Ann Thorac Surg 2003;76:801-804
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Incidence and outcome of radial artery infections following cardiac surgery
Ismaïl El-Hamamsy, MDa,
Nicolas Dürrleman, MDa,
Louis-Mathieu Stevens, MDa,
Tack Ki Leung, MDb,
Sylvie Theoret, RN, MSa,
Michel Carrier, MDa,
Louis P. Perrault, MD, PhDa*
a Research Center and Department of Cardiovascular Surgery, Montreal, Quebec, Canada
b Department of Pathology, Montreal Heart Institute, Montreal, Quebec, Canada
Accepted for publication April 18, 2003.
* Address reprint requests to Dr Perrault, Research Center, Montreal Heart Institute, 5000 Belanger Street East, Montreal, Quebec H1T 1C8, Canada.
e-mail: lpperrau{at}icm.umontreal.ca
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Abstract
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BACKGROUND: Radial artery infections secondary to catheterization for blood pressure monitoring are rare but potentially serious complications. The objective of the study was to evaluate the incidence, the risk factors and the evolution of radial artery infections following cardiac surgery.
METHODS: A retrospective review of 8300 patients undergoing cardiac surgery between 1998 and 2002 at the Montreal Heart Institute (MHI) was undertaken. All patients with superficial radial artery infections, infected radial artery pseudoaneurysms, and arterial catheter-related bacteremia were considered using prospective global surveillance of all nosocomial infections over the study period by an infection control nurse.
RESULTS: Thirteen patients with radial infections were encountered (0.2%) with bacteremia occurring in 9 patients (0.15%). Five patients developed infected radial artery pseudoaneurysms (0.05%) and 5 patients developed subsequent sternal wound infections. Two patients died in their early postoperative evolution. Mean patient age was 67 years old and mean duration of cannulation was 5.8 days. Only 1 patient had diabetes. Seven of 13 patients were positive for Staphylococcus aureus (54%). All patients had undergone cardiopulmonary bypass (CPB) for various procedures. All superficial infections responded well to antibiotic therapy. Early surgical intervention is essential in cases of infected radial artery pseudoaneurysms.
CONCLUSIONS: The postoperative state and cardiopulmonary bypass put patients at risk for infectious complications. Strict systematic changing of arterial lines on a timely basis is unwarranted in our opinion. A high suspicion index, aggressive surgical treatment of bacterial arteritis and appropriate intravenous antibiotics are essential to improve the prognosis.
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Introduction
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The radial artery is the preferred site of catheter insertion for systemic blood pressure monitoring and blood sampling in the perioperative period. Use of the radial artery is associated with a low complication rate in terms of infections and pseudoaneurysm formation, in the range of 0.5% to 4% and 0.05%, respectively [1–8]. The risks of thrombosis and peripheral embolization stand at 1% and 4%, respectively [9, 10]. Radial artery catheterization for preoperative monitoring in cardiac surgery is a necessity that is associated with a significant, albeit rare, range of potential complications. No studies have yet examined its impact on the postoperative outcome in cardiac surgery patients. This retrospective study reports all patients with radial artery infections after hemodynamic monitoring in cardiac surgery encountered over the last 4 years at the Montreal Heart Institute (MHI). The objective of the present study was to identify the incidence, the risk factors and the outcome of radial artery infections following cardiac surgery.
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Patients and methods
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Between January 1998 and July 2002, 8300 patients underwent cardiac surgery at the MHI, requiring arterial pressure monitoring. A total of 7470 radial artery catheters were used for blood pressure surveillance. All patients with superficial radial artery infections, infected radial artery pseudoaneurysms, and arterial catheter-related bacteremia were collected using prospective global surveillance of all nosocomial infections over the study period by an infection control nurse. All arterial catheters used were 1.25-inch, 20-gauge polytetrafluoroethylene (Teflon) catheters (Cathlon Clear; Johnson-Johnson, Arlington, TX) inserted by intensive care unit (ICU) physicians or by anesthesiologists in the operating room at the time of surgery under sterile conditions (alcohol and gluconate chlorexidine 0.5% skin disinfection and sterile gloves). Preoperative nasal prophylaxis using bactroban ointment was administered to patients on the basis of positive intranasal cultures swabs for Staphylococcus aureus. Although not primarily intended for the arterial lines, all patients received antibiotic prophylaxis related to their surgery consisting of a single dose of cefazolin (or vancomycin for penicillin-related allergies) before incision and two doses postoperatively. No standard protocol for systematic arterial line changes based on time criteria was used. Therefore, arterial lines were kept in place until they were not anymore functional or local signs of infection were noted. The catheter site was inspected daily by the nursing personnel. The diagnosis of catheter-related infections or bacteremia were all made according to the definitions for nosocomial infections released by the Center for Disease Control [11].
