Vascular Access: Management of Complications Chris Burrell, South West Cardiothoracic Centre, Plymouth
Alternative Vascular Access Sites Femoral Axillary Brachial Radial Ulnar Femoral v Radial
Vascular Complications: Definitions Major Bleeding requiring transfusion Complication requiring surgical repair Exclude thrombosis/thrombotic occlusion Minor
Diagnostic Cardiac Catheterisation 1992-1997 Femoral Brachial Radial n=2000 n=1966 n=27 n=7 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 1 Papaconstantinou H, Marshall A, Burrell C. Heart 1999;81:465-9
Coronary Angiography with Peripheral Vascular Disease n=297 Femoral Brachial/Radial n=154 n=143 p Value Major vascular complications 6 0 <0.01 Success Rate (%) 79 91 <0.01 Procedure Duration (%) 42+/-22 51+/-19 <0.01 Radiation Dose (CGy) 41+/-25 47+/-26 0.03 Hilldick-Smith DJR et al Cathet Cardiovasc Intervent 2000;49:32-7
ACCESS: A Randomised Comparison of PTCA by the Femoral, Brachial and Radial Approaches 6F Femoral Brachial Radial n=900 n=300 n=300 n=300 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 1997;29:1269-75
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% Benit et al CCD 1997;41:124-30 Kiemeneij et al JACC 1997;29:1269 Shrake et al Am J Cardiol; 2000;85:1024 Mann T et al JACC 1998;32:572 Catheter Cardiovasc Intervent 1997;40:156 Cremanasi J Invas Cardiol 1994;10:464 Kussmaul JACC 1995;25:1685 Sanbourn JACC 1993;22:1272 Ernst JACC 1993;21:851 Ellis Circ 1999;100:I-313
Vascular Complications: Mechanisms Intravascular Spasm Dissection Stenosis Thrombosis/Occlusion Extravascular Rupture AV Fistula Bleeding/Haematoma False Aneurysm
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
Avoiding Radial Occlusion Diabetes Mellitus + Sheath size > Vessel size + Gender * Female 80% Male 18% Heparin 3-5000 units + Nagai et al Am J Cardiol 1999;83:180 * Eur Heart J 1995;16:293 Cath Cardiovasc Intervent; 1999;46:173
Treating Radial Occlusion Conservative Local Thrombolysis Percutaneous Intervention Surgery
Vascular Complications: Mechanisms Intravascular Extravascular Spasm Dissection Stenosis Thrombosis/Occlusion Rupture AV Fistula Haematoma/Bleeding False Aneurysm
Femoral Approach Puncture Common Femoral Artery Train Manual or Device (e.g. Femostop) Compression Avoid Obesity Systemic anticoagulation GP IIb/IIIa inhibitors* Use Closure Devices * EPIC NEJM 1994;330:956 EPILOG NEJM 1997;336:1689 Pursuit NEJM 1998;339:436
Femoral Angiography Prior to Angioseal Deployment n=81 30 0 RAO 20 0 Caudal Talwar S et al Int J Cardiovasc Intervent 2001;4:22
Outside Manufacturer s 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
False Aneurysm Sac Femoral Artery
Spontaneous Closure of Selected Iatrogenic Pseudoaneurysms and Arteriovenous Fistulae n=286 (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 1997;25:803
Ultrasound Compression of Iatrogenic False Aneurysms Introduced 1991* Treatment of choice Painful and time-consuming, especially if anticoagulants *Fellmeth B et al. Radiology 1991;178:671.
Ultrasound Guided Percutaneous Thrombin Injection Treatment of Iatrogenic False Aneurysms n=1 (axillary false aneurysm) Elford J, Burrell C, Roobottom C Heart 1999;82:526. Loose HW, Haslam PJ. Br J Radiol 1998;71:1255. Kang SS, Labropoulos N et al J Vasc Surg 1998;27:1032. Liau CS, Ho FM, Chen MF J Vasc Surg 1997;26:18
xxxxxxxxxxx False Aneurysm Sac Femoral Artery
Human Thrombin Injection for Iatrogenic Pseudoaneurysms n=14: (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 2 nd injection Elford J, Burrell C, Freeman S, Roobottom C. Clin Rad 2001;
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
Transradial Transfemoral Positive Allens Obesity Anticoagulants Thrombolysis+IIb/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?)
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