Authors

1. Anna Elisa Muzio DO – UPMC Pinnacle Health
2. Michael Jones DO – UPMC Pinnacle Health

Abstract

Background: Compartment syndrome of the forearm following transradial access for percutaneous coronary intervention is a rare and potentially devastating complication if not quickly recognized and treated. A 57-year-old Caucasian female underwent percutaneous coronary intervention via right transradial approach for a myocardial infarction. Hours after the procedure, she complained of paresthesias in her right hand. Physical examination revealed involuntary digital clawing and a diffusely swollen forearm. Compartment pressure monitoring confirmed acute compartment syndrome. The patient was subsequently taken to the operating room for emergent forearm fasciotomies.  

Methods: A PubMed literature review was preformed using “compartment syndrome” and “percutaneous coronary intervention” as keywords. 10 articles met criteria for review. Amongst the 10 articles, 7 case reports described patients with acute compartment syndrome following transradial access for percutaneous coronary intervention. Each article was analyzed to find potential risk factors that could lead to the development of acute compartment syndrome following transradial access.

Results: There are several hypothesized risk factors that may lead to the development of a compartment syndrome, but data is limited given the rarity of this clinical entity.  Based on our literature review, excessive anticoagulant use, low patient body surface area, and concomitant chronic kidney disease appear to be risk factors for development of compartment syndrome following transradial access. 

Conclusion: Compartment syndrome of the forearm following transradial access is an exceptionally rare entity that has been documented in only 7 case reports between 1994 and 2019. Knowledge and early detection of this complication can lead to improved patient outcomes and prevent tragic loss of upper extremity function. 

Keywords: Compartment syndrome, coronary angiography

Manuscript

Introduction:

The transradial approach to percutaneous coronary intervention (PCI) has been historically associated with a lower incidence of vascular access site complications when compared to the transfemoral approach¹. Potential complications include radial arterial occlusive thrombi, arterial spasm, pseudoaneurysm, perforations, and forearm hematomas¹. Radial arterial perforation and forearm hematomas can lead to subsequent compartment syndrome of the forearm secondary to increasing intravascular volume in a closed space². Given the low incidence of vascular complications following the transradial approach, compartment syndrome of the forearm is exceedingly rare. Only 7 case reports have been documented between 1994 and 2019.

Case Report

A 58-year-old Caucasian female with a past medical history of hypertension, hyperlipidemia, coronary artery disease status post percutaneous coronary intervention in 2007, and morbid obesity presented to the emergency department with crushing, substernal chest pain. She was diagnosed with an acute inferior wall myocardial infarction, was started on a heparin drip, and was subsequently taken to the cardiac catherization lab. She underwent coronary angiography, left ventriculography, and PCI via right radial arterial access. Two drug eluting stents were placed. Post operatively, she was started on an Aggrastat infusion, began dual antiplatelet therapy with Aspirin and Effient, and a pneumatic transradial vascular hemostatic band was placed over the right radial arterial access site.

Approximately one hour after her cardiac procedure, the patient began to complain of diffuse right upper extremity paresthesias. She noticed difficulty and pain with any attempted range of motion of her digits. The orthopedic team was consulted, and the patient was diagnosed with compartment syndrome based on her physical examination and subsequent intra-compartmental measurements. Her mobile wad, volar compartment, and dorsal compartment had absolute pressure measurements of 3, 55, and 52 mm Hg, respectively. Her delta pressure measurements in the mobile wad, volar compartment, and dorsal compartment were 70, 18, and 21 mm Hg, respectively. She was immediately taken to the operating room for urgent fasciotomies of the right upper extremity.

Intraoperatively, the volar compartment was again measured. It was found to have an elevated absolute pressure and low delta pressure, which was consistent with the preoperative examination. The compartment was subsequently released. Additionally, a small incision was created in the palm of the hand to release the carpal tunnel. The entire course of the radial artery was then closely examined. There was a small area of arterial bleeding distally which was cauterized (See Figure 1). Then, the dorsal and mobile wad compartments were measured. Their measurements were not consistent with compartment syndrome, so they were not released. A wound vac was placed over the volar wound. The patient returned to the operating room four days later for primary closure. At three months post operatively, the patient had a normal neurological exam and complete use of her right upper extremity without any motor or sensory deficit.

