1. Vascular Access Complications
Primer to Percutaneous Endovascular Intervention
February 5, 2012
Vascular Access Complications
Nelson Lim Bernardo, MD Washington Hospital Center

2. Nelson L. Bernardo, MD Honoraria Abbott Vascular Cook Medical
Cordis Endovascular
Covidien
Medtronic
Terumo Medical Corporation

3. Vascular Access for Catheterization
Successful vascular access is paramount in the performance of invasive catheterization procedures (Diagnostic or Interventional)
Uncomplicated hemostasis of the access site is key to the success of any invasive procedure

4. Vascular Access for Catheterization
Successful vascular access is paramount in the performance of invasive catheterization procedures (Diagnostic or Interventional)
Uncomplicated hemostasis of the access site is key to the success of any invasive procedure
Femoral artery is still the most common arterial access site used  contend with groin complications, including retroperitoneal bleed

5. Vascular Access Complications
Vascular access complications will happen
Diagnostic caths: %
Therapeutic/PCI : %
Factors: Patient, Anti-coagulation Tx, anti-platelet Tx, bigger sheath size, delayed sheath removal, etc.
Complications lead to:
Morbidity/Mortality
Increased length of stay
Adds to health care cost

6. Complications: Femoral Artery Access
Femoral artery complications: 2-10%
Complications:
Groin Hematoma
(1-10%)
Pseudoaneurysm
(1-6%)
AV fistula
(<1%)
Retroperitoneal bleed
( %)
Acute closure
Dissection (intimal)
Vessel Laceration
Neural injury
Infection
Venous thrombosis (+/- right heart cath)
Sheath/catheter clot

7. CS: Routine cardiac catheterization
8:50 am – R/L Heart catheterization for evaluation of worsening dyspnea and low EF; (+) stress-MPI study.
Manual compression for hemostasis – obese px.
11:40 am – ‘Rapid response’ for hypotension + “cold and clammy”
Fluid resuscitation  Lab
Pelvis

8. Retroperitoneal Bleed/Hemorrhage (RPH)
Hemodynamic compromise post-catheterization or intervention
Think of bleeding, bleeding, bleeding !!!
Retroperitoneal hemorrhage (RPH) is a serious complication that occurs infrequently after catheterization

9. RPH: ??Standard of Care Current standard of care:
CT Scan of the abdomen/pelvis necessary ??
“Wait and see” if hemodynamically stable  else ??surgery
Monitor in ICU closely  Follow Hgb/Hct and Transfuse prn

10. RPH: ??Standard of Care Current standard of care:
CT Scan of the abdomen/pelvis necessary ??
 Diagnosis made, ??then; not predictive
“Wait and see” if hemodynamically stable  else ??surgery
Monitor in ICU closely  Follow Hgb/Hct and Transfuse prn
 D/C anti-coagulation, anti-platelet Tx

11. RPH??
Protocol

12. Suspected RPH: What do we do?
Low threshold to bring back to the cath lab
Factors:
Review groin/femoral angiogram
Location of arteriotomy
Use of VCD is not devoid of complication

13. Suspected RPH: What do we do?
Low threshold to bring back to the cath lab
Factors:
Review groin/femoral angiogram
Location of arteriotomy
Use of VCD is not devoid of complication
Arteriotomy site vis-a-vis
Inguinal ligament
Inferior epigastric A.
Lateral circumflex A.

14. Suspected RPH: What do we do?
Low threshold to bring back to the cath lab
Factors:
Review groin/femoral angiogram
Location of arteriotomy
Use of VCD is not devoid of complication
Hemodynamic compromise
Post PCI/PEI – on anti-coagulation, anti platelet Tx
Patient – Age, BMI/obesity, bleeding diathesis

15. CS: Routine cardiac catheterization
8:50 am – R/L Heart catheterization for evaluation of worsening dyspnea and low EF; (+) stress-MPI study.
Manual compression for hemostasis – obese px.
11:40 am – ‘Rapid response’ for hypotension + “cold and clammy”
Fluid resuscitation  Lab
Pelvis

16. RPH from perforation of inf. epigastric A.
Right common femoral A.

17. RPH from perforation of inf. epigastric A.
Right common femoral A.

18. RPH from perforation of inf. epigastric A.
Cook 6F Ansel-1 cross-over sheath
Selective cannulation of perforated artery using a 5F Berenstein catheter
Right common femoral A.

