Complicaiile vasculare

locale ale cateterismului

cardiac

COMPLICAIILE VASCULARE
LOCALE
Judkin si colaboratorii sai au raportat o rata de 3,6% complicatii locale
(Society for Cardiac Angiography registries) a raportat o incidenta de 0,5-0,6%
Tromboza arteriala,
Embolizare distala,
Disectii,
Singerare,
Laceratia vasului
Hematoamele,
Anevrism,
Fistula arterio-venoasa .

COMPLICAIILE VASCULARE
LOCALE

Complicatiile brahiale - trombotice pe cind complicatiile

femurale - hemoragice, exceptie la pacientii cu lumen
mic al arterei femurale commune (boli vasculare
periferice, diabetul zaharat, sexul feminin), la pacientii
care au cateter femural cu diametru mare de lunga durata
(de exemplu pompa cu balon intraaortic), sau atunci cind
compresia postprocedurala este prelungita.
Pacientii au piciorul alb, dureros, cu deficit senzorial
distal si deficit motor, precum si impulsurile absente
distal. Consulatatia angiochirurgului - Esecul de a
restabili fluxul de singe in decurs de 2 pina la 6 ore
poate duce la extinderea trombozei in ramurile distale,
mai mici.

COMPLICAIILE VASCULARE
LOCALE
Hemoragia
Daca singerarea se opreste in curs de desfasurare cu compresie mecanica,
hematomul se va resorbi, de obicei, peste 1 pina la 2 saptamini.
Poate fi extrem de dureros
Poate precipita uneori colaps cardiovascular
Se pot dezvolta modificari de culoare pe coapsa si in zona inghinala
Slabiciune in picior in urma compresiei nervului femural
Managementul
Verificati pulsul la periferie
Efectuati ultrasonografia daca nu sunteti siguri
Presiune ferma manuala
Utilizarea dispozitivelor mecanice de compresie
Umflarea mansetei gonflabile
Administrarea pungii cu ghiata
Analgizarea pacientului

COMPLICAIILE VASCULARE
LOCALE

Hematomul reptroperitonial
In urma puctiei feurale superioare (mai sus de ligamentul inghinal).
Hipotensiune arteriala progresiva colaps cardiovascular.
Pe flanc o vinataie poate fi vazuta ocazional
CT a abdomenului va confirma diagnosticul
Managementul
Perfuzia de lichide
Procoagulante
Plastia chirurgicala a arterei

COMPLICAIILE VASCULARE
LOCALE
Pseudoanevrismul
Cavitate cu pereti formati din tesuturile inconjuratoare
Fluxul de singe intra si iese print-un canal (sau git)
Diagnosticul se confirma prin intermediul ecografiei duplex
Managementul
Compresia ghidata cu ultrasunete sau injectarea directa a trombinei
Plastia chirurgicala si inchiderea endovasculara

COMPLICAIILE VASCULARE
LOCALE
Fistula arterio-venoasa
Acul a penetrat atit artera cit si vena
Poate fi asimptomatica citeva zile dupa procedura
Auscultativ suflu continuu
Tratament chirurgical daca fistula nu se inchide timp de 2-4
saptamini

Tromboza arterei femurale

COMPLICAIILE VASCULARE
LOCALE

Hemoragia retroperitoniala.

COMPLICAIILE VASCULARE
LOCALE
Infectia la nivelul locului punctiei vasculare este mai putin
frecventa, rezultat al infectiei cu Staphylococcus Aureus. Pacientii
pot prezenta durere, eritem, eliminari din plaga si febra.
Managementul este tratamentul cu antibiotic (in functie de cultura)
rar drenarea abcesului.

COMPLICAIILE VASCULARE
LOCALE

Disectia coronariana
Separarea patologica a straturilor peretelui vascular coronarian, de obicei intima de
media.
Evitarea disectiei
Nu incercati sa avansati cu cateterul daca se opune rezistenta.
Efectuat injectii blinde pentru a verifica pozitionarea.
Ostiumul lima este mai predispus la disectie
Management
Nu efectuat nici o injectare suplimentara de contrast
Administrati flux de O2 si analgezie
Nitratii intracoronarian pot inlatura spasmul asociat
De urgenta PCI cu insertie de stent sau by-pas coronarian
Disectiile mici asimptomatice se trateaza conservator.
De repetat coronarografia peste citeva luni.

