Transulnar coronary intervention complicated by compartment syndrome

Background

Due to accumulating evidence of lower rates of access-site complications, cardiac death and all-cause mortality and hence higher cost-effectiveness, percutaneous access via the wrist is increasingly accepted as the first-line route for percutaneous coronary angiography (CAG) and percutaneous coronary intervention (PCI) at the expense of transfemoral access.1 2 However, for 5%–15% of patients undergoing a catheterisation procedure via the wrist, the transradial approach is unsuitable.3 Several trials4 have subsequently investigated the possible advantages and disadvantages of transulnar over transradial access, since transulnar access would have the theoretical advantages of (1) saving the radial artery for coronary artery bypass grafting, (2) to prevent the risk of hand ischaemia in case of radial artery occlusion in patients with an abnormal Allen test and to avoid femoral access as the alternative to (3) failed radial access and (4) an occluded radial artery, for example, as observed in about 10% (range 2%–18%) of patients after previous radial catheterisation(s).5 6 On the other hand, expected disadvantages of the ulnar approach were a higher risk of ulnar nerve damage due to the proximity of the ulnar nerve, hand ischaemia and failed cannulation due to its deeper location in the wrist.6 A recent meta-analysis of the 5276 patients included in the trials comparing transradial with transulnar arterial access, however, showed no differences in either major adverse cardiac events; access-site complications, including haematoma, pseudoaneurysms and arteriovenous fistula; or arterial access or fluoroscopy time or contrast loads between the two groups. Hence, it was concluded that there was evidence to support the ulnar artery as an alternative to the radial artery for cardiac catheterisation.4 Compartment syndrome is a rare but possibly devastating complication of percutaneous transarterial angiography and interventions, which has been reported in the setting of transradial angiography.7 Although several cases of major forearm haematoma after transulnar catheterisation have been described in the literature,6 8 9 as well as several cases of compartment syndrome after traumatic injury,10 11 we are unaware of any published case of a compartment syndrome after transulnar CAG or intervention.

Case presentation

A 56-year-old man who is a manual worker and active smoker, with positive family history for cardiovascular disease and a history of hypertension, hypercholesterolaemia, peripheral artery disease and non-ST elevation myocardial infarction for which two drug-eluting stents (DES) were placed in his left anterior descending coronary artery (LAD), presented with intermittent severe chest pain existing for several days. He was using 100 mg of acetylsalicylic acid and 50 mg of metoprolol daily but had stopped using his statin due to myalgia. On admittance, his heart rate was 110 per minute; his blood pressure is 180/100 mm Hg, with a normal temperature of 35.7°C and breathing frequency of 28 per minute with 100% oxygen saturation. Except for weak pulsations in the peripheral arteries, including his bilateral radial arteries, physical examination was normal. No further investigation into the weak pulsations was conducted considering the need for swift diagnosis and treatment of the chief complaint and the assumption that it was caused by extensive peripheral artery atherosclerosis.

His electrocardiogram (EKG) showed a sinus rhythm; normal heart axis; normal conduction times; QS pattern in V1–V2; and, compared with a previous EKG recorded 6 months earlier, new 1 mm ST elevation in V1–V2 and 1 mm ST depression in V4–V6, and negative T-waves in I, aVL and V1–V4 are observed. Laboratory results revealed normal levels of haemoglobin, leucocytes, thrombocytes and electrolytes; slightly elevated glucose (8.4 mmol/L); elevated total cholesterol (5.2 mmol/L), hs troponin T (0.503 µg/L) and CK-MB (16 µg/L); and normal CK level (122 U/L). A second survey revealed stable hs troponin (0.462 µg/L) and CK-MB (13 µg/L). Immediately performed transthoracic echocardiography revealed a moderately reduced left ventricular function with anteroseptal, anterior and apical hypokinesia, without significant valvular regurgitation and a normal right ventricular function.

The diagnosis of postinfarct angina after ambulatory acute coronary syndrome was made, and CAG was scheduled for the same day due to ongoing episodes of chest pain. A ticagrelor loading of 180 mg was given and 5000 IU of intravenous heparin. A CAG was performed by one of our most experienced operators via an ulnar approach due to weak radial pulsations on his right wrist. A 6 French sheath was successfully placed in the right ulnar artery after a single puncture. Wire progression was somewhat difficult, but eventually, the wire and a 6 French Kimney catheter were manoeuvred into the sinus of Valsalva, and both coronary ostia were engaged. A severe and significant in-stent restenosis of the LAD was shown for which a PCI was performed and a DES was placed with a good angiographic result.

Within 1 hour after the procedure, the patient developed severe pain in his right forearm as well as paraesthesia of his fingers. On inspection, pallor and local swelling of the lower forearm were noted, as well as absence of pulsations distal to the swelling, loss of sensation and partial paralysis of the fingers.

Investigations and treatment

An immediately performed duplex ultrasound revealed an increased blood flow velocity in the ulnar artery, suggestive for compartment syndrome, as well as normal flow in the radial artery (figure 1) and thus confirmed the clinical diagnosis of compartment syndrome, and urgent decompression was performed through fasciotomy. Due to the severity of the swelling the skin was left open with a suture system that was closed slowly during the following weeks (figure 2).

Outcome and follow-up

The patient was monitored on an ambulatory base for the next weeks, and the suture system was removed after 1 week. At present, the patient is declared healed by the vascular surgeon and is rehabilitating before going back to work.

A retrospective analysis of 15,161 CAG procedures performed in our clinic between 1st January 2016 and 20th April 2020 showed that of the 13,948 angiographic procedures, 7532 of which were interventions, performed through the wrist, only one definite case of compartment syndrome for which a fasciotomy was performed was recorded, resulting in an incidence rate of 0.007% after CAG and 0.013% after percutaneous intervention. Unfortunately, we were unable to extract the percentage of procedures performed through the ulnar artery from our database. However, in our centre, this access site is only used when a radial approach is unsuccessful, which is very seldom. One additional case of an emergency fasciotomy was recorded 4 days after an emergency PCI through the right radial artery. This particular patient had been presented with cardiogenic shock, had received a multivessel PCI and circulatory support with an Impella device and was subsequently admitted to the intensive care unit where she had received ventilator and haemodynamic support. Before developing compartment syndrome, she had received several punctures in her right radial artery to acquire material for arterial blood gas analyses and eventually had an arterial line placed in the same artery. Taken together, we did not take this latter case into account as a compartment syndrome after transradial CAG due to the late development of symptoms (although one very late presentation has been described earlier12) and the subsequently performed radial punctures and placement of an intra-arterial catheter during intensive care treatment, which are very likely to have at least contributed to this complication.