Clin Res Cardiol (2014) 103:1022–1024 DOI 10.1007/s00392-014-0744-9
LETTER TO THE EDITORS
Ultrasound guided percutaneous thrombin injection in a radial artery pseudoaneurysm following percutaneous coronary intervention Pascal Bauer • Ahmed Koshty • Christian W. Hamm Dursun Gu¨ndu¨z
•
Received: 13 April 2014 / Accepted: 15 July 2014 / Published online: 22 July 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Sirs: A transradial vascular access for both diagnostic coronary angiography and percutaneous coronary intervention (PCI) is rapidly becoming preferable to traditional femoral artery access because of a significant reduction of access-site complications [1, 5–7, 10]. In the STEMI-RADIAL study, the radial and femoral approaches were compared in patients with ST-segment elevation myocardial infarction (STEMI). A transradial vascular access was associated with 80 % reduction in the incidence of complications at the puncture site and local bleeding [1]. The recently published RIVAL study comparing the radial with the femoral approach in patients with ACS showed similar results. There were less major vascular complications at the puncture site requiring surgery in favor of the radial access [5]. It is known that bleeding complications after percutaneous procedures are associated with an increased risk of morbidity and mortality [4]. Bleeding complications at the radial arterial puncture site, such as hematoma, occur in about 1 % of cases and are easy to manage because of the superficial course of the radial artery over bone structures [6, 10]. Nevertheless, transradial coronary angiography may have other complications, including radial artery occlusion [13], nonocclusive injury, spasm, AV fistula, hand ischemia, nerve damage, and pseudoaneurysm.
P. Bauer (&) C. W. Hamm D. Gu¨ndu¨z Department of Cardiology and Angiology, University Hospital Giessen, Klinikstraße 33, 35390 Giessen, Germany e-mail: [email protected] A. Koshty Department of Vascular Surgery, University Hospital, Giessen, Germany
123
Radial pseudoaneurysm after a transradial coronary angiography is a rare complication, which has been reported in less than 0.1 % of the procedures [5, 6]. We report a case of percutaneous thrombin injection in a radial artery pseudoaneurysm following percutaneous coronary intervention. A 65-year-old man with a history of coronary heart disease, hypertension and diabetes mellitus underwent transradial coronary angiography after presenting with acute coronary syndrome. After admission, the patient received intravenous 5,000 IU of Heparin and 500 mg acetylsalicylic acid. The procedure was performed via right radial artery access using a 6-Fr Terumo sheath (Terumo Interventional Systems, USA). Two diagnostic catheters (JL 4; JR 4) were used for angiographic imaging, which demonstrated severe right coronary artery disease in the distal part (culprit lesion). The left anterior descending artery exhibited mild mid-vessel disease with a high-grade stenosis of the ramus diagonalis I. For the following percutaneous coronary intervention of the culprit lesion in the distal part of the right coronary a 6-Fr coronary guiding catheter was used (JR 4). A bioresorbable scaffold was implanted. At the end of the procedure, the radial-vascular sheath was partially removed and a TR band (Terumo Interventional Systems, USA) was applied over the access site. The band was inflated with 12 ml of air and the sheath was fully removed. An additional 1 mL of air was used to further inflate the band to maintain hemostatic control. The patient received 60 mg Prasugrel per os after the procedure. In addition, a single dose of fondaparinux 2.5 mg subcutaneously was administered on ICU in the evening. The TR band was deflated gradually (3 mL/h) and removed after 4 h; no bleeding was observed during this time. The patient left ICU after 48 h. On normal ward, 3 days after the procedure, a painful, pulsatile mass was identified
Clin Res Cardiol (2014) 103:1022–1024
Fig. 1 Duplex ultrasound showing the radial pseudoaneurysm after coronary angiography in longitudinal view, first diagnosis
