Title: VASCULAR ACCESS AND COMPLICATIONS
1VASCULAR ACCESS AND COMPLICATIONS
BARRY F URETSKY CORE CURRICULUM PORTO ALEGRE,
BRAZIL JULY 18, 2006
2AVOIDING 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
-
3OPERATIONAL ANATOMY FOR FEMORAL ACCESS
- LANDMARK INF-MED QUAD FEM HEAD
- POINT OF MAXIMAL IMPULSE gt90
4 VASCULAR ACCESS
Low vascular access
Low vascular access
5THE FRONT-WALL STICK
6CONSIDERATIONS 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)
7Femoral Access Complications
- Hematoma, bleeding, transfusion
- Pseudoaneurysm
- AV fistula
- Thrombosis
- Dissection
- Perforation
- Infection
8RISK 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
9Access 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
10RETROPERITONEAL 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
11HYPOTENSION POST-CATH/PCI
Bleeding Bleeding Bleeding
OTHER CARDIAC TAMPONADE, DRUG EFFECT,
HYPOVOLEMIA WITHOUT BLEEDING
12PSEUDOANEURYSM
- 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
13A-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
14ACCESS 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)
15SHEATH EMBOLISM
POPLITEAL
UK LACING
FINAL
16IATROGENIC DISSECTION
Immediate angiogram
17IATROGENIC DISSECTION
End of procedure
18IATROGENIC DISSECTION
Two weeks later
19VASCULAR 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
20VASCULAR SITE PERFORATION
21VASCULAR SITE PERFORATION
22VASCULAR SITE PERFORATION
23Groin 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.
24NEUROPATHY
- Rare complication
- Due to nerve injury
- Retroperitoneal hematoma with compression of
lumbar plexus - Femoral hematoma with nerve compression
- Femoral nerve injury during access
25BRACHIAL 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
26BRACHIAL COMPLICATION
PTA
27RADIAL 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.
28RANDOMIZED TRIAL OF RADIAL, BRACHIAL, VS FEMORAL
ACCESS
P 0.035
Kiemeneij F. JACC 1997291269.
29METHODS 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!
30(No Transcript)
31MAUAL HEMOSTASIS
CORRECT TECHNIQUE
INCORRECT TECHNIQUE
32VASCULAR ACCESS
- SPECIFIC TECHNICAL ASPECTS AND COMPLICATIONS FOR
EACH SITE - MOST COMPLICATIONS CAN BE TREATED BY THE INVASIVE
CARDIOLOGIST.
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