LAUSR

The routine use of transradial access in cardiology is due to its proven advantages over femoral access. Although hemostasis is easily achieved, bleeding can occur through the puncture site (PS). This bleeding can lead to hematomas and, on rare occasions, acute compartment syndrome (ACS), which can become serious without early and appropriate treatment. Here, we present and discuss an exceptional case of ACS of the hand (ACSh) that was resolved for the first time using a conservative approach involving a quick and simple maneuver. Preoperative coronary angiography was performed in an 82year-old woman with severe aortic stenosis via a right transradial approach using a valved introducer (5-Fr Glidesheath, Terumo) and heparin 5000 IU. The procedure was completed without complications and with compression of the PS with an elastic bandage. Swelling immediately appeared, which progressed rapidly to marked edema of the hand. Attempts were made to compress the PS, first with a pneumatic device and then with manual compression. After 5 minutes of unsuccessful compression attempts, the patient was in intense pain, requiring opioids, and had paresthesia in the affected hand. Physical examination revealed a large tension hematoma and cyanotic and ecchymotic fingers. The hand was flexed and very painful upon movement/ extension (Figure 1A). All of these signs and symptoms are compatible with the diagnosis of ACSh. The radial artery was then compressed 3-5 cm proximal to the PS (in an area without hematoma). Although the compression stopped the progression, the tension edema persisted and there was no improvement in symptoms. Thus, we empirically decided to use a scalpel to extend the initial PS, which produced a gush of nonpulsatile blood (Figure 1B and Figure 1C). After 2 minutes of drainage, the signs and symptoms progressively disappeared. The procedure was finalized by compressing the PS (now hematoma-free) with a pneumatic device. The clinical course in the next 3 weeks was excellent and without sequelae (Figure 2). Acute compartment syndrome, produced by increased pressure in 1 or more fascial spaces, leads to decreased perfusion pressure and muscular and nerve ischemia. Its rapid diagnosis is vital because, without early treatment, it becomes a serious condition with important functional repercussions. There are several ‘‘classic’’ causes, with trauma being the most frequent. Diagnosis is clinical (involving the ‘‘5Ps’’: pain, pulselessness, pallor, paresthesia, and paralysis). The most common and characteristic symptom is intense pain. This pain is refractory to analgesia and frequently disproportionate to the visible injuries.