at the location of the transradial coronary angiography access site. In addition, we observed a painful swelling of the right forearm due to extension of the hematoma. Duplex ultrasonography was performed using a Philips iu22 ultrasound machine with a linear array transducer (9–3 MHz frequency range). It revealed a 26 9 19 9 21 mm pseudoaneurysm of the right radial artery at the level of the wrist (Fig. 1), with some intrapseudoaneurysm thrombus formation. We treated the pseudoaneurysm with compression therapy. The TR band was placed around the right wrist above the pseudoaneurysm and 10 mL of air was instilled. The patient wore this compression device for 12 h. After this treatment the prominence appeared to be smaller in size, the patient reported less pain. The medical treatment with acetylsalicylic acid 100 mg per day and prasugrel 10 mg per day was continued. Due to the occurrence of several episodes of atrial fibrillation and short periods of ventricular tachycardias the multidisciplinary team decided to continue also 2.5 mg fondaparinux medication subcutaneously per day. After 12 h of compression therapy duplex ultrasonography control was performed showing again the pseudoaneurysm, but with less influx (size 19 9 12 9 15 mm). A new TR band was applied and 15 ml of air instilled. It was worn for 24 h, anticoagulatory medication was also continued. Control duplex ultrasonography was performed the next day, revealing persistent pseudoaneursym with the same size. Now decision to treat the pseudoaneurysm with thrombin injection was taken by a specialist multi disciplinary team and agreement with the patient. For treatment human thrombin was used (out of the TISSUCOL duo 0.5 ml set, BAXTER, Germany). The
1023
injections were performed free handed under sterile conditions with permanent ultrasound control. The needle length for thrombin injection was chosen on the basis of the depth to the center of the pseudoaneurysm chamber from the skin surface. We used a 1.5-in., 19-gauge needle (Braun Melsungen, Germany), which seems to be an appropriate size for the treatment of the majority of radial pseudoaneurysms due to its superficial location. Before thrombin injection, saline was drawn up in a separate syringe and then both the saline syringe and the predefined thrombin syringe were loaded to a stopcock that was turned ‘‘off’’ to the thrombin and ‘‘on’’ to the saline syringe. While withdrawing the saline syringe, the needle was inserted into the pseudoaneurysm chamber under ultrasound control. Once blood returned into the saline syringe, saline was then injected into the chamber to confirm correct placement. If so, a short ‘‘color flash’’ in duplex imaging can be seen during injection. Then small aliquots of thrombin (0.1 mL) were injected while observing the ultrasound image. Stepwise injections of thrombin then were continued until the pseudoaneurysm cavity thrombosed completely. In total 200 IU of thrombin were necessary to obtain a complete thrombosis of the pseudoaneurysm (Fig. 2). Postprocedure ultrasonography confirmed good radial artery duplex signals with preserved neurological function. Afterwards a light pressure bandage was applied to the wrist, which was worn for 4 h. The patient reported initially after the injection pain relief, after 4 h he reported no more pain. Serial ultrasound controls revealed persistent thrombosis of the pseudoaneurysm. The patient was discharged without any other complications. One month later we performed medical examination with an ultrasound control of the right wrist, which confirmed good radial artery duplex signals without any hematoma or neurological disorders. In conclusion, strategies to manage complications of the transradial vascular access procedure need to be more developed in the clinical setting due to the increasing frequency of the radial approaches. Pseudoaneuyrsm is a rare but serious complication of transradial access for coronary angiography. Symptoms are a painful, tender, pulsatile swelling in the access site region, but, depending on the size of the pseudoaneurysm, pain might be the only symptom. In the rare cases of large hematoma of the forearm causing neurological dysfunctions, or acting oppressively, surgical therapy of the pseudoaneurysm should be considered. Duplex ultrasonography is the key, first for diagnosis by providing morphology characteristics and hemodynamic information, second by leading the thrombin injection guided treatment, third by providing a non-invasive control assessment.
123
1024
Clin Res Cardiol (2014) 103:1022–1024
therapy [8]. To combine both thrombin injection and compression therapy might be a solution to increase the treatment success rate, but further data are needed.
