Compartment Syndrome of the Arm Caused by Transcatheter Angiography Or Angioplasty

n Case Report

Compartment Syndrome of the Arm Caused by Transcatheter Angiography or Angioplasty

Shinsuke Omori, MD; Junichi Miyake, MD; Kenichiro Hamada, MD, PhD; Norifumi Naka, MD, PhD; Nobuhito Araki, MD, PhD; Hideki Yoshikawa, MD, PhD abstract Full article available online at Healio.com/Orthopedics. Search: 20121217-31

Compartment syndrome of the arm is a rare condition because of the large capacity of the arm compartment. Although several cases of compartment syndrome of the forearm associated with vascular access procedures have been reported, the literature contains few detailed reports of compartment syndrome of the arm caused by transcather angiography or angioplasty. This article presents 4 cases of compartment syndrome of the anterior arm caused by transcatheter angiography or angioplasty; all patients required surgical treatment and anticoagulation therapy. Following urgent fasciotomy and hemostasis, 1 patient experienced recurrent bleeding and another exhibited delayed complex regional pain syndrome of the forearm. The remaining 2 cases had good outcomes.

Because all patients had been prescribed various oral anticoagulants, their compartment syndrome was considered a complication of thrombolytic therapy. In addition, because all patients had a history of multiple arterial diseases, atherosclerosis was considered to be severely advanced and the vessels to be easily damaged. Due to the authors’ experiences with these 4 cases, they recommend that surgery be performed under general rather than local anesthesia and that the bleeding site be sutured or ligated. Compression of the bleeding point alone could allow heavy bleeding or recurrence of bleeding to occur because of Figure: Coronal T2-weighted magnetic resonance the influence of anticoagulation therapy. Continuous bleeding of the arm may expand into image showing a hematoma formation in the ante- the volar compartment of the forearm, leading to a condition similar to chronic compart- rior compartment of the upper arm. ment syndrome. Effective hemostasis, in addition to early decompressive fasciotomy, is essential in compartment syndrome caused by the catheter procedure.

The authors are from the Department of Orthopaedic Surgery (SO, JM, NN, HY), Osaka University Graduate School of Medicine, Suita, and the Musculoskeletal Oncology Service (KH, NA), Osaka Medical Center for Cancer and Cardiovascular Diseases, Higashinari, Osaka, Japan. The authors have no relevant financial relationships to disclose. The authors thank Tsuyoshi Murase, MD, PhD; Hisao Moritomo, MD, PhD; Kiyoshi Okada, MD, PhD; and Makoto Emori, MD, for their contributions to this study. Correspondence should be addressed to: Junichi Miyake, MD, Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871 Japan ([email protected]). doi: 10.3928/01477447-20121217-31

