VASCULAR ACCESS AND COMPLICATIONS

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VASCULAR ACCESS AND COMPLICATIONS
BARRY F URETSKY CORE CURRICULUM PORTO ALEGRE,
BRAZIL JULY 18, 2006
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AVOIDING VASCULAR COMPLICATIONS

• PATIENT HISTORY
• Prior access problems
• Signs or symptoms of PVD
• Inability to lie flat
• PHYSICAL EXAMINATION
• Examine all pulses
• Listen for bruits
• Allens test for radial access
• TECHNICAL PERFORMANCE
• Front wall stick
• Pulsatile flashback
• Wire exits needle without resistance
• Angle of needle maximize guide wire
  entry, minimize subQ tract
• parallel to vascular structures
• Nick and tunnel approach

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OPERATIONAL ANATOMY FOR FEMORAL ACCESS

• GOALCFA

• LANDMARK INF-MED QUAD FEM HEAD

• POINT OF MAXIMAL IMPULSE gt90

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VASCULAR ACCESS
Low vascular access
Low vascular access
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THE FRONT-WALL STICK
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CONSIDERATIONS IN PVD

• With known aorto-iliac disease or prior AFB
  consider brachial or radial access
• Remember that there is often brachiocephalic
  disease in patients with occlusive aorto-iliac
  disease and that there is an increased risk of
  stroke with catheter manipulation in tortuous
  subclavian vessels
• Review any previous angiography
• AFB graft may be used for access avoid
  retrograde access into blind limb of iliac artery
  
• Distal SFA occlusion is not a contraindication.
  Enter CFA !!
• Take care NOT to compromise the patent profunda
  femoris artery (only remaining circulation to the
  leg)

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Femoral Access Complications

• Hematoma, bleeding, transfusion
• Pseudoaneurysm
• AV fistula
• Thrombosis
• Dissection
• Perforation
• Infection

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RISK FACTORS FOR VASCULAR COMPLICATIONS

• Larger arterial sheath.
• Prolonged sheath time.
• Older age.
• Low platelet count.
• IABP.
• Concomitant venous sheath.
• Need for repeat intervention.
• Female gender
• Obesity
• Low body weight
• Hypertension
• OveranticoagulationGp IIb/IIIa
• Elevated serum creatinine

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Access Bleeding/Hematoma

• Incidence 6 (transfusion 3.0)
• Discontinue heparin after procedure
• Reduce heparin dose with IIb/IIIa (60-70 U/Kg)
• Sheath removal with ACT lt 170 sec
• Minimize sheath size

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RETROPERITONEAL HEMATOMA

• Incidence 3.0
• Avoid high CFA punctureFront-wall stick only
  preferred
• Suspect when unexplained blood loss, hypovolemia,
  hypotension, supra-inguinal fullness or
  tenderness or flank pain
• If suspicion is high, and blood loss significant,
  treat before a definitive diagnosis is made.
• Discontinue/reverse anticoagulation
• -Reverse heparin with protamine (10
  mg/1000 U heparin)
• -Platelet transfusion with abciximab
  time with tirofiban/eptifibatide
• Treat with contralateral access and balloon
  tamponade or surgery

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HYPOTENSION POST-CATH/PCI

• DIFFERENTIAL DIAGNOSIS

Bleeding Bleeding Bleeding
OTHER CARDIAC TAMPONADE, DRUG EFFECT,
HYPOVOLEMIA WITHOUT BLEEDING
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PSEUDOANEURYSM

• Duplex 6 Clinical detection 1 - 3
• Risk factors female gt 70 yrs, DM, obesity, low
  (SFA) stick
• TREATMENT
• Small ( 2 cm) may be observed and are
  likely to close spontaneously.
• Larger aneurysms may be closed with
• Ultrasound guided compression
• Thrombin injection (not FDA approved)
• Surgical repair