References
Fig. 2 Duplex ultrasound of the radial pseudoaneurysm after thrombin injection (longitudinal view), showing a complete thrombosis of the pseudoaneurysm
Ultrasound-guided compression treatment was described both with successful [12] and not successful results [9]. The compression treatment of the radial artery is easy to perform, leading the occlusion of the blood flow. Nevertheless compression has to be maintained for several hours to obtain occlusion, and might be uncomfortable for patients. In addition, the failure rate is high, thus imposing in some cases surgical interventions. To avoid surgical treatment, thrombin injection has been used for the treatment of radial pseudoaneurysms [3, 8]. The amount of thrombin that has to be used for a successful treatment of a radial pseudoaneurysm is variable. There exist only few data in literature regarding the amount of thrombin that is necessary for the treatment of a radial pseudoaneurysm. Amounts of 400 and more IU of thrombin were described [2, 11]. In our experience the majority can be treated with maximum 250 IU of thrombin. Therefore, we regularly use predefined syringes with 250 IU of thrombin. One of the advantages of thrombin injection is the immediate effect of clotting. Injections therefore should be undertaken stepwise until a complete clotting can be seen in ultrasound. However, decision for thrombin injection therapy should be made by a multidisciplinary team because the procedure may cause damage and resulting in a thrombosis or embolization in peripheral branches if thrombin spills over the pseudoaneurysm into the radial artery [3, 8]. Failure to occlude pseudoaneurysms with thrombin injection occurs, but at a lower rate as compared to ultrasound compression
123
1. Bernat I, Horak D, Stasek J et al (2014) ST elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol 63:964–972 2. Corso R, Rampoldi A, Vercelli R et al (2005) Percutaneous repair of radial artery pseudoaneurysm in a hemodialysis patient using sonographically guided thrombin injection. Cardiovasc Intervent Radiol 29:130–132 3. D’Achille A, Sebben R, Davies R (2001) Percutaneous ultrasound- guided thrombin injection for coagulation of post-traumatic pseudoaneurysms. Aust Radiol 45:218–221 4. Doyle BJ, Rihal CS, Gastineau DA et al (2009) Bleeding, blood transfusion and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol 53:2019–2027 5. Jolly SS, Yusuf S, Cairns J et al (2011) Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL) A randomised, parallel group, multicentre trial. Lancet 377:1409–1420 6. Kanei Y, Kwan T, Nakra NC et al (2011) Transradial cardiac catheterization: a review of access site complications. Catheter Cardiovasc Interven 78:840–846 7. Kiemeneij F, Laarman GJ, Odekerken D et al (1997) A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol 29:1269–1275 8. Komorowska-Timek E, Teruya T, Abou-Zamzam A et al (2004) Treatment of radial and ulnar artery pseudoaneurysms using percutaneous thrombin injection. J Hand Surg 29:936–942 9. Manghat N, Ellwood F, Roobottom C (2006) Radial artery pseudoaneurysm post-cardiac catheterization: imaging with multidetector row CT peripheral angiography. Heart 9:872 10. Mann J, Cubeddu M, Schneider J et al (1996) Right radial access for PTCA: a prospective study demonstrates reduced complications and hospital charges. J Invasive Cardiol 8:40–44 11. Reus M, Vasquez V, Alonso J et al (2003) Treatment of a radial artery pseudoaneurysm with ultrasound-guided percutaneous thrombin injection in a patient with Behcet’s syndrome. J Clin Ultrasound 31:440–444 12. Witz M, Werner M, Bernheim J et al (2000) Ultrasound-guided compression repair of pseudoaneurysms complicating a forearm dialysis arteriovenous fistula. Nephrol Dial Transplant 15:1453–1454 13. Zankl A, Andrassy M, Volz C et al (2010) Radial artery thrombosis following transradial coronary angiography: incidence and rationale for treatment of symptomatic patients with low-molecular-weight heparins. Clin Res Cardiol 99:841–847
LETTER TO THE EDITORS
Ultrasound guided percutaneous thrombin injection in a radial artery pseudoaneurysm following percutaneous coronary intervention Pascal Bauer • Ahmed Koshty • Christian W. Hamm Dursun Gu¨ndu¨z
•
