Читать книгу Interventional Cardiology - Группа авторов - Страница 84

Hematomas occur in <5% of TRA cases and rarely require imaging or blood transfusions (unlike those associated with femoral access). Typically, they are caused by guidewire‐ or catheter‐induced damage to small arterial branches proximal to the puncture site (Figure 3.3d and e). Bertrand’s Early Discharge After Transradial Stenting of Coronary Arteries (EASY) hematoma scale (<link href="urn:x-wiley:9781119697343:xml-component:w9781119697343c3:c3-fig-0004">Figure 3.4</link>) is helpful for sizing hematoma associated with traditional proximal radial access (<link href="urn:x-wiley:9781119697343:xml-component:w9781119697343c3:c3-fig-0004">Figure 3.4</link>). Grade I, ≤5 cm (local hematoma, superficial); grade II, ≤10 cm (hematoma with moderate muscular infiltration); grade III, >10 cm below the elbow (forearm hematoma and muscular infiltration); grade IV, hematoma extending above the elbow and grade V, compartment syndrome [40,41]. Early detection is key to preventing progression to a major complication such as compartment syndrome [42]. Pressure bandaging, withholding anti‐coagulating medications and inflation of a blood pressure cuff immediately proximal to the hematoma to 20 mmHg below systolic blood pressure for 15 minutes is usually sufficient to manage larger hematomas (Figure 3.3d).

Figure 3.3 Complications of Transradial Access. (a) Radial perforation caused by a hydrophilic 0.035" (Benson) wire. (b) Subclavian artery spiral dissection caused by 0.035 in J‐wire in a patient with marked subclavian tortuousity. (c) Catheter kinking and entrapment (retrieved via the same access site in this case after unwinding and wiring with 0.035" wire). (d) Illustration of forearm hematoma compression. Note the forearm hematoma is proximal and distinct from puncture site at the distal radial artery. This likely resulted from wire or catheter induced damaged to small arterial branches proximal to the puncture site. The manual sphygmomanometer is inflated 15–20 mmHg above systolic blood pressure for 5–10 minutes before a repeat clinical examination of the site. (e) Grade IV hematoma complicating proximal TRA PCI for myocardial infarction in a 94‐year‐old woman with severe chest pain and hypertension. The patient developed a pseudoaneurysm that ruptured during ultrasound examination the following day. The image illustrates her two large skin tears where her skin separated during compression hemostasis of the ruptured vessel. This lady was observed for compartment syndrome and went on to make a full recovery without any surgical intervention. The pseudoaneurysm was treated using ultrasound targeted compression after the skin wounds had healed.

Figure 3.4 Transradial hematoma classification system (From Bertrand et al., Catheter Cardiovasc Interv 75:366–368; 2010. Reproduced with permission of John Wiley & Sons.)