute coronary syndromes, showed that radial access reduced bleeding risk and 30-day mortality compared with femoral access.

Access-site complications are extremely rare in radial access, occurring in <1% of cases (4). Vessel spasm, hematoma, dissection, perforation, and compartment syndrome can complicate radial access procedures, with spasm being the most common and usually occurring with no sequelae (4). Increased tortuosity in the radial artery can increase the risk for complications, as was seen in this patient (Figures 1 and 4). Perforation is a rare complication in transradial access. In a large series of 10,324 patients undergoing radial access coronary procedures, radial perforation occurred in 8 patients (0.08%) (5). Once recognized, radial perforations can be overcome using a balloon-assisted tracking technique to advance a guide, or by using a sheathless guide (6). The guide allows coronary intervention to be completed while tamponading the radial artery perforation. Guide tamponade is a sufficient treatment in most cases, resulting in closure of the perforation by the end of the procedure (6). Insertion of extra long sheaths (up to 23 cm) extending into the brachial artery has also been described, thereby sheath-tamponading the perforation (7). This is considered a useful option if multiple catheter exchanges are expected but comes at the recognized increased risk of placing a large sheath in the brachial artery. Simultaneous external compression with a manual blood pressure cuff can also aid in achieving hemostasis. If there is persistent radial contrast extravasation, prolonged balloon tamponade across the perforation is the logical next step (8). If this fails to stop the contrast leak, then a covered stent can be deployed across the perforation.

Advanced age, female sex, shorter stature, and hypertension are risk factors for radial artery perforation (7). Radial artery spasm, a small-caliber vessel, anatomic variations including radial loop, and aggressive catheter manipulation can also contribute to the occurrence of perforation (8). In this case, perforation occurred because of the advancement of a guiding catheter beyond the guidewire into the radial artery.

To our knowledge this is the first reported case of radial recurrent artery perforation during coronary intervention, treated by the deployment of a covered stent across the radial recurrent branch. Because the left arm was positioned across the patient’s body to allow the operator to reach from the right side, the patient’s left elbow was maintained in a flexed position during the procedure. On reflection, this could have led to selective wire and subsequently catheter advancement into the radial recurrent branch during wire advancement. Strategies that may have reduced the perforation risk in this case and should be considered by all operators when using left radial access, include advancement of the wire across a straightened left elbow as well as careful catheter manipulation.

If forearm swelling is noted post-procedure, external compression with a manual blood pressure cuff inflated to 10 to 15 mm Hg below systolic pressure for 2 periods of 15 min is recommended (9). Unrecognized radial perforations can lead to continuous bleeding into the forearm and can cause compartment syndrome (10). The normal pressure in the forearm compartments is <10 mm Hg, and a pressure >30 mm Hg suggests the development of compartment syndrome (10). Surgical fasciotomy is the definitive treatment for compartment syndrome, which if untreated can lead to tissue ischemia and significant long term-sequelae (10).

Follow-Up

The patient was subsequently reviewed in the outpatient clinic 6 weeks after the procedure and had made a full recovery with no ongoing vascular complications.

Conclusions

Perforation is a rare complication in radial access coronary interventions. Dissection and perforation of the radial artery or its branches is possible as described. Operators should remain calm and use a stepwise approach to manage the situation. Balloon tracking techniques can be used to allow the radial procedures to be completed despite significant endothelial trauma.