Vascular access complications

29.1.1.1

Diagnosis

Lower extremity ischemia has various manifestations:

• Acute limb ischemia: manifests as the 6Ps (pain, pallor, paralysis, pulse deficit, paresthesias, poikilothermia) and is usually caused by thrombosis, dissection, peripheral embolization of large thrombi (in contrast to the cholesterol embolization syndrome described below), or vascular closure device complications.

• Cholesterol embolization syndrome: this is usually caused by showers of microemboli and presents with the classic triad of leg/foot pain, livedo reticularis, and intact peripheral pulses . Patients often develop hypereosinophilia and sometimes acute renal failure.

If the patient is in the catheterization laboratory, angiography of the affected limb can confirm the diagnosis and plan treatment. If the patient has left the cardiac catheterization laboratory usually ultrasound or computed tomography is used to confirm the diagnosis ( Fig. 29.1 ).

29.1.1.2

Causes

• Arterial dissection.

• Thrombosis.

• Distal embolization (of thrombus, closure device components, cholesterol, etc.).

• Vascular closure device complications.

• Occlusive sheath (diseased and/or small size femoral artery, large diameter sheath).

• Large sheath size.

• Prolonged sheath and catheter dwelling time.

• Poor sheath management technique (sheath should always be aspirated first discarding the aspirated blood and then flushed before inserting equipment or administering medications).

• Prolonged or overzealous common femoral artery compression after sheath removal (which may also cause deep venous thrombosis).

• Suboptimal anticoagulation.

29.1.1.3

Prevention

• Meticulous access technique ( Chapter 4 : Access).

• Fluoroscopic guidance of femoral access.

• Ultrasound-guided access—ultrasound can help avoid areas with significant atherosclerosis or calcification.

• Use soft deflectable guidewires.

• Use the smallest sheath size possible.

• Meticulous sheath management technique (always aspirate first and discard the blood, as described above).

• Avoid pushing catheters against resistance.

• Periodic assessment of anticoagulation to ensure optimal ACT levels.

• Radial access

29.1.1.4

Treatment

• Acute limb ischemia: contralateral femoral access is obtained, followed by angiography to determine the cause of acute limb ischemia and often provide treatment (balloon angioplasty, endovascular thrombectomy or thrombolysis). Surgical thrombectomy, endarterectomy or bypass surgery may be needed in some cases ( Fig. 29.1 ).

• Cholesterol embolization syndrome: there is no specific treatment—prevention is key. Statins may help with acute renal injury.

29.1.2.1

Diagnosis

Groin hematoma : this is usually evident as a groin mass that resolves after manual pressure, however diagnosis can be challenging and/or delayed in morbidly obese patients. Ultrasound may be needed to exclude the presence of a pseudoaneurysm or arteriovenous fistula. CT scan can provide accurate assessment of the hematoma location and size ( Fig. 29.2 ).

Retroperitoneal hematoma : retroperitoneal hematomas can be challenging to diagnose. The most common presenting signs are hypotension, diaphoresis, and lower abdominal or back pain. Patients often develop bradycardia and have tenderness on abdominal or suprapubic palpation. Retroperitoneal hematomas usually develop during the first 3 hours after the procedure. Use of vascular closure devices should not exclude the possibility of a retroperitoneal hematoma.

Operators should have a high level of suspicion for retroperitoneal hematoma, especially in obese patients, patients with uncontrolled hypertension prior to puncture and/or during the procedure, patients with high femoral puncture or femoral puncture that was not guided by ultrasound or fluoroscopy and when multiple femoral arterial puncture attempts were made.

If contrast has been given, fluoroscopy of the bladder may reveal displacement (“dented bladder”) sign, which is highly suggestive of retroperitoneal hematoma ( Fig. 29.3 ).

If at the time of diagnosis the patient is still in the cardiac catheterization laboratory, contralateral femoral access is obtained and angiography is performed to determine the source of bleeding and provide treatment (with prolonged balloon inflation and covered stents or coils, as described in Section 29.1.2.4 ).

