Ultrasound guided percutaneous thrombin injection in a radial artery pseudoaneurysm following percutaneous coronary intervention.

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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. 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 P. Bauer (&) C. W. Hamm D. Gunduz Department of Cardiology and Angiology, University Hospital Giessen, Klinikstrase 33, 35390 Giessen, Germany e-mail: pascal.bauer@innere.med.uni-giessen.de