Compartment Syndrome After Radial Artery Catheterization
A review of the literature.
Radial artery catheterization continues to gain increasing popularity due to a lower risk of bleeding and vascular complications as compared with the transfemoral approach.1 Compartment syndrome of the forearm or hand as a complication of radial artery catheterization has been reported.2-11 Despite its rare occurrence, with a reported incidence ranging between 0.004% and 0.13%,3,5,7,8,10 sufficient knowledge of this condition is critical for early recognition to prevent potentially devastating outcomes, which include neurologic dysfunction and Volkmann contracture.
Compartment syndrome occurs when a rise in pressure within a limited space results in compromised tissue perfusion and viability.3 Anatomically, the forearm is divided by fascia into three compartments, whereas the hand is divided into 10 compartments. The most widely accepted theory regarding development of compartment syndrome is the arteriovenous pressure gradient theory.12 As initially described by Matsen et al,13 the increase in local tissue pressure leads to collapse of the thin-walled venules. The pressure head from the arterial side of the circulation results in a progressive rise in intraluminal venous pressure causing them to reopen but only to drain at a higher pressure, thus reducing the arteriovenous pressure gradient and compromising capillary flow. If this cycle continues, metabolic demands of the tissue can no longer be met, and ischemia ensues. In addition, there is progressive buildup of edema as well as collapse of lymphatic vessels, leading to a further increase in pressure and perpetuating the cascade of events.14,15
Any cause of increased volume within a nonexpandable compartment, such as bleeding, edema, or extraneous fluids, can result in compartment syndrome. After radial artery catheterization, bleeding can occur at the access site due to inadequate compression or, more proximally, as a result of side branch perforation from wire-induced injury (particularly if hydrophilic).3 Radial artery laceration can also occur during sheath insertion or removal in the setting of severe radial artery vasospasm.3 Predictors of hematoma formation in patients undergoing radial artery catheterization have been previously identified, and include female sex, smaller patient size, creatinine clearance < 60 mL/min, procedure duration, and sheath size.9 There have been case reports of compartment syndrome developing in the forearm after radial artery catheterization with little or no evidence of hematoma.4,9 In these cases, the authors hypothesized that arterial spasm induced by the radial sheath or catheter resulted in ischemia of the forearm muscles and subsequent tissue edema. Another potential cause for compartment syndrome in patients undergoing cardiac catheterization is intravenous infiltration of medications or even saline solution through a misplaced intravenous catheter.16,17
CLINICAL PRESENTATION AND DIAGNOSIS
Diagnosis of compartment syndrome of the forearm and hand is primarily clinical. Thus, maintaining a high index of suspicion is essential to establish an early diagnosis. The five Ps (pain, pallor, pulselessness, paralysis, and paresthesia) have been historically taught as the classic hallmarks of compartment syndrome. However, most of these symptoms occur late in the course of the disease, and outcomes are poor in this stage even if fasciotomy is performed.18 Patients with compartment syndrome experience tense swelling of the involved compartment. Pain that is aggravated by passive stretching of the affected muscles is the most sensitive and earliest clinical finding.19 If left untreated, evolution into a paralysis, dysesthesia, and loss of pulse eventually occurs. In the long term, an array of disabilities can develop, ranging from a slight contracture and loss of sensitivity of the first three fingers to a complete contracture and disability of the hand and wrist (Volkmann contracture).3 Although the diagnosis is mostly clinical, measurement of intracompartmental pressure (normal, up to 9 mm Hg) can be useful, particularly in deciding the timing of surgical fasciotomy. An absolute pressure of > 30 mm Hg, or a difference of ≤ 20 mm Hg between the diastolic blood pressure and the intracompartmental pressure have been suggested as indicators for requiring emergent fasciotomy.18,19
If pain, swelling, or induration develops in the hand or in the forearm after radial artery catheterization, bleeding into the forearm should be suspected. Initial conservative measures to prevent progression into compartment syndrome include applying manual pressure to control bleeding and assessing for possible infiltrated intravenous lines. When manual pressure is inadequate, inflating a blood pressure cuff at the site of induration to 15 mm Hg below the systolic blood pressure for 15 minutes has been suggested. Cuff pressure can be subsequently adjusted to maintain arterial flow using an oximeter probe. Management of elevated blood pressure, pain control, discontinuation of glycoprotein IIb/IIIa inhibitors, and partial reversal of heparin are all additional important steps to consider. If symptoms persist and progression to compartment syndrome is suspected, urgent surgical consultation should be sought.3
With the increasing number of radial artery catheterization procedures, one must be diligent in recognizing potentially disabling, albeit rare, complications, such as compartment syndrome.
1. Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008;1:379-386.
2. Lin YJ, Chu CC, Tsai CW. Acute compartment syndrome after transradial coronary angioplasty. Int J Cardiol. 2004;97:311.
3. Tizon-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a large series of transradial approach for coronary procedures. J Interv Cardiol. 2008;21:380-384.
4. Araki T, Itaya H, Yamamoto M. Acute compartment syndrome of the forearm that occurred after transradial intervention and was not caused by bleeding or hematoma formation. Catheter Cardiovasc Interv. 2010;75:362-365.
5. Burzotta F, Trani C, Mazzari MA, et al. Vascular complications and access crossover in 10,676 transradial percutaneous coronary procedures. Am Heart J. 2012;163:230-238.
6. Omori S, Miyake J, Hamada K, et al. Compartment syndrome of the arm caused by transcatheter angiography or angioplasty. Orthopedics. 2013;36:e121-e125.
7. Burzotta F, Mariani L, Trani C, et al. Management and timing of access-site vascular complications occurring after trans-radial percutaneous coronary procedures. Int J Cardiol. 2013;167:1973-1978.
8. Tatli E, Buturak A, Cakar A, et al. Unusual vascular complications associated with transradial coronary procedures among 10,324 patients: case based experience and treatment options. J Interv Cardiol. 2015;28:305-312.
9. Sugimoto A, Iwamoto J, Tsumuraya N, et al. Acute compartment syndrome occurring in forearm with relatively small amount of hematoma following transradial coronary intervention. Cardiovasc Interv Ther. 2016;31:147-150.
10. Hahalis G, Tsigkas G, Kakkos S, et al. Vascular complications following transradial and transulnar coronary angiography in 1600 consecutive patients. Angiology. 2016;67:438-443.
11. Jue J, Karam JA, Mejia A, Shroff A. Compartment syndrome of the hand: a rare sequela of transradial cardiac catheterization. Tex Heart Inst J. 2017;44:73-76.
12. Vollmar B, Westermann S, Menger MD. Microvascular response to compartment syndrome-like external pressure elevation: an in vivo fluorescence microscopic study in the hamster striated muscle. J Trauma. 1999;46:91-96.
13. Matsen FA III, Krugmire RB. Compartmental syndromes. Surg Gynecol Obstet. 1978;147:943-949.
14. Elliott KG, Johnstone AJ. Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003;85:625-632.
15. Friedrich JB, Shin AY. Management of forearm compartment syndrome. Hand Clin. 2007;23:245-254.
16. Ouellette EA, Kelly R. Compartment syndromes of the hand. J Bone Joint Surg Am. 1996;78:1515-1522.
17. Dieter RS, Dieter RA Jr, Crisostomo P. Compartment syndrome of the arm from intravenous infiltration during radial artery catheterization. Tex Heart Inst J. 2017;44:163.
18. Prasarn ML, Oulette EA. Acute compartment syndrome of the upper extremity. J Am Acad Orthop Surg. 2011;19:49-58.
19. Whitesides TE, Heckman MM. Acute compartment syndrome: update on diagnosis and treatment. J Am Acad Orthop Surg. 1996;4:209-218.
Samer Mowakeaa, MD
Loyola University Medical Center
(708) 216-9000; email@example.com
Robert S. Dieter, MD, RVT
Loyola University Medical Center
Edward Hines Jr. Veterans Administration Hospital