Discussion:
PTCA via trans-radial route is now more common compared to the trans-femoral route in view of less complication and more patient comfort.1 Vascular complication includes radial artery occlusion, pseudoaneurysm, and AVF. In the RIVAL study, none out of 3507 patients in trans-radial route developed AVF in the trans-radial route.1,2,3 Burzotta et al reported 9 (0.08%) of the 10676 patients who developed AVF post trans-radial access.1,4
AVF can develop due to combined unnoticed puncture of the superficial vein and radial artery during access; however, in most cases the communication seals spontaneously. The factors responsible for radial AVF include less operator experience, multiple puncture attempts, inadequate compression for hemostasis.2 The AVF usually remain asymptomatic or present with mild pain and swelling in most of the cases. It can rarely lead to ischemic symptoms due to the stealing of blood and high output cardiac failure due to increased venous return.
In our case, possible mechanism is combined puncture of radial artery and vein along with prolonged compression of radial artery proximal to puncture site which stopped antegrade flow but allowed retrograde flow and formation of retrograde AVF.
The techniques that can reduce the vascular complication includes avoiding multiple attempts to access, use sheath size less than the arterial diameter, ultrasound-guided needle placement and optimum compression which stops hemorrhage while allowing normal distal flow.2