Delayed re-bleeding after removal of a radial arterial cannula

A 74-year-old woman underwent revision total arthroplasty under general anesthesia with epidural anesthesia. She had no comorbidities and regularly took loxoprofen sodium hydrate. Examinations before the operation had no abnormal findings. Her right radial artery was punctured and cannulated uneventfully with a 22-gauge BD Insyte™ IV Catheter (Japan Becton, Dickinson and Company). The amount of bleeding was 320 mL, and she received 160 mL of autologous fresh-frozen plasma. The arterial cannula was immediately removed at the end of anesthesia. An anesthesiologist achieved hemostasis at the punctured site with 5 min of compression by hand. She exited the operation room with a hemostasis device (STEPTY; Nichiban Co., Ltd., Tokyo, Japan) over the puncture site. The device was removed 2 h after the operation, when her bleeding was confirmed to have stopped. She was observed every 2 h without re-bleeding at the puncture site, and her systolic blood pressure was kept under 120 mmHg. A nurse noted bleeding from the puncture site 13 h after the operation. She compressed the site by hand and called a duty doctor, who advised watchful waiting. They confirmed the stop of bleeding and noticed slightly edema and internal hemorrhaging around the puncture site. The next day, internal hemorrhaging and edema from the fingers to the middle of the upper arm were noted (Fig. 1). Her right forearm was stiff and swollen, but her hand movement was not restricted. She noted no paralysis or paresthesia. The pulse oximeter detected normal waves on her right fingers. Based on these symptoms, compartment syndrome was not suspected. The circumferences of her forearm at two points (proximal wrist joint and distal elbow) were checked eight times over 2 days, with no increase in size noted. The internal hemorrhaging and edema were gradually diminished.