19. Right inferior epigastric A.
PEI of RPH
Strategy:
Advanced 0.018” support catheter over 0.014” guidewire into perforated track
Right inferior epigastric A.

20. Right inferior epigastric A.
PEI of RPH
Strategy:
Advanced 0.018” support catheter over 0.014” guidewire into perforated track
Injected thrombin-blood patch into track
1.5-mm balloon catheter inflated across the ‘ostium’ x 10 mins
Right inferior epigastric A.

21. PEI of RPH
Strategy:
Advanced 0.018” support catheter over 0.014” guidewire into perforated track
Injected thrombin-blood patch into track
1.5-mm balloon catheter inflated across the ‘ostium’ x 10 mins
POBA across ‘ostium’

22. Successful PEI of RPH
Right common femoral A.
Post-therapy

23. CS: Successful PEI of RPH
12:08 pm – Patient on cath table
12:18 pm – Left femoral arterial access obtained and performance of aortogram
12:39 pm – Thrombin-blood patch injected with successful hemostasis
Fluid resuscitation followed by 3 units of PRBC blood transfusion.
No untoward complications after the procedure.

24. Right external iliac artery
RPH
90 y.o. female post-intervention through left groin access on 2/23/2011.
2/24/2011 – Left groin hematoma/RPH. Transfused 1 unit of PRBC (Hct = 32%  26%  21%)
2/26/2011 – Hypotension + Left flank pain (Hct = 27%)
Right external iliac artery

25. Right external iliac artery
RPH: Vessel Wall ‘Disruption’
Right external iliac artery

26. Right external iliac artery
RPH: Free Vessel Wall ‘Disruption’
Right external iliac artery
RAO 55O

27. RPH: Free Vessel Wall ‘Disruption’
Strategy:
‘Covered’ stent
9F Raabe sheath – cross-over
IVUS – vessel size
‘Perforation’

28. RPH: Free Vessel Wall ‘Disruption’
Viabahn 9.0/50-mm

29. RPH: Successful Percutaneous Intervention
Successful ‘closure’

30. Retroperitoneal Hemorrhage: Source
Perforated side branch
Perforated side branch - guidewire-related, etc.
Vessel wall ‘disruption’
‘High’ stick, sheath size > vessel

31. Retroperitoneal Hemorrhage: Source
Perforated side branch
Perforated side branch - guidewire-related, etc.
Thrombin-blood-patch, embolization (coils,
‘glue’, gel-foam, particles, etc.)
Vessel wall ‘disruption’
‘High’ stick, sheath size > vessel
‘Covered’ stent

32. PEI as the 1O treatment approach in RPH
Single center WHC – 10/8/2007 to 7/11/2010
25 patients with RPH
Age: 69 ± 14 years
Sex: Male = 13, Female = 12
Hypotension duration = 39 ± 54 minutes
Hgb = 11.7 ± 1.9  7.9 ± 1.7 g/dl
Hct = 36.3 ± 24.6%
PRBC transfused: 2.8 ± 3.3 units
Tx: PEI in 24, manual compression in 1

33. Pseudoaneurysm (PSA)
False lumen at an arterial puncture site and contains active flowing blood - ‘pulsatile hematoma’
Signs & Symptoms
Pain
Tenderness +/- Ecchymosis
Pulsatile mass
+ Systolic bruit
Diagnostic tool
Ultrasound duplex scan
r/o concomitant A-V fistula