29.1.2.2

Causes

• High/noncompressible puncture (above the inferior border of the inferior epigastric artery). Use of the Angioseal closure device should be avoided in high punctures, as the collagen plug may become entangled within the abdominal wall muscle layers.

• Puncture of the back wall of the femoral artery.

• Supratherapeutic or prolonged anticoagulation and use of glycoprotein IIb/IIIa inhibitors or cangrelor.

• Hypertension.

• Inadvertent perforation of renal or other peripheral arteries, usually by a polymer-jacketed guidewire, such as the Glidewire (Terumo).

29.1.2.3

Prevention

• Meticulous arterial access technique with fluoroscopic and ultrasound guidance and immediate femoral angiography, as described in Chapter 4 : Access.

• Avoid supratherapeutic anticoagulation

• Control hypertension.

• Advance guidewires in the iliac arteries and the aorta under fluoroscopic guidance. NEVER push wires hard if resistance to advancement is felt.

29.1.2.4

Treatment

Groin hematoma : manual compression proximal to the skin entry site. This will often be painful for the patient, requiring use of analgesics. After bleeding is stopped, a compressive bandage should be applied and the patient placed in bed rest for 6–8 hours. Duplex ultrasound can help ensure there is no ongoing bleeding or pseudoaneurysm formation. In case of failure to control the hematoma, emergency endovascular or surgical treatment may be needed as described for retroperitoneal hematoma below.

Suspected retroperitoneal hematoma ( Fig. 29.4 ):

• 1.

  Retroperitoneal hematoma should be suspected in every patient who develops hypotension during or after cardiac catheterization using femoral access .

• 2.

  General measures for bleeding include:

  • Large intravenous access—sometimes a central line may be needed to administer vasopressors and large volume of crystalloids or blood.

  • Administration of normal saline (several liters may be required).

  • Blood should be sent for type and cross, followed by transfusion depending on the magnitude of bleeding and the patient’s hemodynamics.

  • Hemoglobin measurement may be useful, although often acute bleeding does not result in immediate decrease in hemoglobin.

  • Anticoagulation should be reversed (protamine for heparin, discontinue glycoprotein IIb/IIIa inhibitors and cangrelor).

  • Manual pressure should be held over the access site, especially if there is also a groin hematoma.

• 3.

  Patient location.

  If the patient is in the cath lab, fluoroscopy of the abdomen may show bladder displacement (dented bladder sign, Fig. 29.3 , panel A). Femoral angiography can demonstrate the presence and site of bleeding ( Fig. 29.3 , panel B).

• 4.

  Active bleeding

  Similar to coronary perforations, the mechanism of bleeding is important for implementing subsequent treatment. There are two main types of iliofemoral perforations: large vessel perforation or small vessel perforation (such as perforation of the inferior epigastric or lateral circumflex iliac artery). Prior to pursuing definitive treatment a balloon is inflated (at low pressure) over the site of perforation to stop ongoing bleeding.

• 5.

  Covered stent

  If prolonged balloon inflation fails to achieve hemostasis, placement of a covered stent across the site of perforation can seal large vessel perforations ( Fig. 29.5 ) , but may be challenging to deliver. Moreover, stents deployed in the common femoral artery are prone to fracture.

  

  There are several endovascular peripheral covered stents that can be used, both balloon expandable and self-expanding. Balloon expandable covered stents, such as the Viabahn VBX (W.L. Gore, Fig. 29.6 , panel A) and iCast (Atrium) allow more precise positioning than self-expanding covered stents, such as the Viabahn (W.L. Gore, Fig. 29.6 , panel B) and Fluency Plus (Bard). Self-expanding stents are preferred for the common femoral artery, as they are more resistant to deformation during flexion.

  

• 6.

  Coil or microsphere embolization

  Coiling embolization can be used to stop bleeding in case of small branch perforation. If coiling is used, retrograde bleeding through the perforation should be excluded.