Received: 13 April 2014 / Accepted: 15 July 2014 / Published online: 22 July 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Sirs: A transradial vascular access for both diagnostic coronary angiography and percutaneous coronary intervention (PCI) is rapidly becoming preferable to traditional femoral artery access because of a significant reduction of access-site complications [1, 5–7, 10]. In the STEMI-RADIAL study, the radial and femoral approaches were compared in patients with ST-segment elevation myocardial infarction (STEMI). A transradial vascular access was associated with 80 % reduction in the incidence of complications at the puncture site and local bleeding [1]. The recently published RIVAL study comparing the radial with the femoral approach in patients with ACS showed similar results. There were less major vascular complications at the puncture site requiring surgery in favor of the radial access [5]. It is known that bleeding complications after percutaneous procedures are associated with an increased risk of morbidity and mortality [4]. Bleeding complications at the radial arterial puncture site, such as hematoma, occur in about 1 % of cases and are easy to manage because of the superficial course of the radial artery over bone structures [6, 10]. Nevertheless, transradial coronary angiography may have other complications, including radial artery occlusion [13], nonocclusive injury, spasm, AV fistula, hand ischemia, nerve damage, and pseudoaneurysm.
P. Bauer (&) C. W. Hamm D. Gu¨ndu¨z Department of Cardiology and Angiology, University Hospital Giessen, Klinikstraße 33, 35390 Giessen, Germany e-mail: [email protected] A. Koshty Department of Vascular Surgery, University Hospital, Giessen, Germany
123
Radial pseudoaneurysm after a transradial coronary angiography is a rare complication, which has been reported in less than 0.1 % of the procedures [5, 6]. We report a case of percutaneous thrombin injection in a radial artery pseudoaneurysm following percutaneous coronary intervention. A 65-year-old man with a history of coronary heart disease, hypertension and diabetes mellitus underwent transradial coronary angiography after presenting with acute coronary syndrome. After admission, the patient received intravenous 5,000 IU of Heparin and 500 mg acetylsalicylic acid. The procedure was performed via right radial artery access using a 6-Fr Terumo sheath (Terumo Interventional Systems, USA). Two diagnostic catheters (JL 4; JR 4) were used for angiographic imaging, which demonstrated severe right coronary artery disease in the distal part (culprit lesion). The left anterior descending artery exhibited mild mid-vessel disease with a high-grade stenosis of the ramus diagonalis I. For the following percutaneous coronary intervention of the culprit lesion in the distal part of the right coronary a 6-Fr coronary guiding catheter was used (JR 4). A bioresorbable scaffold was implanted. At the end of the procedure, the radial-vascular sheath was partially removed and a TR band (Terumo Interventional Systems, USA) was applied over the access site. The band was inflated with 12 ml of air and the sheath was fully removed. An additional 1 mL of air was used to further inflate the band to maintain hemostatic control. The patient received 60 mg Prasugrel per os after the procedure. In addition, a single dose of fondaparinux 2.5 mg subcutaneously was administered on ICU in the evening. The TR band was deflated gradually (3 mL/h) and removed after 4 h; no bleeding was observed during this time. The patient left ICU after 48 h. On normal ward, 3 days after the procedure, a painful, pulsatile mass was identified
Clin Res Cardiol (2014) 103:1022–1024
Fig. 1 Duplex ultrasound showing the radial pseudoaneurysm after coronary angiography in longitudinal view, first diagnosis
