What is the management for a damaged radial artery post angiogram?

Management of Damaged Radial Artery Post-Angiogram

Immediately assess for the specific type of radial artery injury—hematoma, perforation, occlusion, or laceration—and initiate manual compression for small hematomas or ipsilateral ulnar artery compression for occlusion, while monitoring for hand ischemia signs including pain, weakness, discoloration, reduced temperature, or sensory deficits. 1

Immediate Assessment

Evaluate the patient immediately for signs of vascular compromise 1:

• Hand or finger pain, weakness, or discoloration 2, 1
• Reduced temperature or sensory deficits (numbness, tingling) 1
• Location of hematoma: Access site versus proximal (forearm/upper arm) 2

Distinguish the injury type as this determines management 1:

• Small access site hematoma
• Proximal hematoma (suggests arterial perforation of side branch)
• Radial artery occlusion (RAO)
• Arterial laceration with severe bleeding

Management by Injury Type

Small Access Site Hematoma

Apply manual compression as first-line treatment 1:

• Use direct manual pressure over the hematoma 2
• 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 measures 2

Proximal Hematoma (Arterial Perforation)

Suspect perforation of a side branch when hematoma forms proximal to access site 2, 1:

• If recognized intraprocedurally, the intraluminal sheath or catheter can tamponade the perforated segment, allowing procedure continuation 2, 1
• Perform forearm angiography at case conclusion to assess the perforation 2, 1
• Apply extrinsic compression with elastic bandage or blood pressure cuff inflated to subocclusive pressure 2, 1

Severe Bleeding or Arterial Laceration

Use extrinsic compression with blood pressure cuff inflated to subocclusive pressure 2, 1:

• Apply elastic bandage or blood pressure cuff to achieve hemostasis 2
• If hemostasis cannot be achieved or recognized very late, surgical repair of the laceration and hematoma evacuation may be required to avoid compartment syndrome 2

Radial Artery Occlusion (RAO)

Apply ipsilateral ulnar artery compression for 1 hour immediately upon recognition 1, 3:

• 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 2, 3

RAO is often asymptomatic due to dual circulation through interosseous arteries, but best practice requires preserving radial artery patency for future vascular access 2, 3

Critical Monitoring Parameters

Monitor continuously for complications requiring escalation 1, 4:

• Hand ischemia symptoms: pain, weakness, discoloration, reduced temperature, sensory deficits 2, 1, 4
• Forearm or wrist hematoma expansion to prevent compartment syndrome 4
• Delayed complications: pseudoaneurysm, arteriovenous fistula, persistent pain 1

Prevention Strategies for Future Procedures

To minimize risk of radial artery injury 1, 3:

• 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 using minimal occlusive pressure to preserve radial artery flow 1, 4, 3
• Consider prophylactic ipsilateral ulnar artery compression during hemostasis, which reduces 30-day RAO from 3.0% to 0.9% 2

Common Pitfalls to Avoid

• Do not apply excessive compression to radial access sites, as this increases RAO rates 4
• Do not ignore proximal hematomas—they indicate arterial perforation requiring forearm angiography 2, 1
• Do not delay surgical consultation when hemostasis cannot be achieved with conservative measures, as compartment syndrome may develop 2
• Do not assume RAO is benign—while often asymptomatic, it eliminates future radial access and carries higher risk in patients with dominant radial artery or incomplete palmar arch 3