Title
The radial approach: a pain in the neck
Introduction
The transradial artery approach is preferred access route for coronary angiography. The risk of major vascular complication is 0.2% and typically involves haematoma arising from the radial, brachial or subclavian artery, with pseudoaneurysm of the radial artery previously described. Brachiocephalic pseudoaneurysm is a rare and anatomically challenging clinical entity from a diagnostic and therapeutic perspective.
Clinical Case
An 81 year old woman presented with chest pain and paroxysmal nocturnal dyspnoea. The patient underwent diagnostic coronary angiography via the right transradial artery. There was marked tortuosity of the brachiocephalic artery. There was difficulty engaging the coronary arteries due to the patient’s aortic anatomy noting several catheters were trialled for selective engagement of both the left and right coronary artery. Coronary angiography confirmed minor coronary artery disease only with mild aortic regurgitation confirmed on aortogram. The patient was asymptomatic after the procedure and was discharged home. Two days later the patient re-presented to hospital with chest pain, dyspnoea and dysphagia. Troponin levels, electrocardiogram, chest radiograph and ventilation/perfusion scan of the lungs were within normal limits. Subsequent gastroscopy revealed only mild tortuosity of the upper oesophagus. The patient was subsequently discharged home. Dysphagia persisted and two weeks post coronary angiography, the patient underwent computed tomography chest angiography which revealed a 20x26x12mm pseudoaneurysm of the brachiocephalic artery with associated mural haematoma. There was arterial dissection with intramural haematoma of the right common carotid artery which extended to the carotid bifurcation. Vascular ultrasound showed severe stenosis at the ostium of the right common carotid artery due to compression from the intramural haematoma. The patient underwent open repair with a subclavian-carotid artery Dacron Gelsoft Plus graft (Terumo Corporation, Tokyo, Japan) with ligation of the proximal common carotid artery. The pseudoaneurysm was visualised under fluoroscopy guidance from a femoral approach. Utilising a right brachial artery retrograde approach, an 8Fr sheath was inserted and over a Rosen wire (Cook Medical, Bloomington, Indiana, USA); sequential 11x38mm and 11x29mm VBX stent-grafts (Gore Medical, Newark, Delaware, USA) were deployed and post-dilated with an Armada 35 balloon (Abbott Laboratories, Chicago, Illinois, USA). Digital subtraction angiography and post-operative CT angiography confirmed satisfactory exclusion of the pseudoaneurysm with patency of the right subclavian artery and bypass graft. The patient tolerated the procedure and was discharged.
Discussion
This case highlights the importance of continuing to be vigilant for vascular complications following coronary angiography from the transradial approach. New onset non-specific thoracic symptoms, including atypical chest discomfort as in this case, should prompt consideration of vascular injury following cardiac catheterisation.