What is the management for radial artery injury?

Management of Radial Artery Injury

Apply immediate manual compression for bleeding or hematoma, assess for hand ischemia, and if radial artery occlusion is recognized, compress the ipsilateral ulnar artery for 1 hour while administering systemic anticoagulation to reduce occlusion rates from 2.9% to 0.8%. 1

Immediate Assessment

Evaluate immediately for signs of hand ischemia, which can be devastating if missed:

• Pain, weakness, discoloration, reduced temperature, or sensory deficits require urgent attention 1
• Numbness and tingling, though often benign, warrant prompt evaluation 1
• Distinguish the injury type: hematoma, arterial perforation, thrombosis/occlusion, or arterial laceration 1

Critical pitfall: Even with normal Allen test and patent radial artery on angiography, digital gangrene can occur from thromboembolic dispersion during the injury, requiring finger amputation in severe cases 2. This emphasizes the need for vigilant monitoring even when initial assessment appears reassuring.

Management Algorithm by Injury Type

Hematoma Formation

• Apply manual compression as first-line treatment for small hematomas at the access site 1
• Adjust compression band pressure or reposition more proximally if bleeding persists 1
• For hematomas proximal to the access site, suspect arterial perforation of a side branch 1
• Use extrinsic compression with elastic bandage or blood pressure cuff inflated to subocclusive pressure for severe bleeding 1

Arterial Perforation

• If recognized during the procedure, the intraluminal sheath or catheter can tamponade the perforated segment, allowing continuation 1
• Perform forearm angiography at case conclusion to assess the perforation 1
• Apply prolonged compression for hemorrhagic complications including perforation 3

Radial Artery Occlusion (RAO)

This is the most common complication, occurring in approximately 5-6% of cases 4:

• Apply ipsilateral ulnar artery compression for 1 hour immediately upon recognition - this decreases RAO rates from 2.9% to 0.8% by promoting antegrade flow through the occluded radial artery 1, 5
• Administer systemic anticoagulation concurrently with ulnar compression to facilitate thrombus dissolution 1, 5
• Use unfractionated heparin at therapeutic doses (50-100 IU/kg) as the most studied anticoagulant 5
• Ensure patent hemostasis technique if compression devices are still in place to maintain anterograde flow 5

Important context: Approximately 50% of RAO cases will spontaneously recanalize within 1-3 months even without specific treatment 5. However, 2 of 12 patients with RAT in one series had persistent sensorimotor deficits, and 1 required multiple finger amputations 6, making early intervention critical.

Radial Artery Spasm

• Treat with intra-arterial verapamil and/or nitroglycerin 3
• This affects >20% of patients, with higher risk in younger patients, females, diabetics, and those with lower BMI 4

Hand Ischemia (Rare but Devastating)

• Treat with intraarterial verapamil, IV heparin, and IV diltiazem 3
• This can occur even with normal Allen or Barbeau test 3
• Higher risk in patients with dominant radial artery, incomplete palmar arch, or occluded ulnar circulation 5

Arterial Laceration

• Surgical repair may be required to avoid compartment syndrome in cases unresponsive to conservative measures 5
• Careless treatment can result in aneurysm formation requiring surgical intervention 7

Prevention Strategies for Future Procedures

Sheath size is critical:

• Use smaller sheath sizes (4F or 5F) when possible - 6F sheaths have significantly higher RAO rates (5.9% vs 1.1%) 1, 5
• 14% of men and 27% of women have radial artery diameter smaller than a 6F sheath 4
• When sheath size exceeds artery diameter, there is a threefold increase in severe reduction in blood flow to the hand 4

Anticoagulation:

• Ensure adequate intraprocedural anticoagulation with heparin 50-100 IU/kg 1, 5
• Therapeutic heparin significantly reduces RAO risk 4

Hemostasis technique:

• Maintain patent hemostasis during sheath removal to preserve radial artery flow - this can reduce RAO by 75% 1, 4
• Use hydrophilic-coated sheaths to reduce complications 4, 5

Monitoring for Delayed Complications

Monitor for:

• Pseudoaneurysm (33% of iatrogenic injuries in one series) 6
• Arteriovenous fistula 1, 4
• Persistent pain 1
• Compartment syndrome in severe cases 4

All patients with radial artery pseudoaneurysm who were surgically treated had resolution of symptoms 6, indicating that surgical intervention should not be delayed when pseudoaneurysm is identified.