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

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

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

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

Vascular Access Complications Vascular access complications will happen Diagnostic caths: 0.8 - 1.8% Therapeutic/PCI : 1.5 - 9% 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

Complications: Femoral Artery Access Femoral artery complications: 2-10% Complications: Groin Hematoma (1-10%) Pseudoaneurysm (1-6%) AV fistula (<1%) Retroperitoneal bleed (0.1-0.9%) Acute closure Dissection (intimal) Vessel Laceration Neural injury Infection Venous thrombosis (+/- right heart cath) Sheath/catheter clot

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

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

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

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

RPH?? Protocol

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

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.

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

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

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

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

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.

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

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.

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’

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

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.

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

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

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

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

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

RPH: Successful Percutaneous Intervention Successful ‘closure’

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

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

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

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

Duplex scan of right CFA PSA Right common femoral artery PSA

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):803-808. External Mechanical Compression Application of Femo-stop Painful and time-consuming ??success rate

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

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

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

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: 595-598.

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

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

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

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: 595-598.

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

Thrombin Injection of PSA: Step-by-step Inject Thrombin ‘very slow’ into the neck 50-100 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 100- 200 units (‘cement’ the PSA) Needle From Reeder, S.B. et. al. AJR 2001;177: 595-598.

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

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

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

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.

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