COMPLICAIILE VASCULARE
LOCALE

Embolismul gazos
apare la ~ 0,4% din procedurile de angiografie coronariana.
Preponderent afectate sunt vasele mici distale.
Discomfort toracic, paloare, greata.
In timpul scanarii pulmonare asimptomatice dupa cateterizarea cardiaca au fost descrise
pina la 10% de cazuri de trombembolie pulmonara.
Management
Flux de O2 100%.
Analgetice opiacee pentru durerile ischemice.
Aspirarea pe cateter pentru a disloca bula.
Nitratii intracoronarian pot evita orce spasm coronarian. In cazul ca vasul ramine astupat se
trateaza pacientul ca pentru IM.
Balonul intraaortic de pompare in socul cardiogen.
Pot fi necesare de urgenta by-pass coronarian.

COMPLICAIILE VASCULARE
LOCALE
Perforatia coronariana
Se pot manifesta in 0,3% din procedurile de PCI.
Este vizibil imediat la angiografie, prin scurgeri de contrast din artera.
Hipotensiune arteriala progresiva.
Tamponada cardiaca.
Colaps cardiovascular.
Tratament
Pericardiocenteza imediata
In timpul PCI astupata cu un balon pentru a preveni singerarea

Deep venous thrombosis postcatheterization. This 63-year-old man had an 8-F AngioSeal device used to close
the arterial puncture site in the right groin. When the patient sat up 18 hours after the procedure, he developed
acute pain and swelling in the right groin. Manual pressure was held during 20 minutes for suspected groin
hematoma. Ultrasound was performed for the presence of a bruit and showed that the femoral vein was not
compressible (right panel, arrow), indicating femoral thrombosis. In addition to therapy with aspirin and
clopidogrel, anticoagulation was initiated with enoxaparin until adequately anticoagulated with oral warfarin.
(Case provided courtesy of Dr. Marie Gerhard-Herman, Brigham and Women's Hospital.)

Iliac artery laceration. Left. Baseline sheath insertion angiogram shows marked tortuosity of
the right iliac artery (arrow), which led to the placement of a long sheath past the area of
tortuosity. Center. After the coronary intervention, the patient complained of abdominal pain
and became progressively hypotensive, with sheath reinjection showing extravasation of
contrast from the iliac and compression of the right dome of the bladder, consistent with free
retroperitoneal bleeding. Right. Via contralateral crossover access, a covered WALLGRAFT
was placed in the external iliac to seal the laceration. (Case provided courtesy of Dr. Paul
Teirstein, Scripps Clinic.)

Femoral pseudoaneurysm. Left. To evaluate a pulsatile mass in the left groin following a
catheterization, crossover angiography was performed from the right groin showing a large
pseudoaneurysm over the common femoral artery. Center. An angioplasty balloon was
positioned under the prior puncture site as a needle (arrow) was advanced to puncture the
pseudoaneurysm cavity confirmed by contrast injection. Right. After occlusion of the common
femoral by inflation of the angioplasty balloon, thrombin was injected through the needle into
the pseudoaneurysm cavity, causing it to clot, as shown by the absence of further contrast flow
into it on the postprocedure angiogram (arrow). (Case provided courtesy of Dr. Andrew
Eisenhauer, Brigham and Women's Hospital.)

Puncture closure device

Angioseal

Vasaseal

Puncture closure device

Prostar suture device

Duett device

Puncture closure device

Advantages
Shortens the tine to hemostasis and ambulation

Candidates
Patient with increasing risk of bleeding with manual
compression
Other condition that make prolonged bedrest is
undesirable (back pain, trouble voiding)

Cost
A single, accurate, frontal wall puncture and the
favorable conditions prevail within the vessels
and the surrounding soft tissues are necessary

Alternative sites for left heart

catheterization
Axillary, brachial, radial arteries and lumbar aorta
Transseptal from the right atrium to left atrium or direct
puncture via left ventricular apex in certain cases
The operator wishing to use one of the alternative
access
The local anatomy
Detailed of maximal allowable catheter size
Limitations on catheter selection
Techniques for achieving postprocedure hemostasis
Range of complications that may ensue from bleeding or
thrombosis at that anatomic location

Local vascular complications

One of the most common problems
Problems including
Vessel thrombosis
Distal embolization
Dissection
Poorly controlled bleeding at the punctual site
poorly placed puncture
vessel laceration
excessive anticoagulation
poor technique in either suture closure or groin compression