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ompartment syndrome of the arm is a rare condition because of the Clarge capacity of the arm compartment.1 Several reports on compartment syndrome of the arm caused by a crushing injury,2,3 tendon rupture of the biceps and triceps,4,5 traumatic brachial artery injury,6 compression,1,7 prolonged tourniquet use,8 use of a blood pressure monitor,9,10 and venipuncture in a patient with hemophilia11 have been published. To the current authors’ knowledge, only 1 case of compartment syndrome of the arm secondary to a catheter-induced procedure has been reported; as a complication of thrombolytic therapy, the patient A B sustained acute compartment syndrome of Figure: Coronal (A) and axial (B) T2-weighted magnetic resonance images of the left upper arm showing the posterior arm accompanied by radial a hematoma formation in the anterior compartment of the upper arm. and ulnar nerve palsy after cardiac catheterization.12 The current article reports 4 cases of The authors used the Whitesides meth- Postoperatively, the cardiologist or- compartment syndrome of the anterior od to measure the intracompartmental dered continuation of anticoagulants be- arm caused by transcatheter angiography pressure of the patient’s anterior arm.13 cause of the high risk of occlusive vas- or angioplasty; all patients required surgi- The pressure in the anterior compartment cular disease. On postoperative day 12, cal treatment. Patients provided informed reached 50 mm Hg, and the delta pres- recurrent bleeding occurred when the consent for data concerning their cases to sure (Dp) (ie, the difference between the patient strained during defecation; it took be submitted for publication. diastolic blood pressure and the compart- 1 hour to stop the bleeding using manual ment pressure) was 11 mm Hg. Magnetic compression. On postoperative day 22, Case Reports resonance imaging showed a large hema- the wound was closed and the patient Patient 1 toma in the entire anterior compartment achieved complete recovery without neu- A 55-year-old woman with stenosis of of the upper arm (Figure). Compartment rological impairment. the left subclavian artery was admitted to syndrome of the anterior aspect of the arm the authors’ hospital. She had a history of was diagnosed, and an urgent open fasci- Patient 2 homozygous familial hypercholesterol- otomy was performed while she was un- A 64-year-old man with asymptomatic emia, systemic arteriosclerosis obliterans, der local anesthesia. myocardial ischemia was admitted to the coronary artery disease, and cerebral in- A longitudinal incision was made over authors’ hospital. He had a history of hy- farction. She received oral anticoagula- the anterior aspect of the brachium. The pertension, diabetes mellitus, and bilateral tion therapy with aspirin and ticlopidine biceps brachii was considerably swollen arteriosclerosis obliterans of the lower hydrochloride. Her coagulation laboratory with hematoma, and active bleeding was legs. He was taking oral anticoagulation tests were normal, but her platelet count found at the puncture site of the brachial therapy with aspirin and clopidogrel sul- was 6.03104 cells/µL at admission. artery. The bleeding point was compressed fate. Two months previously, he had un- Angioplasty of the left subclavian artery manually for approximately 30 minutes, dergone diagnostic coronary angiography was performed the following day via the but bleeding could not be controlled. The via the transfemoral approach, which re- left brachial artery through a 7-Fr sheath bleeding eventually stopped after ad- vealed severe stenosis of the left anterior using a bare metal stent. Thirty minutes ditional compression using microfibril- descending coronary artery and left cir- after stenting, she reported marked pain lar collagen (Avitene; Davol, Cranston, cumflex coronary artery. in her anterior arm. The surgeon consulted Rhode Island). Intraoperative blood loss His coagulation laboratory tests were the authors, suspecting acute compartment was 560 mL and was replaced by 2 units normal at admission. Stenting of the left syndrome. The anterior arm was consider- of packed red blood cells via transfusion. anterior descending coronary artery was ably swollen, stiff, and tender. The wound was left open. successfully performed via the right bra-