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A-V FISTULA

• Incidence 0.4
• Associated with low (SFA/Profunda) access and a
  venous branch
• Small fistula may spontaneously close or remain
  stable for many years
• Larger fistula may cause significant AV shunts,
  swelling and tenderness
• TREATMENT 1) surgery, 2)US-guided compression,
• 3)balloon tamponade, 4) covered stent,
  5)observation

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ACCESS VASCULAR INJURY ISCHEMIA/THROMBOSIS/EMBOLI

• Incidence lt1
• Injury can be caused by needle, guide wire,
  and/or sheath.
• May caused leg ischemia or be asymptomatic.
• Some iatrogenic dissections are self-limited,
  may be followed without intervention if blood
  flow is maintained and may heal over time.
• Risk factors 1) relatively large sheath, small
  artery
• 2) PVD 3) Thrombus
  within sheath
• Most complications can be treated by the
  interventional cardiologist.
• Contralateral access and angiography lysis,
  PTA, stent
• Surgery1-3 (pseudoaneurysm, bleeding,
  thrombosis)

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SHEATH EMBOLISM
POPLITEAL
UK LACING
FINAL
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IATROGENIC DISSECTION
Immediate angiogram
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IATROGENIC DISSECTION
End of procedure
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IATROGENIC DISSECTION
Two weeks later
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VASCULAR SITE PERFORATION

• Very rare
• Life-threatening
• Must be treated immediate interventional
• approach should be considered first
• Surgery if interventional approach unsuccessful
  or not feasible
• Primary therapeutic approach is hemostasis
• CFAmanual hemostasis
• CIA, EIA PTA, covered stent

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VASCULAR SITE PERFORATION
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VASCULAR SITE PERFORATION
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VASCULAR SITE PERFORATION
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Groin Infection

• Incidence 0.2
• Risk factors
• Reintervention at same site
• Hematoma formation
• Prolonged sheath placement

N.B. Future series will include infections
secondary to closure devices.
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NEUROPATHY

• Rare complication
• Due to nerve injury
• Retroperitoneal hematoma with compression of
  lumbar plexus
• Femoral hematoma with nerve compression
• Femoral nerve injury during access

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BRACHIAL ACCESS

• Cutdown or percutaneous
• May use specificifically for LIMA PCI
• Heparin is recommended
• Frequency of complications similar to femoral
  access.
• Ischemia, thrombosis, embolization
• -Conservative therapy heparinization
• -Surgical therapyembolectomy
• -Percutaneous lysis, mechanical thrombectomy,
  or balloon inflation to tack-up a dissection flap
• Median nerve injury
• -Brachial fossa hematoma (median n.
  compression)
• -Nerve injury during access
• -Ischemic nerve injury

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BRACHIAL COMPLICATION
PTA
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RADIAL ACCESS

• Successful access 90.
• Normal Allen test required.
• Most common failure is inability to cannulate
  artery.
• Occlusion post-PCI approx 3 - 5.
• Associated with fewest major complications of any
  access site.

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RANDOMIZED TRIAL OF RADIAL, BRACHIAL, VS FEMORAL
ACCESS
P 0.035
Kiemeneij F. JACC 1997291269.
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METHODS OF HEMOSTASIS

• Manual compression.
• Mechanical compression device
• . Equal or superior to manual compression
  for safety
• Pressure dressings do not decrease
  complications and may obscure bleeding
• Require constant attention, patient cannot be
  left unattended
• Patient at bedrest 4 to 6 hrs
• Closure devices.
• Angioseal, Vasoseal, Perclose, Starclose, and
  many others.
• Closure devices
• Have not demonstrated reduction in major
  complications
• Do allow earlier ambulation
• Offer less intensive monitoring post-procedure
• Significant cost
• New set of complications!

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MAUAL HEMOSTASIS
CORRECT TECHNIQUE
INCORRECT TECHNIQUE
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VASCULAR ACCESS

• SPECIFIC TECHNICAL ASPECTS AND COMPLICATIONS FOR
  EACH SITE
• MOST COMPLICATIONS CAN BE TREATED BY THE INVASIVE
  CARDIOLOGIST.

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• MUITO OBRIGADO!