  Another option is microsphere, “cyanoacrylate glue,” or thrombin embolization, especially in cases of very distal vessel perforation, where delivering coils is not always possible. Particular attention should be paid in those cases to avoiding leakage of the sealant outside the perforated vessel.

  Alternatively prolonged balloon inflation or implantation of a covered stent across the origin of the perforated vessel may achieve hemostasis .

• 7.

  Surgery

  If placement of a covered stent across the perforation site fails or is not desirable (e.g., for perforations at the superficial and profunda femoral artery bifurcation), surgical treatment of the perforation may be required.

• 8.

  Hemodynamic stability

  Patients who have left the catheterization laboratory and are hemodynamically stable are usually evaluated with computed tomography to confirm the diagnosis of retroperitoneal hematoma and determine whether there is ongoing active bleeding or not.

  Patients who are not hemodynamically stable need to go emergently either to the cardiac catheterization laboratory or to the operating room for surgical correction of the bleeding site.

  Patients who have a retroperitoneal hematoma but do not have ongoing bleeding are treated conservatively, as described in Section 29.1.2.4 , point 2.

• 9.

  CT scan

CT scan of the abdomen and pelvis can help establish the diagnosis of retroperitoneal hematoma ( Fig. 29.7 ) and determine whether there is ongoing bleeding (active contrast extravasation) or not.

29.1.3.1

Diagnosis

Pseudoaneurysms usually manifest as a pulsatile tender groin mass, often with a bruit. Diagnosis is usually made with Duplex ultrasound that demonstrates blood flow in and out of the pseudoaneurysm cavity.

29.1.3.2

Causes

• Low femoral artery puncture.

• Suboptimal compression of the puncture site at the end of the procedure.

• Challenges with obtaining access, such as kinking of the guidewire.

• Access of both the femoral artery and vein.

• Intensive anticoagulation.

• Vascular closure device failure.

29.1.3.3

Prevention

• Use optimal femoral access technique, as described in Chapter 4 : Access.

• Good hemostasis technique.

29.1.3.4

Treatment

• Small pseudoaneurysms (<2 cm in diameter): conservative management is followed in most patients (unless they have severe groin pain), as many pseudoaneurysms close spontaneously.

• Large pseudoaneurysms (≥2 cm): ultrasound-guided thrombin injection is used in most patients, with follow-up ultrasonography in 2–3 days to confirm no recurrence ( Fig. 29.8 ). This, however, requires that the pseudoaneurysm has a narrow communication “neck.” In pseudoaneurysms with wide neck, there is risk of distal thrombin embolization causing acute limb ischemia. In such cases, surgical repair may be preferable. Additionally, surgery may be needed in patients with very large (>6 cm) pseudoaneurysms, synthetic grafts, infections, limb ischemia, or skin necrosis. In some cases, prolonged compression (occasionally >30–45 min) using the ultrasound probe as a compression arm may be used to achieve closure of the pseudoaneurysm. During the compression process, the operator continuously verifies that pressing the probe over the “neck” of the pseudoaneurysm, sufficiently stops the blood flow though the “neck”. Eventually, complete thrombosis of the pseudoaneurysm is achieved. Pseudoaneurysm compression can cause significant patient discomfort.

  

29.1.4.1

Diagnosis

Patients who develop arteriovenous fistulas after transfemoral cardiac catheterization are usually asymptomatic, although they can rarely develop lower extremity edema or high-output cardiac failure if there is large shunting from the femoral artery to the femoral vein. Patients may have a bruit and palpable thrill over the femoral artery. Diagnosis is usually made by Doppler ultrasound or angiography ( Fig. 29.9 ).

29.1.4.2

Causes

• Low puncture: the femoral vein is often located behind the common femoral artery (or the superficial femoral artery) lower in the groin. Use of ultrasound can reveal the relative location of the femoral artery and vein and prevent access of the femoral vein through the femoral artery.

• Multiple arterial punctures.

• Access of both the femoral artery and femoral vein during the same procedure, especially if done at the same level.