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BMJ Case Rep. 2015; 2015: bcr2015211145.
Published online 2015 August 4. doi:  10.1136/bcr-2015-211145
PMCID: PMC4533665
Case Report

Hand ischaemia after radial artery cannulation

Abstract

Arterial cannulation for haemodynamic monitoring has become a routine procedure in the clinical management of critically ill adults. Thrombosis is the most common complication of this procedure. We report the case of a patient with multiple traumatic injuries in which radial artery cannulation was associated with compartment syndrome of the forearm and hand.

Background

The primary aim of arterial cannulation is to provide uninterrupted display of pulse contour and continuous beat-to-beat haemodynamic measurement.1 Complications associated with radial artery cannulation, such as thrombosis or infection, can be seen rarely. Thrombosis is the most common complication of this procedure.2 The radial artery is the most frequently cannulated site for haemodynamic monitoring.3 Although radial artery thrombosis has a high rate of occurrence (25–33%), clinical hand ischaemia secondary to cannulation is uncommon (≤1/500).4 5 We report the case of a patient with multiple traumatic injuries in which radial artery cannulation was associated with compartment syndrome of the forearm and hand. This case points to the potential morbidity of arterial cannulation.

Case presentation

A 67-year-old man with a history of Alzheimer's disease and cerebrovascular event went into arrest in the service where he was being treated for pneumonia. After responding to cardiopulmonary resuscitation, the patient was transferred to the anaesthesia intensive care unit for further treatment. An arterial cannula (BD Angiocath20G (1.1 mm, 48 mm); Becton Dickinson, Sandy, Utah, USA) was placed in his right radial artery on first trial after performing the Allen's test. Because his blood pressure was low, inotropic and vasopressor support treatment was administered. Blood clotting tests were higher than the normal range (PT:18.2 s, APTT: 36.4 s, INR:1.87). On day 4 of cannulation, coldness and bruising developed in the fingers of the right hand; subsequently, the arterial cannula was removed and pressure was applied. After consultation with cardiovascular surgery, arterial Doppler ultrasonography was carried out; 60 mg enoxaparin (Clexane, Sanofi Aventis, Turkey) 2 times a day for 2 days was initiated, and elevation and heat were applied. Surgical intervention was not considered. However, the patient did not respond to anticoagulant treatment and heating. Total necrosis developed in the thumb of the right hand, with necrosis in the distal phalanxes of the second and third fingers and the dorsal of the right hand, the wrist and the dorsal aspect of the forearm (figure 1). Also, sepsis developed, of which the source was unclear. The brachial artery to the ulnar artery wrist level and the radial artery to the middle portion were patent. On consultation with the orthopaedics department, amputation was carried out at the wrist. The patient died due to septic shock on day 3 following amputation.

Figure 1
Total necrotic right hand after radial arterial cannulation.

Outcome and follow-up

The Allen's test is a poor predictor, a fact that should be kept in mind in the clinical setting. The benefits of monitoring with arterial cannulation must be balanced against the associated risks, and the benefits must outweigh the potential harm.