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chial artery through a 7-Fr sheath because tervention of the right coronary and left The authors used the Whitesides of the presence of arteriosclerosis oblit- circumflex coronary arteries. He received method to measure the tissue pressure in erans in the lower leg. One week later, oral anticoagulation therapy with ticlopi- the anterior compartment of the arm.13 stenting of the left circumflex coronary dine hydrochloride and cilostazol. The intracompartmental tissue pressure artery was performed via the same ap- His coagulation laboratory tests were was 50 mm Hg and Dp was 4 mm Hg. proach. Soon after the procedure ended, normal at admission. Routine coronary Compartment syndrome of the anterior he reported marked pain and tenderness in angiography via the right brachial artery aspect of the arm was diagnosed, and an the anterior aspect of the arm, which was was performed through a 5-Fr sheath the urgent open decompression fasciotomy becoming markedly stiff and swollen, and following day. The brachial introducer was performed while she was under gen- hypoesthesia and paralysis of the right sheath was removed immediately after the eral anesthesia. Surgical examination re- thumb and index finger appeared within procedure, and brachial compression was vealed edema of the muscles of the ante- 30 minutes. applied as usual with a bandage. One hour rior compartment, hematoma formation The authors used the Whitesides meth- later, he reported pain and tenderness on in the biceps, and active bleeding from a od to measure the intracompartmental the anterior aspect of his right arm. branch of the brachial artery. The authors pressure of the patient’s anterior arm.13 The The authors used the Whitesides were able to stop the bleeding with liga- intracompartmental tissue pressure was 50 method to measure the tissue pressure in tion, and the wound was left open for 10 mm Hg and Dp was 2 mm Hg. Although the anterior compartment of the arm.13 days. On postoperative day 10, the wound the posterior arm and forearm were slightly The intracompartmental tissue pressure was sutured. The patient recovered and swollen, the compartment pressures were was 40 mm Hg and Dp was 19 mm Hg. was discharged, with full movement of less than 5 mm Hg. Compartment syn- Compartment syndrome of the anterior her upper extremity having been obtained. drome of the anterior arm was diagnosed, aspect of the arm was diagnosed, and and an open decompressive fasciotomy an urgent fasciotomy was performed Discussion was performed immediately while he was while he was under general anesthesia. Acute compartment syndrome occurs under general anesthesia. Hematoma formation in the biceps bra- when pressure within closed myofascial An incision was made over the an- chii muscle and active bleeding from a spaces containing muscles, arteries, veins, terior aspect of the brachium when the branch of the brachial artery were found. and nerves is markedly increased. For a biceps brachii appeared to be markedly Bleeding was stopped with ligation. One definitive diagnosis of compartment syn- swollen with a hematoma, and active week after the fasciotomy, he underwent drome, it is useful to measure intracom- bleeding was found at the puncture site complete closure of the entire wound and partmental tissue pressure. Hargens et al14 of the brachial artery. Bleeding was con- achieved complete recovery without neu- proposed that fasciotomy be performed trolled by suturing the bleeding site. The romuscular problems. when the absolute compartment pressure wound was left open for 8 days to allow is more than 30 mm Hg. edema to resolve. On postoperative day Patient 4 Whitesides et al13 and Whitesides and 8, the wound was closed. However, the A 79-year-old woman with an existing Heckman15 reported that the tissue perfu- patient reported persistent pain and ten- myocardial infarction was admitted to the sion of the compartment depends on the derness of the volar aspect of the fore- authors’ hospital. She had undergone mul- difference between the diastolic blood arm. Although he had been treated by tiple percutaneous coronary interventions pressure and the intracompartmental pres- medication and stellate ganglion block and had been taking oral anticoagulation sure, known as the Dp. They stated that a under the diagnosis of complex regional therapy with aspirin and clopidogrel sul- Dp less than 20 mm Hg indicates the need pain syndrome, he reported persistent fate. Her coagulation laboratory tests were for fasciotomy.15 The authors also moni- pain without neurological impairment at normal at admission. tored intracompartmental tissue pressure 31-month follow-up. The following day, she underwent cor- using the Whitesides method in suspected onary angiography via the right transra- patients. In all cases, the absolute intra- Patient 3 dial approach through a 5-Fr sheath. The compartmental pressure of the anterior An 80-year-old man with a history of sheath was removed immediately after the arm was more than 30 mm Hg and Dp was myocardial infarction was admitted to the procedure with no problems, and com- less than 20 mm Hg, supporting the early authors’ hospital. He had a history of ar- pression of the puncture site was applied diagnosis of the compartment syndrome. teriosclerosis obliterans of the lower legs, with a bandage as usual. Thirty minutes Ricci et al16 described iatrogenic vas- cerebral infarction, and coronary artery later, she reported pain and tenderness on cular complications, such as hematoma, disease treated with multiple catheter in- the anterior aspect of her right arm. bleeding, pseudoaneurysm, thrombo-

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embolism, and arteriovenous fistula, oc- brachialis muscle. From an anatomical a condition similar to chronic compart- curring at a rate of 1% after diagnostic point of view, compartment syndrome of ment syndrome. transcatheter angiography, and this inci- the arm due to injury of the brachial artery dence increased to 3% after angioplasty. is considered to be a more likely incident Conclusion Kiemeneij et al17 reported a 2.3% inci- in the anterior compartment than in the To treat compartment syndrome of the dence of entry site–related bleeding com- posterior compartment. Although pos- anterior arm due to transcatheter angiog- plications, such as hematoma and pseu- terior compartment syndrome can occur raphy or angioplasty, effective hemostasis doaneurysm, after transbrachial coronary after cardiac catheterization, other etiolo- and early decompressive fasciotomy are angioplasty, whereas no bleeding compli- gies such as minor trauma may correlate essential. cations were recorded after the transradial mainly with posterior compartment syn- procedure. drome.12 References To the current authors’ knowledge, 7 The current authors reported 4 cases of 1. Leguit P Jr. Compartment syndrome of the cases of compartment syndrome of the compartment syndrome of the arm due to upper arm. Neth J Surg. 1982; 34(3):123- 126. forearm due to bleeding following the transcatheter angiography or angioplasty. 2. Ridings P, Gault D. Compartment syndrome transradial approach have been report- Because all patients had been treated with of the arm. 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