at the location of the transradial coronary angiography access site. In addition, we observed a painful swelling of the right forearm due to extension of the hematoma. Duplex ultrasonography was performed using a Philips iu22 ultrasound machine with a linear array transducer (9–3 MHz frequency range). It revealed a 26 9 19 9 21 mm pseudoaneurysm of the right radial artery at the level of the wrist (Fig. 1), with some intrapseudoaneurysm thrombus formation. We treated the pseudoaneurysm with compression therapy. The TR band was placed around the right wrist above the pseudoaneurysm and 10 mL of air was instilled. The patient wore this compression device for 12 h. After this treatment the prominence appeared to be smaller in size, the patient reported less pain. The medical treatment with acetylsalicylic acid 100 mg per day and prasugrel 10 mg per day was continued. Due to the occurrence of several episodes of atrial fibrillation and short periods of ventricular tachycardias the multidisciplinary team decided to continue also 2.5 mg fondaparinux medication subcutaneously per day. After 12 h of compression therapy duplex ultrasonography control was performed showing again the pseudoaneurysm, but with less influx (size 19 9 12 9 15 mm). A new TR band was applied and 15 ml of air instilled. It was worn for 24 h, anticoagulatory medication was also continued. Control duplex ultrasonography was performed the next day, revealing persistent pseudoaneursym with the same size. Now decision to treat the pseudoaneurysm with thrombin injection was taken by a specialist multi disciplinary team and agreement with the patient. For treatment human thrombin was used (out of the TISSUCOL duo 0.5 ml set, BAXTER, Germany). The
1023
injections were performed free handed under sterile conditions with permanent ultrasound control. The needle length for thrombin injection was chosen on the basis of the depth to the center of the pseudoaneurysm chamber from the skin surface. We used a 1.5-in., 19-gauge needle (Braun Melsungen, Germany), which seems to be an appropriate size for the treatment of the majority of radial pseudoaneurysms due to its superficial location. Before thrombin injection, saline was drawn up in a separate syringe and then both the saline syringe and the predefined thrombin syringe were loaded to a stopcock that was turned ‘‘off’’ to the thrombin and ‘‘on’’ to the saline syringe. While withdrawing the saline syringe, the needle was inserted into the pseudoaneurysm chamber under ultrasound control. Once blood returned into the saline syringe, saline was then injected into the chamber to confirm correct placement. If so, a short ‘‘color flash’’ in duplex imaging can be seen during injection. Then small aliquots of thrombin (0.1 mL) were injected while observing the ultrasound image. Stepwise injections of thrombin then were continued until the pseudoaneurysm cavity thrombosed completely. In total 200 IU of thrombin were necessary to obtain a complete thrombosis of the pseudoaneurysm (Fig. 2). Postprocedure ultrasonography confirmed good radial artery duplex signals with preserved neurological function. Afterwards a light pressure bandage was applied to the wrist, which was worn for 4 h. The patient reported initially after the injection pain relief, after 4 h he reported no more pain. Serial ultrasound controls revealed persistent thrombosis of the pseudoaneurysm. The patient was discharged without any other complications. One month later we performed medical examination with an ultrasound control of the right wrist, which confirmed good radial artery duplex signals without any hematoma or neurological disorders. In conclusion, strategies to manage complications of the transradial vascular access procedure need to be more developed in the clinical setting due to the increasing frequency of the radial approaches. Pseudoaneuyrsm is a rare but serious complication of transradial access for coronary angiography. Symptoms are a painful, tender, pulsatile swelling in the access site region, but, depending on the size of the pseudoaneurysm, pain might be the only symptom. In the rare cases of large hematoma of the forearm causing neurological dysfunctions, or acting oppressively, surgical therapy of the pseudoaneurysm should be considered. Duplex ultrasonography is the key, first for diagnosis by providing morphology characteristics and hemodynamic information, second by leading the thrombin injection guided treatment, third by providing a non-invasive control assessment.
123
1024
Clin Res Cardiol (2014) 103:1022–1024
therapy [8]. To combine both thrombin injection and compression therapy might be a solution to increase the treatment success rate, but further data are needed.
