Acute Forearm Compartment Syndrome Following Transradial Coronary Angiography: A Case Report

Abstract

The use of the transradial approach for performing coronary angiography is now a trend owing to the low risk of bleeding as well as quick recovery. Rare but life-threatening complications, such as acute compartment syndrome, must be identified promptly. A 60-year-old man presented to the hospital with excruciating pain and swelling in the forearm 2 hours post a transradial coronary angiography procedure. He was later diagnosed with acute compartment syndrome secondary to radial artery injury and managed with emergency fasciotomy, achieving full functional recovery. The transradial approach, while commonly used, can be associated with rare but serious complications such as acute compartment syndrome. In this case, early diagnosis and timely surgical intervention were crucial in preventing permanent damage. Clinicians should remain vigilant to ensure prompt management and favorable outcomes.

Introduction

With the increasing use of angiography and percutaneous coronary intervention, the transfemoral approach has been associated with a higher risk of access-site bleeding and longer hospital stays. This has led to the transradial approach becoming the preferred method.^1,2

Acute compartment syndrome is diagnosed when a critical rise in pressure occurs within a closed fascial compartment, obstructing blood flow and circulation to tissues which without rapid treatment can lead to muscle and nerve damage. Early recognition is crucial to prevent permanent neurovascular injury and to ensure timely surgical intervention. ³

The incidence of acute compartment syndrome of the forearm following the transradial approach is very low, under 0.01%. In a series of 51 296 transradial procedures, the incidence was 0.004%. Both cases occurred in female patients with low body surface area who were receiving anticoagulation therapy. ⁴ Risk factors include vascular injury, prolonged limb immobilization from anticoagulation, unnoticed bleeding at the puncture site, extended procedural manipulation and patient factors such as low body surface area, advanced age, use of anticoagulants or thrombolytics and undetected hematoma or pseudoaneurysm. Several recent case reports and series have confirmed these associations.^5-8 Early fasciotomy, performed alongside surgical repair, facilitates the recovery of limb function; therefore, surgery must be carried out promptly. ⁹

This report presents a case of acute compartment syndrome of the forearm caused by transradial coronary angiography and emphasizes the importance of clinical vigilance and timely surgical intervention to prevent potentially disabling complications.

Case Presentation

A 60-year-old male with chronic chest pain underwent coronary angiography through the right radial artery. The patient was on aspirin therapy, increasing the risk of post-procedural bleeding. No immediate complications were observed during the procedure, and the radial compression device used for hemostasis was successfully removed. During angiography, a 6F sheath was used. After sheath removal, a TR band was applied for about 1 hour to control bleeding and prevent hematoma.

Approximately 2 hours after the procedure, the patient experienced sharp pain and severe swelling in the right forearm. The pain was disproportionate to the clinical findings and worsened with gentle finger extension. Decreased sensation in the hand and restricted movement were also reported. The forearm was tense, swollen, and very painful to touch. A positive passive stretch test and sensory changes were observed. Distal pulses were weak but detectable.

Intracompartmental pressure was not measured, as the patient presented with a completely typical clinical picture of acute compartment syndrome. In our judgment, performing this measurement would only have wasted valuable time and delayed the urgent intervention required. For the same reason, neither CT angiography nor Doppler ultrasonography was performed. The diagnosis was made immediately on clinical grounds. A discussion of differential diagnoses including compressive hematoma, arterial spasm, and complex regional pain syndrome has been added.

Based on the patient’s clinical presentation, immediate surgical intervention was warranted. Fasciotomy and lavage were performed through a marked incision. Through the volar fasciotomy incision, the superficial, intermediate, and deep compartments were fully released. Pressure on the median and ulnar nerves was relieved and the radial artery injury caused by angiography was repaired by the vascular surgeon through the same incision. All compartments were released, all muscles were freed, and the median, ulnar, and radial nerves were completely decompressed and intact. Only compressive effects on the tissues were present, which were relieved by the fasciotomy. During surgery, the injured radial artery was identified and repaired by the vascular surgeon with suturing. Both volar and dorsal forearm fasciotomies were performed (Figure 1). Active bleeding from the radial artery injury was observed intraoperatively. Surgical repair of the artery and compartment decompression were completed without complications. Postoperatively, the patient received a splint, limb elevation, and ice packs for 48 hours. After 48 hours, the patient returned to the operating room for re-exploration and debridement. The swelling had resolved, and the wound was subsequently closed.

