Pseudoaneurysm after Left Distal Transradial Access
Consult this Twitter case concerning a patient presenting with NSTEMI, referred for coronary angiography after cardiac arrest
This case concerns a patient presenting with NSTEMI, referred for coronary angiography after cardiac arrest. She complained of a gradually increasing swelling at the puncture site of left distal radial artery 3 months after coronary angiography.
Achmad Fauzi Yahya1 , Miftah Pramudyo1, Mohammad Iqbal1, Hawani Sasmaya1, Syarief Hidayat1, Teguh Marven Djajakusumah2, Ferdinand Kiemeneij3
This case was originally shared on Twitter by @uziyahya46 via #CardioTwitterCase
Clinical presentation
A 64 year old female presented with Non-ST Elevation Myocardial Infarction (NSTEMI) with history of return of spontaneous circulation (ROSC) following sudden cardiac arrest was referred to our hospital to have coronary angiography.
Swelling around the patient’s left distal radial puncture site
Case Management
The previous electrocardiography (ECG) showed intermittent LBBB and persistent atrial fibrillation (AF). Cardiovascular risk factors were hypertension and dyslipidemia. She had a history of hyperthyroidism. Several medications were given, including aspirin, clopidogrel, thiamazole and fondaparinux. Echocardiography showed mild dilated of left ventricle and left atrial with mild-moderate mitral regurgitation and borderline anterior wall hypokinesia. The left ventricle systolic function was normal.
She underwent coronary angiography via ldTRA access using a 6F sheath. Anterior puncture without ultrasonography (US) guide was performed without any difficulty. An intra-arterial bolus of 300 mcg of nitroglycerine trinitrate was administered afterward. Diagnostic coronary angiogram was done using a 5F TIG diagnostic catheter. Coronary angiogram revealed ulcerated plaque at the distal left main and severe diffuse calcified lesion of ostial to mid Left Anterior Descending (LAD) artery. There were mild-moderate stenosis of left circumflex (LCX) and right coronary artery (RCA). The procedure was completed within 12 minutes. Based on diagnostic angiography findings in a hemodynamically stable patient without chest pain, the procedure was stopped. She was offered to have coronary artery bypass graft (CABG). The 6F sheath was removed from the distal radial artery and manual hemostasis with a small pile of gauze and semi-elastic bandage was placed over the puncture site for 1 hours. There was no hematoma after bandage removal. Regarding the revascularization option, patient turned down operation and opted to have percutaneous coronary intervention (PCI), 10 days after coronary angiography.
Considering the complexity of the procedure and the intended use of rotablation, the femoral approach was chosen. Intravascular ultrasound (IVUS) guided PCI was successfully performed and three drug eluting stents were implanted to LM-LAD. Two days after procedure patient was discharged with cardiovascular drugs including aspirin 81 mg, clopidogrel and rivaroxaban 20 mg.
There was no significant complaint up to two months after hospital discharge. On the 3rd month, she noticed a gradually increasing swelling at the puncture site in the left anatomical. The swelling was tender and pulsatile. Doppler examination confirmed the presence of PSA.
A longitudinal image of a distal left radial artery pseudoaneurysm and corresponding spectral Doppler waveform from the communicating jet
A longitudinal image of the distal left radial artery shows a defect in the anterior wall following catheter access
Surgery with local anesthesia was successfully performed while patient was on dual antiplatelet and rivaroxaban. The PSA was removed, and the radial artery was ligated. The patient was allowed to discharge the day after surgery.
On follow up, there were no swelling nor tenderness in the surgical site.
Patient’s left hand after pseudoaneurysm operation
Radial artery pulsation can be detected at the distal artery, and there was no sign of pallor at the thumb.
References
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran/Dr.Hasan Sadikin Hospital , Bandung , Indonesia
- Department of Surgery, Faculty of Medicine Universitas Padjadjaran/Dr.Hasan Sadikin Hospital , Bandung , Indonesia
- Department Cardiology, MC Zuiderzee, Ziekenhuisweg 100, 8233AA Lelystad, the Netherlands
Original tweet and Twitter discussion
Pseudoaneurysm , 3 months after coronary angiography via #ldTRA. A 64 yo/F with AF had history PCI of LM-LAD . She is on aspirin and rivaroxaban What is your plan ? @ferdikiem@SVRaoMD@Radial_ICG@jedicath@sbrugaletta@EuroInterventiopic.twitter.com/WFoaIwVLwL
— A. Fauzi Yahya (@uziyahya46) 19 septembre 2018
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