References
Fig. 2 Duplex ultrasound of the radial pseudoaneurysm after thrombin injection (longitudinal view), showing a complete thrombosis of the pseudoaneurysm
Ultrasound-guided compression treatment was described both with successful [12] and not successful results [9]. The compression treatment of the radial artery is easy to perform, leading the occlusion of the blood flow. Nevertheless compression has to be maintained for several hours to obtain occlusion, and might be uncomfortable for patients. In addition, the failure rate is high, thus imposing in some cases surgical interventions. To avoid surgical treatment, thrombin injection has been used for the treatment of radial pseudoaneurysms [3, 8]. The amount of thrombin that has to be used for a successful treatment of a radial pseudoaneurysm is variable. There exist only few data in literature regarding the amount of thrombin that is necessary for the treatment of a radial pseudoaneurysm. Amounts of 400 and more IU of thrombin were described [2, 11]. In our experience the majority can be treated with maximum 250 IU of thrombin. Therefore, we regularly use predefined syringes with 250 IU of thrombin. One of the advantages of thrombin injection is the immediate effect of clotting. Injections therefore should be undertaken stepwise until a complete clotting can be seen in ultrasound. However, decision for thrombin injection therapy should be made by a multidisciplinary team because the procedure may cause damage and resulting in a thrombosis or embolization in peripheral branches if thrombin spills over the pseudoaneurysm into the radial artery [3, 8]. Failure to occlude pseudoaneurysms with thrombin injection occurs, but at a lower rate as compared to ultrasound compression
123
1. Bernat I, Horak D, Stasek J et al (2014) ST elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol 63:964–972 2. Corso R, Rampoldi A, Vercelli R et al (2005) Percutaneous repair of radial artery pseudoaneurysm in a hemodialysis patient using sonographically guided thrombin injection. Cardiovasc Intervent Radiol 29:130–132 3. D’Achille A, Sebben R, Davies R (2001) Percutaneous ultrasound- guided thrombin injection for coagulation of post-traumatic pseudoaneurysms. Aust Radiol 45:218–221 4. Doyle BJ, Rihal CS, Gastineau DA et al (2009) Bleeding, blood transfusion and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol 53:2019–2027 5. Jolly SS, Yusuf S, Cairns J et al (2011) Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL) A randomised, parallel group, multicentre trial. Lancet 377:1409–1420 6. Kanei Y, Kwan T, Nakra NC et al (2011) Transradial cardiac catheterization: a review of access site complications. Catheter Cardiovasc Interven 78:840–846 7. Kiemeneij F, Laarman GJ, Odekerken D et al (1997) A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol 29:1269–1275 8. Komorowska-Timek E, Teruya T, Abou-Zamzam A et al (2004) Treatment of radial and ulnar artery pseudoaneurysms using percutaneous thrombin injection. J Hand Surg 29:936–942 9. Manghat N, Ellwood F, Roobottom C (2006) Radial artery pseudoaneurysm post-cardiac catheterization: imaging with multidetector row CT peripheral angiography. Heart 9:872 10. Mann J, Cubeddu M, Schneider J et al (1996) Right radial access for PTCA: a prospective study demonstrates reduced complications and hospital charges. J Invasive Cardiol 8:40–44 11. Reus M, Vasquez V, Alonso J et al (2003) Treatment of a radial artery pseudoaneurysm with ultrasound-guided percutaneous thrombin injection in a patient with Behcet’s syndrome. J Clin Ultrasound 31:440–444 12. Witz M, Werner M, Bernheim J et al (2000) Ultrasound-guided compression repair of pseudoaneurysms complicating a forearm dialysis arteriovenous fistula. Nephrol Dial Transplant 15:1453–1454 13. Zankl A, Andrassy M, Volz C et al (2010) Radial artery thrombosis following transradial coronary angiography: incidence and rationale for treatment of symptomatic patients with low-molecular-weight heparins. Clin Res Cardiol 99:841–847
