1) A 74-year-old male developed a large radial artery pseudoaneurysm following transradial coronary angiography. Ultrasound-guided compression was unsuccessful in treating the pseudoaneurysm. 2) Due to the large size of the pseudoaneurysm and failure of conservative treatment, the patient underwent surgical repair. 3) At one month follow up after surgical repair, the radial artery patency was restored with complete healing of the access site and no recurrence of the pseudoaneurysm.

1. Clin Case Rep. 2020;00:1–4.  | 1wileyonlinelibrary.com/journal/ccr3
1 | INTRODUCTION
The TRA is getting popular because of a fewer number of
complications at the site in comparison with femoral access.
RAP is a rare complication of TRA.1
Lack of close follow-up
and inadequate compression immediately after sheath re-
moval can lead to RAP. The various approaches to treat RAPs
are ultrasound-guided compression bandage,2
thrombin injec-
tion into the sac of the RAP,3
surgical repair,4
and implanta-
tion of covered stent.5
Recently, in a novel case report, a long
dwelling catheter-based approach has been reported to suc-
cessfully repair RAP.6
However, all these above approaches
are in the learning curve because of rare incidence of RAPs.
To reduce access site complications and preservation of pa-
tency of radial artery, some trans-radialists are using distal
TRA (dTRA) access.7
We report a case of a 74-year-old male who had a large ra-
dial artery pseudoaneurysm which was managed by surgical
repair because the ultrasound-guided compression was not
successful.
2 | CASE REPORT
A 74-year-old male was referred to evaluate cardiac sta-
tus regarding surgical fitness to undergo radical excision
of malignant melanoma over face under general anesthe-
sia as the patient had shortness of breath on exertion and
resting T-wave inversion in precordial leads in 12 lead
ECG (Figure 1). He was not a diabetic patient. Coronary
angiogram was done through the right radial artery. Radial
artery puncture was done by using 20-gauge Jelco nee-
dle with a single attempt of puncture using transfixation
technique.A 5Fr sheath was secured in place after giving
radial artery cocktail containing 5000 IU of unfraction-
ated heparin(UFH), 200 µg of Nitroglycerin, and 4 mL 2%
Lidocaine without Adrenaline. The coronary angiogram
showed mild coronary artery disease. Hemostasis at the
transradial access site was tried to be achieved using ad-
equate indigenous compression bandage made using cot-
ton and gauge, which is a routine practice in our CATH
Lab, which provides almost hundred percent hemostasis.
Received: 8 October 2019
| Revised: 28 November 2019
| Accepted: 8 December 2019
DOI: 10.1002/ccr3.2643
C A S E R E P O R T
Surgical repair of postcatheterization radial artery
pseudoaneurysm
Dibyasundar Mahanta1
| Rudraprasad Mahapatra2
| Ramachandra Barik1
|
Jogendra Singh1
| Siddhartha Sathia2
| Satyapriya Mohanty2
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium,
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© 2020 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.
1
Department of Cardiology, All India
Institute of Medical Sciences (AIIMS),
Bhubaneswar, India
2
Department of Cardiothoracic Surgery,
All India Institute of Medical Sciences
(AIIMS), Bhubaneswar, India
Correspondence
Dibyasundar Mahanta, Department of
Cardiology, All India Institute of Medical
Sciences (AIIMS), Bhubaneswar, India.
Email: drdibyasundar@gmail.com
Abstract
Radial artery pseudoaneurysm (RAP) at the site of transradial access (TRA) for coro-
nary angiography is rare. A clean puncture, secure bandage, and watchful follow-up
are must to prevent complete occlusion and aneurysm formation at the access site.
This illustration describes surgical repair as one of the successful strategies to repair
a postcatheterization RAP after TRA.
K E Y W O R D S
radial artery pseudoaneurysm, surgical repair, transradial coronary angiogram

2. 2
| MAHANTA et al.
Significant swelling of the right hand was noted within
20-30 minutes of the procedure when patient was still in
postcath recovery room for same day discharge after a few
hours of observation. Immediately, the cardiothoracic team
was informed. The compression bandage was removed and
was reapplied after confirmation of the proper puncture site.
The arterial saturation of right thumb was 97% by pulse oxi-
metry. The further progress of swelling was reduced. The
patient was retained in ward for three days to monitor the
size of swelling. On discharge, the patient was counselled
to report at the earliest if the swelling increases in size
with or without fever and pain. The patient returned after
2 weeks with fever, increase in the size of swelling visible
pulsation and ecchymosis over the wrist area. The patient
admitted for conservative care using intravenous antibiot-
ics, elevated right hand by sling, dressing of the swollen
FIGURE 1 A 12 lead EKG of the patient shows T inversion in chest leads
FIGURE 2 Pseudoaneurysm at the site of transradial puncture
after 1 mo as seen in clinical examination
FIGURE 3 Detection of pseudoaneurysm of by color Doppler
just before 3rd admission for ultrasound-guided compression and
bandage.The size of the aneurysm was 4 cm × 3 cm, and the size of
neck was nearly 2 mm