34. Duplex scan of right CFA PSA
Right common femoral artery PSA

35. Pseudoaneurysm (PSA): Treatment options
Conservative Therapy
“Watch and Wait”
~ < 2-3 cm in size
89% spontaneous closure in 2 months
< 3 cm in size and asymptomatic
Toursarkissian, B. et. al. J Vasc Surg 1997;25(5):
External Mechanical Compression
Application of Femo-stop
Painful and time-consuming
??success rate

36. Pseudoaneurysm (PSA): Treatment options
Ultrasound-guided Compression
Introduced in 1991 Fellmeth, B. et. al. Radiology 1991;178:671.
Painful and time-consuming (1-2 hours)
Variable results ~ 74% effective
Percutaneous Thrombin Injection
Treatment of choice
2-3% failure/repeat rate
Case selection to avoid catastophy
Risk: Distal embolization

37. Pseudoaneurysm (PSA): Treatment options
Catheter-based Therapy
PSAs not ‘ideal’ for thrombin injection
i.e. “wide”, “short” neck
Coil embolization
‘Covered’ stent
Balloon occlusion
+/- ‘thrombin blood-patch’
+/- percutaneous thrombin injection
‘Open’ Surgical Repair

38. PSA: Percutaneous Thrombin Injection
Equipments/Materials:
Thrombin – reconstitute 1:1000 units/ml
Lidocaine – local anesthesia
Spinal needle 21 gauge
Trocar prevents insinuation of tissue into needle lumen
1-2 cm of needle tip is “scored” by scalpel to make needle sonolucent
Ultrasound machine + probe

39. Thrombin Injection of PSA: Step-by-step
Check ABI (Ankle-Brachial Index)
Baseline and post-injection
Prep Groin
Betadine
Local anesthesia
From Reeder, S.B. et. al. AJR 2001;177:

40. Thrombin Injection of PSA: Step-by-step
Correctly identify vessels/structure
?? Concomitant A-V fistula

41. Thrombin Injection of PSA: Step-by-step
Correctly identify vessels/structure
?? Concomitant A-V fistula
Check doppler flow signal of each structure

42. Thrombin Injection of PSA: Step-by-step
Ideal PSA Morphology
‘Long’ and ‘Narrow’ neck
How ‘short is short’ or ‘wide is wide’?
Very subjective, operator-dependent

43. Thrombin Injection of PSA: Step-by-step
Check ABI (Ankle-Brachial Index)
Baseline and post-injection
Prep Groin
Betadine
Local anesthesia
Under direct ultrasound guidance, insert spinal needle
Direct needle to the “neck” area
Needle
From Reeder, S.B. et. al. AJR 2001;177:

44. Thrombin Injection of PSA: Step-by-step
Needle  just above the ‘neck’ of the PSA

45. Thrombin Injection of PSA: Step-by-step
Inject Thrombin ‘very slow’ into the neck
units using Tuberculin syringe
‘Clot begets clot’
If multi-lobe, go for the neck of the lobe closest to the CFA
Pull needle back, give units (‘cement’ the PSA)
Needle
From Reeder, S.B. et. al. AJR 2001;177:

46. Successful PSA Thrombin Injection
Check post-procedure ABI
Repeat arterial duplex scan following morning

47. PSA: WHC Experience Single center: 2008 - 2010 period
Incidence: 3.8% to 6.0% (VCD use of 20.2 – 28.4%)
Treatment: Percutaneous thrombin injection
Success – 100%
Repeat/1O Failure – 1.3% (3 of 226; on Coumadin)
Complications: None

48. Vascular Access Complication
Early recognition
Learn to manage your “own” complication

49. Conclusions:
Groin complications should be avoided as much as much possible with careful arterial/venous access and judicious sheath removal to ensure adequate hemostasis.
Life threatening groin complications happens infrequently but needs to be recognized early and promptly treated.
Percutaneous endovascular intervention should be considered ‘early’ and is a viable treatment strategy in the management of access site complications.

50. Thank you. Have a Good Day!
On the road to Mount Everest
Yamdro Yumtso Lake