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Results
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From 1998 to 2002, 8300 procedures were performed at the MHI. All patients required blood pressure monitoring through arterial catheters. Radial artery catheters were used in 90% of patients (n = 7470). The remainder was monitored through femoral artery lines. Local infection at the site of radial artery catheterization was noted in 13 patients (0.2%). Of these, 7 were superficial infections. The 6 remaining patients were deep radial artery infections. The 13 cardiac operations included: eight coronary artery bypass grafting (CABG) procedures, five valve procedures (three aortic and two mitral), and one left ventricular aneurysmectomy. Average age of the 13 patients was 67 ± 6 years (Table 1). Average duration of catheterization was 5.8 ± 3.3 days. Bacteremia was identified in 9 patients (0.15%), including all patients with deep radial infections. Five patients with infected pseudoaneurysms (Fig 1)
were encountered (0.05%). Staphylococcus aureus was isolated from 7 of 13 patients (53%) including 4 of 5 pseudoaneurysms. Other isolated organisms included Staphylococcus epidermidis, Enterobacter cloacae, and Pseudomonas aeruginosa. All superficial infections resolved with antibiotic treatment alone. All 13 patients with radial artery infections had undergone surgery with the use of CPB. Only one patient was diabetic. Sternal wound infections subsequently developed in 5 patients, 3 of 5 patients with infected pseudoaneurysms and 2 patients following superficial radial artery infections Staphylococcus epidermidis and Enterobacter cloacae, respectively. Both rapidly resolved with appropriate antibiotic therapy. All sternal wound infections developed several days after the arterial catheters were removed. Two patients died of MOF secondary to sepsis after developing deep sternal wound infections. No patients with infective endocarditis (IE) were diagnosed. No signs of peripheral emboli were noted in any patient and no ischemic sequelae of the hand were present after surgery.
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Fig 1. Cross section of the radial artery pseudoaneurysm illustrating an interruption of the intima and tunica media layers leaving only adventitia and perivascular fibroadipous tissue surrounding the aneurysmal area. Note the intramural thrombus inside the pseudoaneurysm.
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Comment
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Radial artery catheterization is the preferred site for blood pressure monitoring in cardiac surgery because of its ease of cannulation, its low complication rate, and its compatibility with early patient ambulation. It is also increasingly used for percutaneous coronary interventions (PCI). Local infectious complications present a serious impediment to postoperative evolution. Arterial lines create a significant portal of entry for bacteria and because of its rarity, may be overlooked as a source of septicemia. In this series, the overall incidence of local infection, of infected pseudoaneurysms and of bacteremia related to radial artery infections were 0.2%, 0.15%, and 0.05% respectively. These incidences are lower than those reported by other investigators [1, 6]. This difference might be explained by the fact that cardiac surgery patients usually require arterial monitoring for short periods of time and by the preoperative preventive measures taken at the MHI since 1998 in known carriers of intranasal Staphylococcus aureus (topical mupirocin ointment), thereby minimizing the infectious risk. An alarming feature of this report, however, is that 2 of 13 patients who developed radial artery infections died perioperatively. Whether the radial artery infections per se were the main precipitating factor is difficult to determine but definitely contributed to their septic state. In fact, both patients died of MOF secondary to septic shock following a long unrecognized deep radial artery infection with pseudonaeurysm formation, creating an unopposed portal of entry for infectious organisms. Therefore, it is recommended that catheterization sites be examined systematically in septic states, even after removal of the arterial lines, in light of the fact that all our cases of sepsis and superficial infections became apparent only after catheter removal.