Hemorrhage and hematoma evident within 12 hours;

false lumen evident for days or even several weeks
later

Local vascular complications

Diagnostic catheterization
The Society for Cardiac Angiography registries 0.5
to 0.6% in incidence
Brachial approach
Arterial thrombosis
Causes
Formation of a thrombus in the proximal arterial part and failure to
remove prior to repair
Secondary to an intimal flap within the arterial lumen
Secondary to local spasm

Preventions
Meticulous attention to the details of arterial repair
Adequate heparinization: systemic and local

Treatment
Fogarty catheter thrombectomy
Percutaneous transluminal angioplasty

Local vascular complications

Diagnostic catheterization
Brachial approach (cont.)
Other complications
Injury to median nerve
Cutdown or compression by hematoma
Mild case: numbness and weakness for 3 to 4 weeks and return to normal:
occasionally up to 6 months

Delayed dehiscence of arterial sutures with late arterial bleeding

Bacterial arteritis
Local cellulitis-phlebitis
Extensive soft tissue is dissected
Large vein are used and tied off
The catheterization procedure is long
Seroma and hematoma forms
Nonviable tissue is left in the incision
Poor surgical technique or violation of sterile procedure occurs

Local vascular complications

Diagnostic catheterization
Femoral approach
Thrombosis (femoral artery)
Extremely rare, except a small femoral artery lumen (PAOD,
DM,
(
female), a large-diameter catheter or sheath (IABP) or long duration of
catheter
S/S: leg pain or numbness, diminished distal pulse
Obstructive limb ischemia generally resolves and distal pulse returned
when the sheath is removed
Ongoing complaint and diminished or absent distal pulse with catheter
removal flow-obstructing dissection or thrombus urgent vascular
surgery within 2 to 6 hours!!
Results in extension of thrombosis into smaller distal branch and muscle
necrosis if delayed

Femoral venous thrombosis or pulmonary embolism

Rare (multiple venous lines or compression by large arterial hematoma
etc.) but may be underreported: up to 10% asymptomatic positive lung
perfusion scan
Continuous drip of heparinized saline t venous sidearm throughout the
procedure to avoid this problem

Local vascular complications

Diagnostic catheterization
Femoral approach (cont.)
Poorly controlled bleeding more common
Suggest laceration of the femoral artery
Try next-larger-diameter sheath or compressed manually until the procedure
is completed
Reverse heparin and control bleeding with prolonged cpompression
Blood transfusion

Hematoma formation
usually resolve over 1 to 2 weeks
S/S: femoral nerve compression quadriceps, weakness takes weeks
even months to resolve; surgical repair is not required generally
Hematoma may extend to retroperitoneal bleeding if puncture site is
above inguinal ligament
unexplained hypotension, decreased Hct, ipsilateral flank pain; response to
fluid challenge
best prevention

Local vascular complications

Diagnostic catheterization
Femoral approach (cont.)
Pseudoaneurysm
Hematoma continuity with the arterial lumen
Blood flow in and out of the arterial puncture, expanding the cavity
pulsation, audible bruit, Duplex scan
Therapy
Surgical repair
transducer compress the neck for 30 to 60 minutes
procoagulant solutions or embolization coils with echo guiding

Prevention: accurate puncture of the common femoral artery and effective initial
control of bleeding

A-V fistula
Not be clinically evident for days after procedure
Ongoing bleeding may decompress into the adjacent venous puncture site
To and fro continuous bruit
Surgical repair if fistula tends to enlarge with time or does not close within 2-4
weeks
High risks: low puncture site (superficial or profunda femoral arteries)

Local vascular complications

Interventional procedure
A significantly high incidence of local vascular
complications than pure diagnostic procedure 1 to 2%
Use of larger sheath
The intensity and duration of anticoagulation
Removal of the sheaths only after an overnight dwell

Various approaches for collagen plugging or

percutaneous suture-mediated closure have been used
Avoid the discomfort of prolonged manual or mechanical
compression
Allow early even immediate ambulation
Failed to demonstrate significant reduction of major vascular
complications compared with compression

Catheterization via the femoral artery and vein

Selection of puncture site
Perform the puncture at the correct level 1 or 2 cm below the
inguinal ligament (runs from the anterior superior iliac spine to the
pubic bone)
Skin nick in reference to the skin crease may be misleading in obese patients
Inferior border of femoral neck by fluoroscopy

