What is the management of a radial artery aneurysm after percutaneous coronary intervention (PCI)?

From the Guidelines

Management of a radial artery aneurysm after PCI requires prompt intervention to prevent complications such as rupture, thrombosis, or distal embolization, with the initial approach including ultrasound evaluation to confirm the diagnosis and determine the size and characteristics of the aneurysm. The most recent and highest quality study, 1, provides guidance on antithrombotic therapy post-PCI, which is crucial in managing radial artery aneurysms. For small aneurysms (<10 mm) without symptoms, conservative management with observation and regular ultrasound follow-up may be appropriate. For larger, symptomatic, or expanding aneurysms, surgical intervention is typically necessary. Surgical options include:

• Resection of the aneurysm with end-to-end anastomosis
• Aneurysmectomy with vein graft interposition
• Ligation if adequate collateral circulation exists through the ulnar artery Ultrasound-guided compression or thrombin injection may be considered for pseudoaneurysms specifically. Endovascular approaches using covered stents are emerging alternatives in selected cases. During management, patients should continue appropriate antiplatelet therapy as needed for their cardiac condition, typically including aspirin 81 mg daily indefinitely and a P2Y12 inhibitor (clopidogrel 75 mg daily, ticagrelor 90 mg twice daily, or prasugrel 10 mg daily) for the prescribed duration following their PCI, as recommended by 1. The timing of any surgical intervention should be coordinated with the patient's cardiologist to balance the risks of aneurysm complications against the risks of modifying antiplatelet therapy too early after PCI.

From the Research

Management of Radial Artery Aneurysm after PCI

• The management of radial artery aneurysm after percutaneous coronary intervention (PCI) is crucial to prevent further complications 2.
• Radial artery pseudoaneurysm is an extremely uncommon complication, but it may occur due to inadequate hemostasis following the procedure and delayed bleeding complicating systemic anticoagulation 2.
• The clinical presentation, likely precipitating mechanisms, and treatment options for radial artery pseudoaneurysm are discussed in the literature 2.

Risk Factors for Radial Artery Occlusion

• Risk factors for access site-related complications after transradial coronary angiography (CAG) or PCI include age, sheath size, the dose of heparin, and the frequency of PCI 3.
• Sheath size and body mass index (BMI) are significant risk factors for bleeding complications, while sheath size and the lack of statin pretreatment are risk factors for occlusive complications 3.
• Female gender, age, manual compression, and radial artery diameter are independent predictors of radial artery occlusion (RAO) 4.

Treatment Options

• The use of smaller sheath size and statins can reduce access site-related complications after transradial catheterization 3.
• The distal radial artery approach has been shown to have a lower radial artery occlusion rate and shorter compression time compared to the classic radial artery approach 5.
• The use of TR band for hemostasis for only 2 hours can be a potent independent predictor of radial artery patency on day 1 and 6 months after the procedure 4.

Complications

• Radial artery occlusion is considered the most common and devastating complication of the transradial approach 4.
• The incidence of radial artery occlusion can be reduced with careful management and close follow-up, especially in patients with high predictors of RAO 4.
• Other complications such as radial artery spasm, local hematoma, and aneurysm can occur, but the incidence is generally low 5.