Discussion

Radial artery ischaemia has been associated with various risk factors. These include female gender, low body mass index, advanced age, history of hypertension or prolonged hypotension, vascular disease (Raynaud), catheter size and composition (eg, long and large), cannulas left in place longer than 48–72 h, low cardiac output, use of vasopressors,6 excessive trauma from multiple attempts at the same site, hyperlipoproteinaemia, thrombosis and haematoma formation at the site,7 disseminated intravascular coagulation, and wrist circumference <18 cm.8 Each of these factors can be associated with increased risk of radial artery thrombosis resulting from local injury, vasospasm or decreased arterial flow. Management options of patients who develop ischaemia after radial artery cannulation include medical and/or surgical therapy.9 In the treatment of ischaemia subsequent to artery cannulation, the following measures should be taken: removal of catheter, tissue elevation and heating, and the addition of anticoagulants, thrombolytics and vasodilators if ischaemia continues.10 Medical options are likely best for patients with multiple medical comorbidities. In suitable cases, embolectomy, surgical bypass or cervical sympathetic blockage should be considered; however, surgical intervention incidence and outcomes for complications of radial arterial lines are low.11 Catastrophic complications after radial arterial cannulation, especially clinical hand ischaemia, are rare. Various methods, including the Allen's test, Doppler ultrasound, digital plethysmography and pulse oximetry, have been proved useful in studying the collateral circulation of the hand.12 However, these tests are not predictors for ischaemic changes after cannulation. For example, the modified Allen’s test predictor value for ischaemic complications is 52–80%, and a number of studies refute this value.13 Slogoff et al6 reported the incidence of partial or complete occlusion after radial artery cannulation with a negative Allen's test, before cannulation, to be as high as 25%. Some other studies (including the present work) confirm that ischaemic complications may occur despite normal Allen's test results.7

Learning points

  • Thrombosis is the most common complication of artery catheterisation.
  • In the treatment of ischaemia subsequent to artery cannulation, removal of catheter, tissue elevation and heating, and the addition of anticoagulants, thrombolytics and vasodilators, if ischaemia continues, should be carried out.
  • Allen's test, Doppler ultrasound, digital plethysmography and pulse oximetry are not predictors for ischaemic changes after cannulation.
  • The point in time when artery cannulation raises a high index of suspicion for possible infectious and vascular complications should be keep in mind.
  • Since complications are related to duration of artery catheterisation, the cannula should be removed as soon as possible.

Footnotes

Contributors: OO conceived, designed and carried out the statistical analysis, and editing of the manuscript. OO, ES, FY and MK carried out data collection. OO wrote the manuscript, reviewed and gave final approval of the manuscript. OO takes the responsibility and is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

References

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2. Cederholm I, Sorensen J, Carlsson C Thrombosis following percutaneous radial artery cannulation. Acta Anaesthesiol Scand 1986;30:227–30. doi:10.1111/j.1399-6576.1986.tb02402.x [PubMed]
3. Durbin CG., Jr Radial arterial lines and sticks: what are the risks? Respir Care 2001;46:229–31. [PubMed]
4. Piccolo R, Galasso G, Capuano E et al. Transradial versus transfemoral approach in patients undergoing percutaneous coronary intervention for acute coronary syndrome. A meta-analysis and trial sequential analysis of randomized controlled trials. PLoS ONE 2014;9:e96127 doi:10.1371/journal.pone.0096127 [PMC free article] [PubMed]
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8. Bedford RF. Wrist circumference predicts the risk of radial-arterial occlusion after cannulation. Anesthesiology 1978;48:377–8. doi:10.1097/00000542-197805000-00021 [PubMed]
9. Mirbagheri N, Hoy C Hand ischaemia post-radial artery cannulation: a cautionary reminder of an uncommon complication of a common procedure. ANZ J Surg 2008;78:719–20. [PubMed]
10. Cannon BW, Meshier WT Extremity amputation following radial artery cannulation in a patient with hyperlipoproteinemia type V. Anesthesiology 1982;56:222–3. doi:10.1097/00000542-198203000-00016 [PubMed]
11. Chim H, Bakri K, Moran SL Complications related to radial artery occlusion, radial artery harvest, and arterial lines. Hand Clin 2015;31:93–100. doi:10.1016/j.hcl.2014.09.010 [PubMed]
12. Glavin RJ, Jones HM Assessing collateral circulation in the hand: four methods compared. Anaesthesia 1989;44:594–5. doi:10.1111/j.1365-2044.1989.tb11452.x [PubMed]
13. McGregor AD. The Allen test: an investigation of its accuracy by fluorescein angiography. J Hand Surg [Br] 1987;12:82–5. doi:10.1016/0266-7681(87)90065-9 [PubMed]

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