Falk and colleagues [1] reported 6 patients with infected radial artery pseudoaneurysms in nonsurgical ICU patients. Patient age and duration of catheterization were found to be significant risk factors for development of infectious complications. In our series, the average age of the 13 patients was in the same range (67 years old). No consistent findings were found in our patients to explain any susceptibility to infection other than their postoperative state and the use of CPB in all of them. Interestingly, although diabetes represents a risk factor for sternal wound infections following cardiac surgery, only 1 of 13 patients with radial artery infections was diabetic. The length of catheterization in our patients averaged only 5.8 days, much shorter than the 12.5 days reported by Falk and colleagues [1], raising the issue of a state of relative immunocompromise following cardiac surgery with CPB [12]. Most reports in the literature demonstrate a strong inflammatory reaction following CPB with upregulation of different components of the immune system. Moreover, no link between CPB and increased infection rates has been reported. However, Ascione and colleagues [13], in a prospective study, recently demonstrated a significant increase in postoperative chest infections following CPB when compared with beating heart surgery. CPB patients received more transfusions and were intubated significantly longer, which could possibly account for their observations. Indeed, post-CPB requirements of blood components are higher than beating heart surgery [14] and it is well known that transfusions induce a state of relative immunosuppression [15]. A plausible explanation for the observed 100% rate of CPB patients with arterial line infections. A study is now underway to prospectively compare the infection rate in patients undergoing CABG with or without CPB at our institution. In fact, in the present cohort, the average number of blood transfusions in the first 24 hours averaged 4 U, much higher than the institution’s 1.3 U on average per patient. In addition, the length of mechanical ventilation averaged 7.3 days in this group (versus an average of 19 hours) and the average age of the patients was 67 years old, compared with an overall average of 62.5 years old. Understandably, these findings did not reach any statistical significance due to the limited number of infections. Nonetheless, they provide a profile for patients at risk of such complications.
In 1979 Band and Maki [3] recommended changing arterial lines after 4 days of catheterization to avoid infectious complications. The average duration of catheterization in our 13 patients was 5.8 days, and 7.5 days for infected pseudoaneurysms. Interestingly, 3 patients developed infections despite a length of catheterization of less than 4 days. Particular attention must hence be exercised after 4 days, but replacement of lines before that time does not guarantee freedom from infections. In fact, there are no indications at the moment to support any such practice [16]. Presently, at MHI, no standard protocol for systematic arterial line changes based on time criteria is in place.
According to the most recent guidelines for intravascular catheter-related infections [17], initial empiric therapy should consist of intravenous vancomycin for coverage of methicillin-resistant Staphylococcus aureus (MRSA) and a third- or fourth-generation cephalosporin for enteric gram-negative bacilli and Pseudomonas species. Treatment should then be adjusted according to culture results and antibiograms and prolonged for 2 weeks if no complications arise (endocarditis, osteomyelitis, etc). However, if, as in our valvular patients, risk factors are present (previous valve surgery, rheumatic heart disease, mitral valve proplapse), treatment should be prolonged to 4 to 6 weeks. All patients responded well to that antibiotic regimen, except for 2 of 5 patients with deep radial artery infections and pseudoaneurysms. Incidentally, surgical excision of infected pseudoaneurysm in these 2 patients was not undertaken due to their poor clinical status. Pseudoaneurysm formation at the catheterization site represents the major complication of radial artery infections with a risk of rupture and external bleeding owing to their proximity to the skin surface. Therefore, early surgical excision should be undertaken to remove the aneurysm with or without surgical reconstruction of the radial artery depending on the vascular supply of the affected hand. In the 3 patients (patients 1, 4, and 5) who survived despite developing infected pseudoaneurysms, surgery was performed soon after discovery of the pseudoaneurysm, and the clinical improvement after aneurysmectomy was striking, allowing full recovery from their septic state. Indeed, surgical excision of the origin of infection in patients with pseudoaneurysm formation is an essential part of the treatment, combined with intravenous antibiotic therapy, which has previously been advocated by other groups [18–20].
In conclusion, radial artery catheter-related infections constitute a rare but potentially lethal complication in patients following cardiac surgery. The patients’ weakened immune state after surgery and CPB makes them vulnerable targets to infection. Older age, a longer period of mechanical ventilation, and a higher number of transfusions are all contributing factors. A strict protocol for systematic changing of arterial lines on a timely basis could possibly avoid these rare events, but most likely at the expense of higher complication rates due to multiple arterial catheterization sites and, therefore, is unwarranted at this time in our opinion. A high index of suspicion as well as prompt and aggressive surgical treatment of bacterial arteritis with or without pseudoaneurysm formation as an adjunct to intravenous antibiotics is essential to improve the prognosis of this complication at high risk of leading to uncontrolled sepsis and death.
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Abstract
Introduction
