What is the management plan for a patient with a damaged radial artery from an angiogram?

Management of Damaged Radial Artery from Angiogram

The immediate priority is to identify the specific type of radial artery injury—hematoma, perforation, thrombosis/occlusion, or laceration—and apply targeted compression techniques, with most injuries managed conservatively through manual compression or compression devices, while monitoring closely for hand ischemia. 1

Immediate Assessment

Evaluate immediately for signs of hand ischemia, which include:

• Pain, weakness, or sensory deficits 1
• Discoloration or reduced temperature of the hand 1
• Numbness and tingling (though often benign, require prompt attention) 1

Determine the injury type by location and presentation:

• Access site hematoma: Small, localized bleeding at puncture site 2
• Proximal hematoma (forearm/upper arm): Indicates arterial perforation of a side branch 2
• Radial artery occlusion (RAO): Most common complication, often asymptomatic due to dual circulation 2
• Arterial laceration: Rare, presents with severe uncontrolled bleeding 2

Management by Injury Type

Small Access Site Hematoma

• Apply manual compression as first-line treatment 1
• If bleeding persists, adjust compression band pressure or reposition to a more proximal location 2, 1
• These hematomas are generally small and readily managed with these simple measures 2

Proximal Hematoma (Suspected Arterial Perforation)

• If recognized during the procedure: The intraluminal sheath or catheter can tamponade the perforated segment, allowing the procedure to continue 2, 1
• Perform forearm angiography at the conclusion of the case to assess the perforation 2, 1
• Apply extrinsic compression with elastic bandage or blood pressure cuff inflated to subocclusive pressure for severe bleeding 2, 1

Radial Artery Occlusion (RAO)

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, 3

• Administer systemic anticoagulation (unfractionated heparin 50-100 IU/kg) concurrently with ulnar compression to facilitate thrombus dissolution 1, 3
• Approximately 50% of RAO cases will spontaneously recanalize within 1-3 months even without specific treatment 3
• RAO is often asymptomatic due to dual circulation through the ulnar artery and interosseous arteries 2, 3

Arterial Laceration with Uncontrolled Bleeding

• Apply extrinsic compression with elastic bandage or blood pressure cuff inflated to subocclusive pressure 2, 1
• If hemostasis cannot be achieved with compression measures or if recognized very late: Surgical repair of the laceration and evacuation of hematoma may be required to avoid compartment syndrome 2, 3

Critical Pitfalls to Avoid

Compartment syndrome is the most devastating complication and occurs when:

• Arterial laceration is recognized very late 2
• Hemostasis cannot be achieved with conservative measures 2
• Large hematomas are not evacuated promptly 4

Monitor for delayed complications including:

• Pseudoaneurysm (33% of iatrogenic injuries in one series) 4
• Arteriovenous fistula 2
• Persistent pain or neurological deficits 2
• Sensorimotor deficits or digital necrosis (rare but reported) 4

Adjunctive Measures

For radial artery spasm (which may complicate injury management):

• Apply warm compress to the affected area 5
• Maintain comfortable temperature to reduce sympathetic tone 5
• Consider pharmacological approaches such as calcium channel blockers or nitroglycerin 5

Prevention Strategies for Future Access

• Use smaller sheath sizes (4F or 5F) when possible—6F sheaths have significantly higher RAO rates (5.9% vs 1.1%) 1, 3
• Ensure adequate intraprocedural anticoagulation (heparin 50-100 IU/kg) 1, 3
• Maintain patent hemostasis during sheath removal to preserve radial artery flow 1, 3
• Consider prophylactic ipsilateral ulnar artery compression during hemostasis, which reduces 30-day RAO from 3.0% to 0.9% 2