12: UPPER EXTREMITY ISCHEMIA: ACCESS SITE COMPLICATIONS

PATIENT STORY

A 63-year-old woman develops progressive pain, tenderness, and discoloration in the right wrist within several days of undergoing a cardiac catheterization using a radial artery approach. Her examination is remarkable for a tender, ecchymotic, and pulsatile protuberance along the distal radial artery. The right hand and fingers are warm and without distal embolic phenomena. Sensorimotor function of the right upper extremity is intact, and the forearm muscle compartments are soft. A duplex arterial ultrasound of the affected area documents a 1.5-cm pseudoaneurysm involving the distal radial artery.

INTRODUCTION

• Brachial artery access is declining for coronary angiography but still holds an important role for complex endovascular interventions, particularly in cases of concomitant severe peripheral artery disease. The majority of brachial access is achieved percutaneously, with a small minority of cases requiring brachial cutdown.

• Transradial artery access for cardiac catheterization is widely embraced in Europe and increasingly is being adopted in the United States as a potentially safer means of access than the conventional transfemoral approach.

EPIDEMIOLOGY

• Brachial artery access site complications occur in up to 7% of cases. In a review of 323 cases using brachial artery access, the first and second most common complications were pseudoaneurysm and brachial artery thrombosis, respectively (Figures 12-1,12-2, and 12-3).¹

• This relatively high complication rate is probably a function of low operator volume and declining experience in this access over the transradial approach.

• Radial artery catheterization is typically associated with a complication rate between 0.5% and 15%.^2,3 However, the incidence may be higher than reported due to excellent collateral circulation supplying the hand. For instance, in a 2012 prospective ultrasound-assisted registry, radial access complications developed in 33% of patients when a 6F sheath was utilized.⁴

ETIOLOGY AND PATHOPHYSIOLOGY

• The majority of brachial and radial artery complications arise in women. This gender difference is attributed to a smaller arterial caliber in females.

Brachial Artery

• Potential complications of brachial artery access include pseudoaneurysm, hematoma, bleeding, thrombotic occlusion, distal emboli, infection, dissection, and arteriovenous fistula.

• Brachial artery pseudoaneurysm is the most commonly encountered complication (Figure 12-2).¹

• The rate of access site ...