Anesthesiologists have long known the complications of radial artery (RA) cannulation.1 We present the case of a patient who underwent emergency vascular surgical intervention to treat complications related to the use of a transradial cardiac catheterization (TRAC) sheath for perioperative hemodynamic monitoring after an emergency coronary artery bypass grafting (CABG) procedure.
TRAC procedures cause temporary and permanent changes in the RA wall and lumen. There is histologic and radiologic evidence that smooth muscles become hypertrophic, and there is disruption of the endothelial cells, which causes narrowing of the RA in some patients. Anesthesiologists need to be aware of the short-term and long-term consequences of this intervention, including nonocclusive RA injury and asymptomatic RA occlusion, as in our patient (Table 1).
Because only 1 patient was involved, our institution did not require us to apply for IRB approval to publish this case report. Nonetheless, we attempted to contact the patient, but we received no reply. The manuscript was written in compliance with hospital and Health Insurance Portability and Accountability Act regulations. The manuscript was approved by the Health Insurance Portability and Accountability Act officer at our institution.
A 73-year-old man presented to our hospital with acute myocardial infarction. He was taken urgently to the catheterization laboratory, and the right RA was used to perform coronary angiography with a 6F sheath. The distal left main coronary artery was 100% occluded, and the right coronary artery was 80% occluded. An intra-aortic balloon pump was inserted, and the patient went immediately to the operating room for emergency CABG. Because the patient was already anticoagulated and the need for CABG surgery was urgent, the anesthesiologist decided to monitor the patient’s hemodynamics by using the RA sheath that had been left in situ after angiography. Heparin was reversed with protamine, and the patient was transferred to the intensive care unit postoperatively. The arterial line sheath was continuously flushed with normal saline, and the sheath was removed 2 days after the procedure.
Two days after the RA sheath was removed, the patient was noted to have a cold, pulseless right hand. A stat ultrasonogram showed thrombus in the right radial, ulnar, and brachial arteries, extending just below the axilla on the right side. He was taken emergently to the operating room to re-establish arterial flow. After thrombectomy, the surgeon was able to regain the radial and palmar arch pulses at the end of the procedure. At 2 months’ follow-up, the patient’s hand had normal range of motion and strength. At 4 months, the right thumb tip had a 1-cm scar, which was the only remaining sign of prior superficial ischemia.
Our patient required urgent surgical intervention for acute vascular complications of the RA after TRAC and emergency CABG. The use of TRAC and coronary intervention is becoming increasingly common because of its advantages over the femoral artery approach. Similar to many institutions, we use TRAC because of the advantages of radial rather than femoral artery catheterization (Table 2).2–10
A recent editorial10 stated that the TRAC procedure has gained popularity among interventional cardiologists in the United States, but there is controversy in the cardiology literature about whether the widespread use of this approach is justified.11–13 Anesthesiologists should be aware of this controversy because some complications interfere with intra-arterial monitoring or require surgical intervention. Table 3 compares the complication rates related to RA cannulation for monitoring with those of TRAC.4,14–23
One of the most frequent and under-recognized complications of TRAC is asymptomatic RA occlusion. It is observed in 1% to 10% of interventions24–30 and can lead to permanent occlusion.31–33 This complication is “silent” until the artery is recannulated for hemodynamic monitoring, used as an arterial conduit, or used to create an arteriovenous fistula.
Yonetsu et al.34 reported that 46 of 69 patients who underwent optical coherence tomography imaging of the RA had an intimal tear after the arterial sheath was removed. Also, 23 of the RAs examined had medial dissection. A luminal surface disruption extended into the media in a radial or circumferential direction in every case in which a 6F sheath was used. Intimal hyperplasia was increased in patients who had recently had another RA cannulation. This study raises the question of whether the vessels should be imaged after TRAC, especially in cases of successive RA cannulation.35 Other studies confirm that luminal diameters and area are reduced in patients who have had previous TRAC because the procedures lead to increased intimal hyperplasia and intimal media thickness.36,37
Our case raises an important general question: After a TRAC procedure (complicated or uncomplicated), should the same RA be used for perioperative hemodynamic monitoring? A palpable radial pulse is not indicative of antegrade flow. Kanei et al.38 found that 2% of their patients had no pulse early after the procedure. Furthermore, 9% had a palpable pulse, yet color Doppler did not detect radial blood flow. Patients with a palpable radial pulse may have proximal occlusion with retrograde filling of the RA due to collateral flow from the ulnar artery.
Using routine ultrasonography 2 days and 3 months after TRAC, Nagai et al.28 reported that 21 of 162 patients had segmental stenosis at the arterial puncture site, and 2 of these 21 patients had no flow in the RA. In 28 of the 141 patients who initially had no stenosis, diffuse stenosis was found on long-term follow-up. This finding raises concerns about using the same site, or the ulnar artery in the same arm, for future hemodynamic monitoring. Although certain risk factors appear to predict which patients will develop luminal narrowing of the RA after TRAC, additional prospective studies are needed to further define these factors, delineate the subclinical changes that occur in the RA, and determine the incidence of complications.27
Additionally, in our case, it may not have been optimal to leave the RA sheath in situ after TRAC, or to use normal saline solution for flushing, even though the patient was anticoagulated and the procedure was urgent. In retrospect, the sheath should have been removed as soon as possible during the postoperative period.
The RA is a common site for invasive arterial blood pressure monitoring during cardiac and major noncardiac surgery. The native RA pressure without TRAC can underestimate the central aortic pressure after cardiopulmonary bypass, even in patients who have not had TRAC.39–41 TRAC-related changes in the RA may further impair the accuracy of RA pressure monitoring. Underestimation of the central aortic pressure may prompt unnecessary vasoconstrictor therapy.
Regarding the steps interventional cardiologists are taking to reduce the risk of RA occlusion, 2 randomized control trials, PROPHET42 and RACOMAP,43 confirm that using a patent hemostasis technique reduces this risk. This technique involves compressing the RA just enough to prevent bleeding while using the reverse Barbeau test (in which plethysmography and pulse oximetry are used to improve the sensitivity of the modified Allen test)44 to ensure that some antegrade RA flow is maintained. In addition, systemic anticoagulation and smaller sheaths are being used to prevent this complication.
The anesthesiologist should identify the arterial location used during cardiac catheterization by physical examination, discussion with the patient, and review of the catheterization report and any postprocedure imaging. It is important that anesthesiologists and all cardiovascular specialists (cardiologists, vascular surgeons, interventional nephrologists, and cardiac surgeons) discuss the issue of RA occlusion and stenosis after TRAC procedures. The currently available evidence suggests that anesthesiologists should not recannulate an RA that has been previously used in a TRAC procedure.
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