3.
| 3MAHANTA et al.
area using magnesium sulfate (MgSO4) and glycerin. The
edema significantly reduced, and the patient was very com-
fortable. There was no suspicion of pseudoaneurysm. He
was discharged. However, he again returned with throbbing
pain at the access site with a pulsatile swelling (Figure 2)
and confirmed to be aneurysm by ultrasonography (Figure
3 and Video S1). Ultrasound showed pseudoaneurysm of
radial artery of size 4 cm × 3 cm with neck of 2 mm by
color Doppler (Video S2).More than 50% of the aneurysmal
cavity was filled up with layered thrombus. The patient was
readmitted. Repeated ultrasound-guided compression was
attempted but failed to reduce the pseudoaneurysm. Patient
was referred to cardiothoracic department for surgical re-
pair because the patient was not willing for covered stent.
The pseudoaneurysm resolved and the patency of radial
artery was restored after surgical repair (Figure 4). At the
follow-up 1 month after surgical repair, the lumen and flow
in the radial artery was normal (Figure 5) and the access site
was completely healed (Figure 6).
3 | DISCUSSION
Because of rare incidence of RAP, there is no uniform
consensus or guideline to manage this condition.8
Any
swelling at the transradial access site is quite painful, and
the progress of swelling is easily seen and felt. Therefore,
early diagnosis of this condition with close follow facili-
tates timely management to avoid risk of rupture and as-
sociated morbidity. Significant edema due compression of
veins caused by tight pressure bandage sometimes poses
challenges in the early diagnosis of RAP. In such situation,
an angiography using computed tomogragy (CT) or mag-
netic resonance imaging (MRI) would be quite helpful but
additional cost.
There are several factors like multiple puncture attempts,
ongoing systemic anticoagulation, inadequate hemostasis or
postprocedure compression, vascular site infection, and the
use of larger sheaths are responsible RAP.
A conservative approach is an effective strategy, starting
initially with mechanical compression and if this fails, use
a thrombin injection into the aneurysmal sac. However, un-
like femoral artery pseudoaneurysm, the direct compression
of the RAP should be avoided to avoid rupture because of
superficial location.
When the aneurysm is detected very early, they are
smaller in size and can be easily treated by compression
while a large aneurysm requires surgical intervention.9
Other treatment strategies include the use of an external
compression device or thrombin injection when the aneu-
rysm has a narrow neck.
The patient must be informed to report at the earliest if
there is increase in the size of the swelling, throbbing pain, and
ecchymosis at the access site to reduce the chances of pseu-
doaneurysm formation. Unlike transfemoral access where the
puncture is located deep, the transradial access site and its sur-
rounding site can be explored whenever felt it is necessary. If
the neck is quite narrow and the RAP is not responding to mod-
erate compression by using pressure bandage with elevation of
limb, a dose of thrombin equal to 500 IU (1 mL) with support
of ultrasound guide can be used for thrombosis of sac. Some
FIGURE 4 The condition of right hand after 5 d when opened
for dressing after surgical repair before removing stiches
FIGURE 5 The site of surgical repair
of right hand showed complete healing of
the access site and neighboring area with
normal patency of right artery

4. 4
| MAHANTA et al.
intervention cardiologists do suggest using covered stents, but
experience is limited to case report only. Surgery is reserved for
all large aneurysms where the conservative managements fail.
4 | CONCLUSION
Radial pseudoaneurysm can be mostly managed by con-
servative approach when detected early using compression
bandage, ultrasound-guided thrombin injection into the an-
eurysmal sac. When the conservative approaches fail or the
aneurysm is significantly large, the condition can be man-
aged effectively with minimum expenditure by using surgical
repair when patient cannot accept or afford covered stent, as
in this case report.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
AUTHOR CONTRIBUTIONS
DM and RB: were the patient's cardiologists, reviewed the
literature, and contributed to manuscript drafting. RM, SS,
and SM: were the cardiothoracic surgeon. JS (Senior resident
cardiology): assisted in improving the quality of drafting. All
authors issued final approval for the version to be submitted.
DECLARATION OF PATIENT CONSENT
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal.
INFORMED CONSENT STATEMENT
Informed written consent was obtained from the patient for
publication of this report and any accompanying images.
ORCID
Dibyasundar Mahanta https://orcid.
org/0000-0002-2705-0361
Rudraprasad Mahapatra https://orcid.
org/0000-0002-6561-6960
Ramachandra Barik https://orcid.
org/0000-0003-1965-8454
Siddhartha Sathia https://orcid.
org/0000-0001-7929-6200
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SUPPORTING INFORMATION
Additional supporting information may be found online in
the Supporting Information section.
How to cite this article: Mahanta D, Mahapatra R,
Barik R, Singh J, Sathia S, Mohanty S. Surgical repair
of postcatheterization radial artery pseudoaneurysm.
Clin Case Rep. 2020;00:1–4. https​://doi.org/10.1002/
ccr3.2643
FIGURE 6 Continuous wave Doppler of right radial artery at the
site of repair shows normal flow pattern