Copy Here VASCULAR ACCESS COMPLICATIONS TYPICAL ARTERIAL COMPLICATION PROTOCOL ARTERIAL EXAMINATION: NORMAL FINDINGS X X

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1 VASCULAR ACCESS COMPLICATIONS X X Copy Here Natalia Fendrikova Mahlay, MD, RPVI ARTERIAL EXAMINATION: NORMAL FINDINGS TYPICAL ARTERIAL COMPLICATION PROTOCOL Indications Prior vascular access Pulsatile mass Access site pain Bruit Expanding hematoma or drop in hematocrit Arteries are examined for the presence of: Pseudoaneurysm Stenosis/occlusion Dissection True aneurysm AV Fistula Veins are examined for the presence of thrombus Incidental findings (i.e hematoma, fluid collection) are recorded Antegrade flow Triphasic signal with brisk upstroke, open acoustic window Assessing for arterial stenosis

2 VENOUS EXAMINATION: NORMAL FINDINGS B-mode cannot differentiate vascular from non-vascular structure Compressible vein Flow is with antegrade, spontaneous, respirophasic, augmentable?complex cyst?hematoma?seroma?aneurysm?pseudoaneurysm?complex cyst?hematoma?seroma?aneurysm?pseudoaneurysm CASE: 49yoM ESRD with groin pain s/p left heart catheterization and PCI PSEUDOANEURYSM: ACC/AHA PAD Guidelines, 2005 Nonoperative intervention: Vascular, yin-yang sign To and Fro Flow Color Dopper Sn 94%, Sp 97% Vascular structure To and Fro flow within the tract Connection with an artery should be established Length of the tract and width of the neck needs to be measured Evaluate for additional chambers Rule out arteriovenous fistula US-GUIDED COMPRESSION (USGC) Success rate of 75-98%. In patients on anticoagulation 30-73% Selective compression is important US-GUIDED THROMBISN INJECTION (UGTI) Off label use of thrombin Cumulative success rate of 97% Complications rate 0-4 % Distal arterial embolization 0-2% Recurrence rate 0-9%. Surgical treatment: Symptomatic PSA PSA at the site of the vascular anastomosis Spontaneous J Am Coll Cardiol. 2006;47:e1 e192 Edgerton JR et al. Ann Thorac Surg 2002;74:S Olsen DM et al.. J VascSurg 2002;36: La Perna L et al, Circulation 2000;102: Webber et al,circulation.2007;115:

3 CASE: 82yoF with severe aortic stenosis s/p TAVR undergoes VDU to rule out DVT ARTERIOVENOUS FISTULA Artery proximal to AVF: may see low resistance flow Artery distal to AVF: normal or dampened (if significant steal) Fistulous tract: increased velocities and low resistance flow pattern Venous flow proximal to fistula: arterialized and/or turbulent flow Negative for DVT Turbulent venous flow 33% resolve spontaneously within 1 yr Observation in asymptomatic patients Surgical or endovascular treatment reserved for symptomatic patients (distal ischemia, high output heart failure, venous hypertension) 51yoF with ILD, respiratory failure, s/p ECMO is referred for an incidental finding on abdominal CT Two-flow channels Dissection flap Dissection flap Courtesy of Heather Gornik, MD

4 ARTERIAL DISSECTION 74yoM with severe AS planned for TAVR who is referred for postprocedure evaluation Echogenic dissection flap on grey scale images Parallel two flow channels on color Doppler images Manage conservatively for non-flow limiting dissection Interventional management for flow limiting dissection/ limb ischemia 74yoM with severe AS planned for TAVR who is referred for postprocedure evaluation Wall based filling defect : _ plaque?_ dissection? _ thrombus? CLOSURE DEVICES Device On the market Mechanism Disadvantage Active arterialclosure devices AngioSeal 1997 to present Collagen and suture mediated Intraarterialal component Possible thromboembolic complications, infection related to wick Need clinical correlation to patient s history Perclose 1997 to present Suture mediated Intraarterialal component Device failure may require surgical repair Image courtesy of Alia Grattan, RVT Found it! Patient underwent recent preoperative LHC Finding is related to closure device StarClose 2005 to present Nitinol clip Passive closure devices Mynx 2007 to present PEG-hydrogel plug No intraarterial component No intraarterial component Adequate skin contact is needed to prevent failure Possible intraarterial injection of sealant Kern M. The Cardiac Catheterization Handbook, 5 th ed

5 CLOSURE DEVICE ASSOCIATED ARTERIAL STENOSIS PSV 585 cm/s TAKE HOME POINTS Ultrasound is a great modality of choice for evaluation of postprocedural complications Dedicated protocol allows consistency of evaluation and prevents missing a diagnosis Clinical correlation is important in diagnosis and management Image courtesy of Susan Whitelaw, RVT THANK YOU