Vascular Access: Management of Complications

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Vascular AccessManagement of Complications
Chris Burrell, South West Cardiothoracic Centre,
Plymouth
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Alternative Vascular Access Sites

• Femoral
• Axillary
• Brachial
• Radial
• Ulnar

Femoral v Radial
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Vascular Complications Definitions
Major

• Bleeding requiring transfusion
• Complication requiring surgical repair
• Exclude thrombosis/thrombotic occlusion

Minor
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Diagnostic Cardiac Catheterisation 1992-1997

Femoral Brachial
Radial n2000
n1966 n27
n7
Surgical vascular complication 5
(0.25) Non-surgical vascular complication
10 (0.5) Large Haematoma 4 False Aneurysm
4 Re-bleed 1 Entry site infection
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Papaconstantinou H, Marshall A, Burrell C. Heart
199981465-9
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Coronary Angiography with Peripheral Vascular
Disease

Femoral Brachial/Radial n297

n154 n143 p Value
Major vascular complications 6
0 lt0.01 Success Rate ()
79 91
lt0.01 Procedure Duration () 42/-22
51/-19 lt0.01 Radiation Dose (CGy)
41/-25 47/-26 0.03
Hilldick-Smith DJR et al Cathet Cardiovasc
Intervent 20004932-7
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ACCESS A Randomised Comparison of PTCA by the
Femoral, Brachial and Radial Approaches

6F Femoral Brachial Radial
n900
n300 n300 n300
Major entry site complications () 2.0
2.3 0 Successful coronary
cannulation () 99.7 95.7
93.0 Primary PTCA success ()
90.7 90.7 91.7 Asymptomatic
occlusion -
- 3.0
Kiemeneij et al JACC 1997291269-75
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Major Vascular Complications for PCI
Access Site Major Vascular
Thrombotic
Complication Occlusion
Femoral Compression 2 - 4 Device
Closure 1.2 - 2.8 Brachial
2 - 3 Radial 0.1
3 5
Cremanasi J Invas Cardiol 199410464 Kussmaul
JACC 1995251685 Sanbourn JACC
1993221272 Ernst JACC 199321851 Ellis Circ
1999100I-313
Benit et al CCD 199741124-30 Kiemeneij et al
JACC 1997291269 Shrake et al Am J Cardiol
2000851024 Mann T et al JACC 199832572 Cathete
r Cardiovasc Intervent 199740156
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Vascular Complications Mechanisms
Intravascular

• Spasm
• Dissection
• Stenosis
• Thrombosis/Occlusion
• Rupture
• AV Fistula
• Bleeding/Haematoma
• False Aneurysm

Extravascular
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Avoiding Radial Spasm

• Keep patient warm and hydrated
• Use anxiolytics
• Minimise manipulation and trauma
• Use hydrophilic sheaths
• Use vasodilators
• (Apply warm saline bag)
• Use coronary (014) guidewire
• Be prepared to use femoral approach

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Avoiding Radial Occlusion

• Diabetes Mellitus
• Sheath size gt Vessel size
• Gender Female 80
• Male 18
• Heparin 3-5000 units

Nagai et al Am J Cardiol 199983180
Eur Heart J 199516293 Cath Cardiovasc
Intervent 199946173
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Treating Radial Occlusion

• Conservative
• Local Thrombolysis
• Percutaneous Intervention
• Surgery

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Vascular Complications Mechanisms
Intravascular

• Spasm
• Dissection
• Stenosis
• Thrombosis/Occlusion
• Rupture
• AV Fistula
• Haematoma/Bleeding
• False Aneurysm

Extravascular
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Femoral Approach

• Puncture Common Femoral Artery
• Train Manual or Device (e.g. Femostop)
  Compression
• Avoid
• Use Closure Devices

• Obesity
• Systemic anticoagulation
• GP IIb/IIIa inhibitors

EPIC NEJM 1994330956 EPILOG NEJM
19973361689 Pursuit NEJM 1998339436
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Femoral Angiography Prior to Angioseal Deployment

n81
300 RAO 200 Caudal
Talwar S et al Int J Cardiovasc Intervent
2001422
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Outside Manufacturers Recommendations
1. Low Puncture 5 (8) SFA 3 PF 2 Not
deployed successfully
2. Bifurcation Puncture 17 (19)
3. PVD 21 (32) All deployed successfully
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False Aneurysm Sac
Femoral Artery
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Spontaneous Closure of Selected Iatrogenic
Pseudoaneurysms and Arteriovenous Fistulae
n286 (196 pseudoaneurysms, 81 arteriovenous
fistulae, 9 mixed lesions)
diagnosed by Duplex scan

147 managed without surgery 86 resolved without
limb threatening complication 14 eventually
required surgical closure
Toursarkissian et al J Vasc Surg 199725803
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Ultrasound Compression of Iatrogenic False
Aneurysms

• Introduced 1991
• Treatment of choice
• Painful and time-consuming, especially if
  anticoagulants

Fellmeth B et al. Radiology 1991178671.
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Ultrasound Guided Percutaneous Thrombin Injection
Treatment of Iatrogenic False Aneurysms
n1 (axillary false aneurysm)
Elford J, Burrell C, Roobottom C Heart
199982526.
Loose HW, Haslam PJ. Br J Radiol
1998711255. Kang SS, Labropoulos N et al J Vasc
Surg 1998271032. Liau CS, Ho FM, Chen MF J Vasc
Surg 19972618
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False Aneurysm Sac
Femoral Artery
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Human Thrombin Injection for Iatrogenic
Pseudoaneurysms
n14 (10 CFA, 3 SFA, 1 Ax )
Size 2.5-7.5 cm
1000 IU Human Thrombin under ultrasound
guidance Repeat colour Doppler at 24h
14/14 occluded at 24h 2
additional balloon inflation across neck 2
required 2nd injection
Elford J, Burrell C, Freeman S, Roobottom C.
Clin Rad 2001
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Managing Pseudoaneurysms (and Arterio-venous
Fistulae)

• Conservative (2-4/52 if small asymptomatic)
• Ultrasound-Guided Compression
• Human (or Recombinant) Thrombin Injection
• Coil Embolisation
• Stent Graft
• Surgical Repair

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Transradial Transfemoral

• Positive Allens
• Obesity
• Anticoagulants
• ThrombolysisIIb/IIIa
• Peripheral Vasc Dis
• Dilated Aortic Root
• Use Heparin
• (3-5000 units)

• Negative Allens
• Diabetes Mellitus
• Small Vessel/Large Sheath
• Anxious/Young/Female
• Tortuous Anatomy
• Grafts (LIMA)
• Use Closure Device
• (Femoral angiogram?)

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Conclusions

• Radial approach offers advantages
• but not in all patients nor in all circumstances

• Straightforward technique but learning curve

• Best way to manage complications is to avoid them

• Involves familiarity with both techniques
  combined with flexibility

• Next generation will use radial approach