Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

Radial pseudoaneurysm after a puncture for blood gas analysis

Abstract

Radial pseudoaneurysm (PA) is a rare complication of the transradial approach for the arterial catheterization.

We reported a case of a 75-year-old woman in anticoagulation ther- apy for mitral and aortic mechanical valves who underwent a blood gas analysis in the workup of dyspnea.

One month before, our patient was admitted to the hospital for a large right pleural effusion and dyspnea. During hospital staying, she underwent thoracentesis after replacement of Oral anticoagulation ther- apy with fractional heparin.

A month after discharge, she presented for pneumological control and underwent a radial puncture for blood gas analysis. She was in oral anticoagulation therapy, and her international normalized ratio value was 3.3. The procedure was done without any problem, but 1 week after, she presented in our clinic complaining painful swelling over the radial puncture site on the left hand (Fig. 1). Allen test was neg- ative. At the left wrist, a Pulsatile mass was present, and a systolic bruit was audible. She had no fever.

Color Doppler ultrasonography demonstrated the presence of a radi- al PA of 8 x 11 mm dimension with a narrow neck and bidirectional flow; no thrombus was present (Fig. 2). The hand was hot, without mo- tion or sensitive defects. We applied a compressive clamp at the wrist and kept the oral anticoagulation at lower level (international normal- ized ratio, 2.5-2.7); every 3 days, we checked the dimension of the PA with color Doppler ultrasonography. No sign of ischemia or neuropathy developed at the level of left hand. After 2 weeks, we noted a thrombus formation and a reduction of flow inside the cavity (Fig. 3). After 1 month, the dimension of the PA was halved, and no flow was detectable (Figs. 4 and 5).

Pseudoaneurysm is a cavity which does not consist of 3 layers of ar- terial wall and communicates with the arterial lumen. Pseudoaneurysm is a rare complication of radial Arterial puncture; in literature, it is corre- lated to arterial cannulation, for catheterization or invasive monitoring of blood pressure, and its incidence is approximately 0.5% to 0.6% [1]. Since now, only Leone et al [2] described a PA due to single puncture for blood analysis. Our case is a really Unusual presentation after a single arterial puncture for blood analysis.

Usually, the factors correlated to upper extremity PA are history of hypertension, atrial fibrillation, chronic kidney disease, infections of the catheter, vessel wall alterations, repeated puncture attempts [2,3], not to sheath size, anticoagulation or Antiplatelet therapy, and proce- dure type or department performing the arterial puncture [3]. In our

patient, the Predisposing factors were the anticoagulation therapy and permanent atrial fibrillation. We decided to treat the patient with a con- servative approach with a compressive clamp and a strict ultrasound monitoring. The PA took a long time to close, about 2 weeks, probably for the concomitant anticoagulation therapy which could not be with- drawn. After 12 months of follow-up, no recurrence of PA was found.

Previously, the standard treatment of PA was surgical; newer treat- ments were ultrasound-guided local compression and thrombin injec- tion [4]. Now, surgical intervention is usually limited to complicated arterial pseudoaneurysms, by infections, Distal ischemia, or neuropathy, or in cases of failure of compression or thrombin injection. Only another case described by Nazer and Boyle [5] needed a prolonged compression for recurrence of arterial PA, avoiding, as in our patient, to undergo more invasive treatment.

Giulia Russo, MD, PhD^? Antonella Cherubini, MD Maurizio Fisicaro, MD

Cardiovascular Center, AAS1 Triestina, Trieste, Italy

?Corresponding author at: Cardiovascular Center, ASS1 Triestina, Via

Slataper, 9-34125 Trieste, Italy Tel.: +39 0 403 992902; fax: +39 0 403 992935

E-mail address: [email protected]

Giovanni Cioffi, MD

Cardiology, Villa Bianca Hospital, Trento, Italy

Andrea Di Lenarda, MD

Cardiovascular Center, AAS1 Triestina, Trieste, Italy

http://dx.doi.org/10.1016/j.ajem.2015.07.064

References

1. Collins N, Wainstein R, Ward M, Bhagwandeen R, Dzavik V. Pseudoaneurysm after transradial cardiac catheterization: case series and review of the literature. Catheter Cardiovasc Interv 2012;80:283-7.
2. Leone V, Misuri D, Console V. Radial artery pseudoaneurysm after a single arterial puncture for blood-gas analysis: a case report. J Cases 2009;2:2890.
3. Garvin RP, Ryer EJ, Yoon HR, Kendrick JB, Neidrick TJ, Elmore JR, et al. Ultrasound- guided percutaneous thrombin injection of iatrogenic upper extremity pseudoaneurysms. J Vasc Surg 2014;59:1664-9.
4. Vivek J, Sambhaji C, Prakashini K. Radial artery pseudoaneurysm managed by prolonged ultrasound-guided compression repair and aided by interval application of compression device. Australas Med J 2013;6:192-5.
5. Nazer B, Boyle A. Treatment of recurrent radial artery pseudoaneurysms by prolonged mechanical compression. J Invasive Cardiol 2013;25:358-9.

   

   Fig. 1. The patient’s wrist and the large pseudoaneurysm. A, Pseudoaneurysm dilatation of the left radial artery at first observation; inside, there is thrombotic material.

   

   Fig. 2. Colur Doppler flow between the radial artery and the pseudoaneurysm.

   Fig. 4. No color Doppler flow between the radial artery and pseudoaneurysm.