Percutaneous coronary intervention is the accepted optimum strategy in the treatment of both myocardial infarction and stable angina resistant to medical therapy.1 Traditionally most procedures have been performed via the femoral access route however adverse events due to vascular complications are not uncommon. In addition the use of evidence based therapies such as clopidogrel,2 fondiparinux,3 low-molecular weight heparins4 and glycoprotein (GP) IIb/IIIa antagonists5 increase the risk of such complications. Recent studies have shown the transradial route to be a feasible alternative with lower rates of vascular complications but requiring greater technical skill. A recent meta-analysis of pooled data has shown localized vascular complications to be virtually eliminated by the transradial route,6 and similar results are seen in subjects receiving GP IIb/IIIa antagonists.7 In the recent FARMI study the use of smaller 5 Fr catheters via the transradial route was associated with lower vascular complication rates in the context of acute MI with the additional use of GP IIb/IIIa antagonists.8 In addition the transradial route is associated with reduced vascular complications in obese subjects in whom femoral access is particularly hazardous9 and in elderly patients.
Despite these favorable results, rare problems do occur and the ability to manage these complications is an essential skill required by the interventional cardiologist or multidisciplinary team. Arterial perforation secondary to direct catheter trauma may occur at any point through the arterial system, but is more common in areas of tortuosity such as brachial loops or congenital abnormalities.
Case Report. A 78-year-old male arrived at our emergency department with acute onset of central crushing chest pain. Past medical history include previous bladder carcinoma treated with radiotherapy and intravesical BCG and previous ischemic stroke.
Initial electrocardiograms (ECGs) demonstrated ST-segment elevation in the anterior chest leads for which he was given prompt thrombolytic therapy with intravenous streptokinase. Despite rapid treatment, his chest pain continued and the ECGs performed 60 minutes post therapy showed little resolution of STsegments. Thus the patient was transferred to the cardiac catheterization laboratory for rescue coronary angioplasty (PCI).
PCI was performed via the right radial approach using a 6 Fr sheath and an EBU guide catheter. Angiography demonstrated a critical stenosis with thrombus in the distal left anterior descending artery (LAD), which was clearly the target lesion with further critical stenoses in the proximal LAD, circumflex and right coronary arteries. At this stage, a decision was made to intervene on the target vessel and to defer revascularization of the coexisting lesions with either further PCI or bypass surgery for a later time. The proximal LAD lesion was predilated and stented, however, it was not possible to treat the distal lesion due to severe calcification and tortuosity in the mid LAD. Bolus GP IIb/IIIa antagonists (abciximab) and weight-adjusted heparin were given, and he was transferred to the coronary care unit.
Following the procedure he developed a significant hematoma in his upper arm. Despite applying over 90 minutes of manual pressure, it was not contained and was increasing in size. Angiography of the right brachial artery was performed via the left femoral approach. This confirmed a perforation in the right brachial artery (Figure 1). To seal this perforation, a JR4 guiding catheter was used to deploy a 4 x 19 mm covered coronary stent (Jostent®, Abbott Vascular, Abbott Park, Illinois) (Figure 2). This was performed successfully and subsequent angiography showed no evidence of further leakage (Figure 3). Clinically, there was no evidence of increasing swelling or onset of compartment syndrome. He returned to the ward with no further complications and was subsequently referred for coronary artery bypass to our nearest surgical center. Clinical follow at 16 months postprocedure showed no evidence of vascular insufficiency in the affected limb.
Discussion. Evidence suggests that vascular complications are low following coronary intervention via the radial route. However, with the rapidly increasing numbers of radial procedures performed, it is likely that rare complications will be seen, and in addition, the increasing use of powerful antiplatelet and anticoagulant therapy exacerbates any potential vascular damage. It is essential that radial operators are pre- pared for such eventualities and strategies developed by which these rare complications may be overcome.
Our case describes the occurrence of a brachial perforation that was likely secondary to arterial trauma directly from the cardiac catheter or guidewire. Such trauma to the brachial artery is often self-limiting, with arm swelling and forming a physiological “tamponade” on the artery. However, our subject had received both bolus GP IIb/IIIa antagonist, streptokinase and weight-adjusted heparin, and thus was at a significantly higher bleeding risk.
The use of covered stents for the sealing of coronary perforations is well described,11 however, we believe we are the first to describe this novel use of such a stent in this clinical setting. The procedure was performed without significant complication and led to a successful sealing of the brachial perforation with improvement both radiographically and clinically. To date, the patient has no long-term complications from this procedure, and it is therefore unlikely to cause further issues. Alternative therapeutic strategies may have involved vascular surgical procedures, however, our patient was at very high anesthetic risk in view of his recent acute myocardial infarction and significant coronary disease, and the facilities to perform this procedure percutaneously are readily available in the cardiac catheterization laboratory.
In summary, we describe a novel technique for the management of brachial artery perforation, which may provide an alternative to vascular surgery in such a situation.
1. Silber S, Albertsson P, Aviles FF, et al. Percutaneous coronary interventions. Guidelines of the European Society of Cardiology - ESC. Kardiol Pol 2005;63:265–320; Discussion 321–323.
2. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345:494–502.
3. Yusuf S, Mehta SR, Chrolavicius S, et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med 2006;354:1464–1476.
4. Antman EM, Morrow DA, McCabe CH, et al. Enoxaparin versus unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction. N Engl J Med 2006;354:1477–1488.
5. Kastrati A, Mehilli J, Schuhlen H, et al. A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. N Engl J Med 2004;350:232–238.
6. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–356.
7. Choussat R, Black A, Bossi I, et al. Vascular complications and clinical outcome after coronary angioplasty with platelet IIb/IIIa receptor blockade. Comparison of transradial vs transfemoral arterial access. Eur Heart J 2000;21:662–667.
8. Brasselet C, Tassan-Mangina S, Nazeyrollas P, et al. Randomized comparison of femoral versus radial approach for percutaneous coronary intervention using abxicimab in acute myocardial infarction: Results of the FARMI Trial. Heart 2007;93:1556–1561.
9. Cox N, Resnic FS, Popma JJ, et al. Comparison of the risk of vascular complications associated with femoral and radial access coronary catheterization procedures in obese versus nonobese patients. Am J Cardiol 2004;94:1174–1177.
10. Louvard Y, Benamer H, Garot P, et al. Comparison of transradial and transfemoral approaches for coronary angiography and angioplasty in octogenarians (the OCTOPLUS study). Am J Cardiol 2004;94:1177–1180.
11. Ramsdale DR, Mushahwar SS, Morris JL. Repair of coronary artery perforation after rotastenting by implantation of the JoStent covered stent. Cathet Cardiovasc Diagn 1998;45:310–313.