In adult surgical patients with peripheral arterial catheters for intraoperative hemodynamic monitoring, what evidence describes sex‑based differences in complications (radial artery occlusion or thrombosis, hematoma, bleeding, ischemic injury, infection, pseudoaneurysm, nerve injury, catheter failure, repeat placement), including effect sizes and whether sex remains an independent predictor after adjustment for age, vessel diameter, body mass index, diabetes, peripheral vascular disease, anticoagulant use, catheter size, duration, insertion site, number of attempts, and ultrasound guidance, and how this evidence differs from that for transradial cardiac catheterization?

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Last updated: November 14, 2026 • View editorial policy

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Sex-Based Differences in Arterial-Line Complications: Evidence Specific to Intraoperative Monitoring

Critical Evidence Gap

The available evidence does not adequately address sex-based differences in complications from peripheral arterial catheters used specifically for intraoperative hemodynamic monitoring in surgical patients. The overwhelming majority of research examines transradial cardiac catheterization (TRA for PCI or peripheral vascular interventions), which differs fundamentally from arterial monitoring catheters in catheter size, duration of placement, anticoagulation protocols, and procedural context 1, 2, 3.

What the Cardiac Catheterization Literature Shows (Not Directly Applicable)

The transradial cardiac catheterization evidence consistently demonstrates sex-based disparities, but these findings cannot be extrapolated to intraoperative arterial monitoring:

Radial Artery Occlusion

  • Female sex is an independent predictor of radial artery occlusion after transradial cardiac procedures, with rates of 5-6% overall 1, 4
  • Women experience higher occlusion rates even after adjustment for vessel diameter, sheath-to-artery ratio, age, and smoking status 1
  • Small radial artery caliber and sheath-to-artery ratio >1 are the strongest predictors, both more common in women 1

Access-Site Bleeding and Hematoma

  • Women undergoing transradial PCI have 1.84-fold higher risk of access-site bleeding (RR 1.84,95% CI 1.23-2.75) and 1.70-fold higher risk of hematoma (RR 1.70,95% CI 1.00-2.91) compared to men 3
  • With femoral access and manual compression, women had 4.5% vs. 1.6% bleeding rates compared to men (p<0.001), though this gap narrowed with closure devices 5
  • The absolute risk reduction with vascular closure devices was greater for women (2.8%) than men (0.8%) 5

Radial Artery Spasm

  • Female sex is an independent predictor of radial artery spasm, occurring in >20% of transradial procedures 1
  • Women had 3.40-fold higher risk of radial artery spasm (RR 3.40,95% CI 1.30-8.87) in the 2026 meta-analysis 3
  • Younger age, diabetes, and lower BMI are additional independent predictors 1

Other Complications

  • Access-site crossover was 1.87-fold higher in women (RR 1.87,95% CI 1.58-2.22) 3
  • Radial artery perforation rates did not differ significantly by sex 3
  • Pseudoaneurysm and nerve injury were not analyzed by sex in the available evidence

Catheter Failure and Repeated Placement

  • Women had slightly lower procedural success rates (RR 0.98,95% CI 0.97-0.99) despite shorter procedure duration 3
  • No specific data on catheter failure or need for repeated placement in the context of monitoring catheters

Proposed Mechanisms (From Cardiac Literature)

The cardiac catheterization literature attributes sex differences to:

  • Smaller vessel diameter in women, leading to higher sheath-to-artery ratios 1
  • Anatomic factors including vessel tortuosity and caliber differences
  • Procedural factors such as multiple catheter exchanges and larger sheath sizes relative to vessel diameter 1

However, these mechanisms are derived from interventional procedures using 5-7 French sheaths for prolonged periods with aggressive anticoagulation, not from 20-gauge arterial monitoring catheters placed for hours during surgery.

Why This Evidence Cannot Be Applied to Intraoperative Monitoring

Fundamental Procedural Differences:

  1. Catheter size: Monitoring catheters are 20-gauge (approximately 1 mm diameter) vs. 5-7 French sheaths (1.7-2.3 mm) used in cardiac procedures
  2. Duration: Intraoperative monitoring typically lasts hours vs. the brief catheterization procedure followed by immediate removal
  3. Anticoagulation: Surgical patients may have minimal or no systemic anticoagulation vs. high-dose heparin (50-100 IU/kg) in cardiac procedures 1, 2
  4. Insertion technique: Monitoring catheters use smaller gauge needles with different insertion angles and techniques
  5. Hemostasis method: Different compression protocols and durations
  6. Patient population: Surgical patients have different risk profiles than those undergoing cardiac catheterization

What Remains Unknown for Intraoperative Arterial Monitoring

No high-quality evidence exists addressing:

  • Whether sex remains an independent predictor of complications after adjustment for confounders in the context of arterial monitoring catheters
  • Effect sizes for any complication stratified by sex in surgical patients with monitoring catheters
  • Whether smaller catheter size in monitoring lines eliminates the vessel diameter disparity seen with larger sheaths
  • Sex-specific rates of ischemic injury, infection, pseudoaneurysm, or nerve injury from monitoring catheters
  • Gender-related social or healthcare factors affecting arterial line management in perioperative settings

Clinical Implications

Given the absence of specific evidence for intraoperative arterial monitoring catheters, sex-specific management protocols cannot be recommended. The dramatic differences in catheter size, duration, and procedural context between cardiac catheterization and intraoperative monitoring mean that observed sex disparities in the former may not translate to the latter.

Common Pitfalls to Avoid:

  • Do not assume that sex-based differences in transradial cardiac catheterization apply to 20-gauge arterial monitoring lines
  • Do not extrapolate sheath-to-artery ratio concerns from 5-7 French cardiac sheaths to much smaller monitoring catheters
  • Do not implement sex-specific arterial line protocols based solely on cardiac catheterization data

Research Priorities:

The perioperative and critical care literature urgently needs:

  • Prospective studies examining sex-based complications specifically in arterial monitoring catheters
  • Multivariable analyses adjusting for vessel diameter, BMI, catheter size, duration, and other confounders in surgical populations
  • Standardized definitions and systematic assessment of complications including asymptomatic occlusion detected by ultrasound

Until such evidence emerges, standard arterial line management should be applied uniformly regardless of sex, with attention to established risk factors (multiple attempts, prolonged duration, inadequate collateral circulation) that apply to all patients.

References

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