Most difficulties in entering the femoral artery and vein arise as a

result of inadequate identification of these landmarks
Puncture above inguinal ligament
Catheter advancement difficult
Predispose to inadequate compression
Hematoma formation or retroperitoneal bleeding following catheter removal

Puncture at more 3 cm below the inguinal ligament

Failed to enter the vessel lumen
Increase the risk of false aneurysm or thrombotic occlusion due to smaller
caliber
Excessive bleeding
AV-fistula

Femoral artery puncture

As venous puncture (Seldinger needle or single-wall-puncture
needle)
Smart needle which contains a Dopple crystal when the femoral pulse is
difficult to palpate or numerous needle insertions have been fruitless

Guidewire should move freely up

If flow is not brisk or if the wire still cannot be advanced, the needle
should be removed and the groin should be compressed for 5 minutes

A third attempt on the same vessel is unwise!!

Resistance (+) : extensive iliac disease or subintimal position of
the wire a small bolus of contrast injected gently under
fluoroscepic monitoring
Subintimal wire passage has occurred cath should be relocated the other
femoral artery of other approach

Abdominal aortic aneurysm : favor to use soft-tip guidewire;

avoid perforation or dislodgment of cavitary thrombus or debris

Femoral artery puncture

Prosthetic aortobifemoral graft : not ideal approach
Frequently in an aging population with diffuse atherosclerotic
disease
the graft wall is tough, diffuse atherosclerotic or thrombotic
debris, graft closure or infection
The graft should be identified as a separate structure from the
adjacent native femoral artery
Avoid guidewire pass through the anastomosis and into the
native lumen
Prophylactic antibiotics (Kefzol 1gm q8h x 1 day)

Control of the puncture site following sheath

removal
ACT < 160 sec removing sheath
Three fingers of the left hand that are positioned sequentially up the
femoral artery beginning at the skin puncture (10 to 15 min)
More prolonged compression (30 to 45 min) for larger arterial sheaths
(balloon valvuloplasty) or performed in the setting of thrombolytic agents
or Iib/IIIa receptor blockers
Mechanical device (Compressar or FemoStop) to apply similar local
pressure
Adequate control of puncture site bleeding and not compromising distal
perfusion
Inspection for hematoma or active oozing and assessed distal pulse
Bed rest for 4 to 6 hours with a sandbag (and pressure bandage in
hypertension, obesity, or AR) in place over the puncture site
Elevation of the head and chest to 30 to 45
Orthostatic hypotension Lie completely flat

Reinspection for recurrent bleeding, hematoma formation, a bruit of

pseudoaneurysm or A-V fistula formation, or loss of distal pulses

Percutaneous entry of the axillary

artery
Axillary fossa exposure and local anesthesia, needles
puncture and guidewire techiniques as prescribed
earlier enter over the head of the humerus
Left axillary artery is generally preferred to allow use
of performed Judkins catheter and avoid the
brachicephalic trunk
Effective control of the puncture site after catheter
removal is critical accumulation of even modest
amounts of hematoma around the artery can cause
nerve compression

Percutaneous entry of the brachial

aetery
Surgical cut-down or using percutaneous
techniques shorter procedure time and no
increase in complications
A 21-gauge arterial needle, a special 0.021
heavy-duty guide-wire and a 5F or 6F sheath
Compressed manually or proximal occlusion
obtained by inflation of a blood pressure cuff for
20 to 25 minutes

Percutaneous entry of the radial artery

Adapted to the performance of diagnostic
angiography and many types of percutaneous
coronary intervention
Liberal use of lidocaine, nitroglycerin, calcium
channel blocker to control local spasm
wrist-band compression devices to control
bleeding
Patients can get up and walk immediately
Radial artery thrombosis 5%
Allen test

Percutaneous entry of the radial artery

A preferred access in many lab
Rapid ambulation
Availability of stents or other devices that can be
used through current large-lumen guiding catheter
Paucity of entry-site complications

Percutaneous entry of the lumbar aorta

A technique of radiologists to study extensive
vascular disease
Adapted to the performance of coronary
angiography and stent placement recently
Prone position
Complicates angiographic views
Limits resuscitative efforts
Inability to apply direct pressure over the arterial
entry site limits aggressive anticoagulation