Discussion

Compartment syndrome can lead to irreversible neurological damage and ischemic contractures. Though most of the data is based on lower limb compartment syndrome after traumatic tibial injuries, it can occur in all compartments in the body. It is truly a clinical diagnosis that is made based on history and physical examination. Patients will often present with the classic 5 P’s of symptomatology: pain out of proportion to their injury, paresthesias, pallor, pulselessness, and poikilothermia of the involved limb. Criteria for release varies depending the resource. Absolute compartment pressures that measure between 30-45 mm Hg should be released to prevent ischemic complications. The delta pressure or “delta p” is a more sensitive number that provides criteria for release. To calculate the delta p, subtract the patient’s compartment pressure from the awake, non-anesthetized patient’s diastolic blood pressure. Delta pressure measurements of less than 30 mm Hg should be released.

The transradial approach to percutaneous coronary intervention has been historically associated with a lower incidence of vascular access site complications when compared to the transfemoral approach. Albeit rare, complications include radial arterial occlusive injuries, spasm, pseudoaneurysm, perforation, and forearm hematomas¹. Compartment syndrome can occur as a sequela from a radial arterial perforation and forearm hematoma^2,4. In a retrospective review of 3369 patients by Sanmartin, only 5 patients suffered a radial artery perforation¹. Garg reviewed 520 patients that underwent transradial PCI; only 53 patients developed a hematoma and no patients developed subsequent compartment syndrome³. Given the low incidence of vascular complications following the transradial approach, compartment syndrome of the forearm is exceedingly rare. In a large retrospective review of more than 50,000 patients undergoing PCI via transradial access, only 2 patients developed compartment syndrome². Only 7 case reports have been documented between 1994 and 2019. Table 1 highlights the 7 patients, their past medical histories, and intraoperative findings^2,5-9. When comparing the 7 patients, most patients had a distinct site of radial artery damage or a large forearm hematoma that lead to the development of compartment syndrome. Based off of this data, most patients were older than 55 years old and were preoperatively anticoagulated. All patients were treated with urgent compartment releases. Thankfully, all patients with the exception of 1 had a complete neurovascular recovery.

Several studies highlight possible predictors of the development of compartment syndrome following transradial access. In a large retrospective review by Tizon et al, patients with low body surface area, concomitant chronic kidney disease, and excessive anticoagulation were associated with developing compartment syndrome². The authors postulate that older, thin, frail patients are at higher risk because the anticoagulant medications are renally excreted². An excess of anticoagulants can lead to hematoma development, especially in the setting of an arterial injury². Additionally, older patients may have a more tortuous arterial supply, causing increased susceptibility to arterial injury given their difficult anatomy¹⁰.  Given the paucity of data that exists, it is difficult to make overarching recommendations on which patients are at higher risk.

Conclusion

Compartment syndrome of the forearm following transradial access for percutaneous coronary intervention is a rare entity. Based on literature review, this would be the 8th documented case since 1994. There are several hypothesized risk factors that may lead to the development of a compartment syndrome, but data is limited given the rarity of this clinical entity. Clinicians must have a high suspicion for compartment syndrome and quickly involve the surgical team, as it is a limb threatening diagnosis if not expediently treated. 

Clinical Message

Compartment syndrome of the forearm following transradial access for percutaneous coronary intervention is an uncommon, but limb threatening, complication. Providers need to consider compartment syndrome as a potential postoperative diagnosis for patients with increasing pain, paresthesias, digital paralysis, and pallor of the involved extremity following transradial access. Early diagnosis leads to expedited orthopedic evaluation and treatment, which subsequently leads to improved patient outcomes.

Statement of Informed Consent

The patient involved in this case report was informed that their information was submitted for publication. The patient is in full agreement.

References

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