Figure 1.

Volar fasciotomy.

Recovery after surgery was uneventful (Figure 2). The patient demonstrated remarkable improvement within 24 hours of surgery. At follow-up, no permanent neurological or vascular damage was noted, and full function of the extremity was preserved (Figure 3).

Figure 2.

Full range of motion (1 month follow up).

Figure 3.

Volar compartment fasciotomy.

Discussion

Although the transradial approach is well known and associated with fewer complications than the transfemoral route, acute compartment syndrome remains a rare but serious complication that is often underestimated.^10,11 Recent publications, including a case series from Egypt, two separate patients with NSTEMI developing acute compartment syndrome post-transradial catheterization, underscore that while rare, rate may increase in populations with risk factors. ⁷ The presented case highlights a rare but significant complication following transradial coronary angiography, where early signs of acute compartment syndrome were promptly recognized and managed surgically.

The pathophysiology of acute compartment syndrome is well established and increased intracompartmental pressure compromises capillary perfusion which leads to ischemia and potential tissue necrosis. ¹² This condition can progress rapidly, and a delayed diagnosis may result in irreversible damage. Pain out of proportion to the injury, pain on passive stretch, paresthesia, pallor, and pulselessness are classic features, with pain being the earliest and most sensitive sign. ¹³

In the context of the transradial approach, the risk of acute compartment syndrome increases with arterial injury, use of compression devices, anticoagulants or thrombolytics and patient factors such as advanced age, low body surface area, pseudoaneurysm and delayed bleeding. ¹⁴ Several reports have documented cases in which pseudoaneurysm or undetected hematoma contributed to the condition.^6,15,16 Differential diagnoses include compressive hematoma, arterial spasm, and complex regional pain syndrome. In this case the diagnosis was made clinically and intracompartmental pressure was not measured because doing so would have delayed urgent treatment.

Intraoperative findings revealed an active radial artery bleed, likely responsible for the rising compartment pressure. This underscores the importance of meticulous hemostasis and post-procedural monitoring, especially in elderly patients or those with vascular fragility. As in the case reported by “vascular avulsion” after neurointervention, vascular injury can be remote from the puncture site and may manifest late. ⁸ As also seen in the Egyptian case series, coagulation derangements can exacerbate bleeding and swelling, worsening compartment pressure. ⁷ As in this case, clinical suspicion and decisive action rather than waiting for imaging or pressure monitoring particularly in resource limited settings resulted in complete functional recovery. This highlights the importance of maintaining a high index of suspicion and acting decisively even without advanced imaging.

This report adds to the limited literature documenting acute compartment syndrome as a rare but limb-threatening complication of the transradial approach. Compared with previous reports, in which patients developed long-term disability from pseudoaneurysm and hematoma, our case emphasizes that early detection and prompt intervention lead to better functional outcomes. ¹⁶ Collaboration between interventional cardiology and orthopedic teams is essential for early detection of warning signs and for preventing long-term functional impairment.

This report is limited by its single case design, and the absence of intracompartmental pressure measurement or advanced imaging may be considered limitations. However, the clinical picture was typical and urgent surgery was prioritized. Further studies with larger series are needed to strengthen the evidence regarding acute compartment syndrome after transradial access.

Conclusion

Early recognition and prompt surgical intervention for acute compartment syndrome following transradial coronary angiography are essential to prevent permanent limb dysfunction. This case emphasizes the importance of close clinical vigilance and interdisciplinary collaboration. Although the transradial approach is considered safe and is widely used, acute compartment syndrome remains a rare but serious complication. The case highlights the importance of recognizing disproportionate pain, swelling, and neurological symptoms promptly and acting without delay. Waiting for confirmatory tests can lead to irreversible consequences.

Fasciotomy remains the gold standard treatment, providing excellent functional outcomes when performed without delay. This case also underscores the importance of collaboration between interventional cardiology and orthopedic surgery in diagnosing and treating rare but debilitating complications. Proactive management is crucial to prevent long-term disability, particularly when managing risks associated with transradial coronary procedures.