We read with interest Dr. Neustein’s comments. Our article1  was published as “Images in Anesthesiology” and not as a Case Report. Because of the word limitation of this educational forum, many relevant details of the case were not included.

Under sterile conditions, skin preparation was done using Povidone-Iodine Prep Pad (PDI, Orangeburg, NY) and 70% isopropyl alcohol prep. Our institution also provides Prevantics Swab (PDI) containing 3.15% chlorhexidine gluconate and 70% isopropyl alcohol for skin preparation. Radial artery cannulation was performed with a 20-gauge 1¾-inch catheter (B. Braun Medical, Bethlehem, PA), and a Tegaderm Film dressing (3M Health Care, St. Paul, MN) was applied. After pneumonectomy for lung cancer, the patient was transferred to the intensive care unit for monitoring multiple comorbidities such as hypertension, coronary artery disease, and chronic obstructive pulmonary disease.

The Center for Disease Control 2011 Guidelines for prevention of catheter-related infections recommend preparing skin with a more than 0.5% chlorhexidine preparation with alcohol before peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. With regard to dressing, the Center for Disease Control recommends using a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in cases of persistent central line-associated bloodstream infections. No recommendations are made for other types of chlorhexidine dressings due to insufficient evidence or lack of consensus regarding efficacy.

Catheter-related infections result from the convergence of many factors. These include patient-related factors, catheter-related factors, and institutional factors. To assign causation of the pseudoaneurysm to a departure from sterility alone overlooks the fact that this patient was immunocompromised with underlying comorbidities. Furthermore, infections related to arterial catheters are influenced not only by insertion techniques, but also by pressure transducer assemblies and number of entries into the monitoring system.

Although preventive measures for such a rare complication are indeed important, our main objective was to educate anesthesia providers, who may have never seen a radial artery pseudoaneurysm, to be familiar with its appearance and presentation to make an early diagnosis and timely management.

Radial artery pseudoaneurysm: A rare complication with serious risk to life and limb.