Update on complications and their management during transradial cardiac catheterization

ABSTRACT

Introduction: Transradial artery access (TRA) was introduced in 1989 and has been universally used as an alternative approach to the traditional transfemoral access (TFA). Complications of TRA include asymptomatic and less likely symptomatic radial artery occlusion, nonocclusive radial artery injury, radial artery spasm, radial arterial perforation, radial artery pseudoaneurysm, arteriovenous fistula, granuloma formation, access-site bleeding, nerve damage, complex regional pain syndrome along with other rare complications.

Areas covered: A literature search was performed using MedLine, PubMed, and Google Scholar (dating to 1 May 2019). Authors reviewed all articles related to transradial artery catheterization, its complications, as well as novel techniques for their management. The article provides insight on the incidence, risk factors, and prevention of such complications along with a description of usual and newer techniques to decrease morbidity.

Expert opinion: With increasing experience, TRA complication rate is decreasing and new very uncommon complications are being described. A ‘radial first’ approach should be implemented in all catheterization laboratories and a physician’s familiarity with minor and major complications is a must. Distal radial artery access through the snuff box might be the preferred site of accessing the radial artery and further studies will be needed to prove its superiority to the current access site.

KEYWORDS:

• Transradial catheterization or access
• vascular complications
• percutaneous coronary intervention
• coronary angiography
• acute coronary syndrome
• radial artery
• distal radial artery access
• snuffbox

Article highlights box

• Transradial access (TRA) for cardiac catheterization is now widely accepted as a safe and viable approach among the invasive cardiology community. TRA is considered safer than transfemoral access in ACS.

• Asymptomatic RAO is the most frequent complication encountered and usually follows an uneventful course. Symptomatic radial arterial occlusion is rare due to the redundant blood supply of the hand through the ulnar artery.

• Radial artery spasm is a relatively common and significant challenge during transradial access. The use of various intra-arterial cocktails of vasodilators and the use of hydrophilic sheaths have been employed for its prevention and treatment, with partial success. Pressure-mediated dilatation is a novel technique for management.

• Radial artery perforation is a rare complication that, if not recognized early, can lead to forearm hematoma, compartment syndrome and acute limb ischemia. Balloon-assisted tracking and other techniques can be used for management.

• Generally, access-site complications can be minimized by avoiding multiple punctures, use of smaller sheaths, gentle catheter manipulation, adequate anticoagulation, appropriate compression devices, and careful observation for any ominous signs/symptoms in the peri-procedural period. Distal radial artery access through the snuff box is a novel technique which might be safer than the usual TRA though additional studies are needed.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.