complicatii locale cateterism

Complicațiile vasculare locale ale cateterismului

cardiac

COMPLICAŢIILE VASCULARE

LOCALE

Tromboza arteriala,

Embolizare distala,

Disectii,

Singerare,

Laceratia vasului

Hematoamele,

Anevrism,

Fistula arterio-venoasa .

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%


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.


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 inghinalaSlabiciune in picior in urma compresiei nervului femural

ManagementulVerificati pulsul la periferieEfectuati ultrasonografia daca nu sunteti siguriPresiune ferma manuala Utilizarea dispozitivelor mecanice de compresieUmflarea mansetei gonflabileAdministrarea pungii cu ghiata Analgizarea pacientului


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 ocazionalCT a abdomenului va confirma diagnosticul

ManagementulPerfuzia de lichideProcoagulante Plastia chirurgicala a arterei


LOCALE Pseudoanevrismul

Cavitate cu pereti formati din tesuturile inconjuratoareFluxul de singe intra si iese print-un canal (sau git)Diagnosticul se confirma prin intermediul ecografiei duplex

ManagementulCompresia ghidata cu ultrasunete sau injectarea directa a trombineiPlastia chirurgicala si inchiderea endovasculara


LOCALE

Fistula arterio-venoasa Acul a penetrat atit artera cit si venaPoate fi asimptomatica citeva zile dupa proceduraAuscultativ suflu continuuTratament chirurgical daca fistula nu se inchide timp de 2-4

saptamini

Tromboza arterei femurale


LOCALE Hemoragia retroperitoniala.


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.


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.


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.


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 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 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 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 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 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. 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.)(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 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 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 tortuosity. Center. After the coronary intervention, the patient complained of abdominal pain and became progressively hypotensive, with sheath reinjection showing extravasation of 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 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 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 was placed in the external iliac to seal the laceration. (Case provided courtesy of Dr. Paul Teirstein, Scripps Clinic.)Teirstein, Scripps Clinic.)

Femoral pseudoaneurysm. Left. To evaluate a pulsatile mass in the left groin following a 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 catheterization, crossover angiography was performed from the right groin showing a large pseudoaneurysm over the common femoral artery. Center. An angioplasty balloon was 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 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 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 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 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 into it on the postprocedure angiogram (arrow). (Case provided courtesy of Dr. Andrew Eisenhauer, Brigham and Women's Hospital.)Eisenhauer, Brigham and Women's Hospital.)

Puncture closure devicePuncture closure device

Vasaseal

Angioseal

Puncture closure devicePuncture closure device

Prostar suture device Duett device

Puncture closure devicePuncture closure deviceAdvantagesAdvantages

Shortens the tine to hemostasis and ambulationShortens the tine to hemostasis and ambulation

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

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

Alternative sites for left heart Alternative sites for left heart catheterization catheterization

Axillary, brachial, radial arteries and lumbar aortaAxillary, brachial, radial arteries and lumbar aortaTransseptal from the right atrium to left atrium or direct Transseptal from the right atrium to left atrium or direct puncture via left ventricular apex in certain casespuncture via left ventricular apex in certain casesThe operator wishing to use one of the alternative The operator wishing to use one of the alternative accessaccess

The local anatomyThe local anatomyDetailed of maximal allowable catheter sizeDetailed of maximal allowable catheter sizeLimitations on catheter selectionLimitations on catheter selectionTechniques for achieving postprocedure hemostasisTechniques for achieving postprocedure hemostasisRange of complications that may ensue from bleeding or Range of complications that may ensue from bleeding or thrombosis at that anatomic locationthrombosis at that anatomic location

Local vascular complicationsLocal vascular complicationsOne of the most common problemsOne of the most common problemsProblems includingProblems including

Vessel thrombosisDistal embolizationDissectionPoorly controlled bleeding at the punctual site

poorly placed puncturevessel lacerationexcessive anticoagulationpoor 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 complicationsLocal vascular complicationsDiagnostic catheterizationDiagnostic catheterization

The Society for Cardiac Angiography registries The Society for Cardiac Angiography registries ― ― 0.5 0.5 to 0.6% in incidenceto 0.6% in incidenceBrachial approachBrachial approach

Arterial thrombosisArterial thrombosisCausesCauses

Formation of a thrombus in the proximal arterial part and failure to Formation of a thrombus in the proximal arterial part and failure to remove prior to repairremove prior to repairSecondary to an intimal flap within the arterial lumenSecondary to an intimal flap within the arterial lumenSecondary to local spasmSecondary to local spasm

PreventionsPreventionsMeticulous attention to the details of arterial repairMeticulous attention to the details of arterial repairAdequate heparinization: systemic and localAdequate heparinization: systemic and local

TreatmentTreatmentFogarty catheter thrombectomyFogarty catheter thrombectomyPercutaneous transluminal angioplastyPercutaneous transluminal angioplasty


Brachial approach (cont.)Brachial approach (cont.)Other complicationsOther complications

Injury to median nerveInjury to median nerveCutdown or compression by hematomaCutdown or compression by hematomaMild case: numbness and weakness for 3 to 4 weeks and return to normal: Mild case: numbness and weakness for 3 to 4 weeks and return to normal: occasionally up to 6 monthsoccasionally up to 6 months

Delayed dehiscence of arterial sutures with late arterial bleedingDelayed dehiscence of arterial sutures with late arterial bleedingBacterial arteritisBacterial arteritisLocal cellulitis-phlebitisLocal cellulitis-phlebitis

Extensive soft tissue is dissectedExtensive soft tissue is dissectedLarge vein are used and tied offLarge vein are used and tied offThe catheterization procedure is longThe catheterization procedure is longSeroma and hematoma formsSeroma and hematoma formsNonviable tissue is left in the incisionNonviable tissue is left in the incisionPoor surgical technique or violation of sterile procedure occursPoor surgical technique or violation of sterile procedure occurs


Femoral approachFemoral approachThrombosis (femoral artery)Thrombosis (femoral artery)

Extremely rare, except a small femoral artery lumen (Extremely rare, except a small femoral artery lumen (PAOD, DM, female), a large-diameter catheter or sheath (IABP) or long duration of catheterS/S: leg pain or numbness, diminished distal pulseObstructive limb ischemia generally resolves and distal pulse returned when the sheath is removedOngoing 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 embolismRare (multiple venous lines or compression by large arterial hematoma etc.) but may be underreported: up to 10% asymptomatic positive lung perfusion scanContinuous drip of heparinized saline t venous sidearm throughout the procedure to avoid this problem


Femoral approach (cont.)Femoral approach (cont.)Poorly controlled bleeding Poorly controlled bleeding ― ― more commonmore common

Suggest laceration of the femoral artery Suggest laceration of the femoral artery Try next-larger-diameter sheath or compressed manually until the procedure Try next-larger-diameter sheath or compressed manually until the procedure is completedis completedReverse heparin and control bleeding with prolonged cpompressionReverse heparin and control bleeding with prolonged cpompressionBlood transfusionBlood 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 generallyHematoma may extend to retroperitoneal bleeding if puncture site is above inguinal ligament

unexplained hypotension, decreased Hct, ipsilateral flank pain; response to fluid challengebest prevention


Femoral approach (cont.)Femoral approach (cont.)PseudoaneurysmPseudoaneurysm

Hematoma continuity with the arterial lumenHematoma continuity with the arterial lumenBlood flow in and out of the arterial puncture, expanding the cavityBlood flow in and out of the arterial puncture, expanding the cavitypulsation, audible bruit, Duplex scanTherapy

Surgical repairtransducer compress the neck for 30 to 60 minutesprocoagulant solutions or embolization coils with echo guiding

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

A-V fistulaNot be clinically evident for days after procedureOngoing bleeding may decompress into the adjacent venous puncture siteTo and fro continuous bruitSurgical repair if fistula tends to enlarge with time or does not close within 2-4 weeksHigh risks: low puncture site (superficial or profunda femoral arteries)

Local vascular complicationsLocal vascular complicationsInterventional procedureInterventional procedure

A significantly high incidence of local vascular A significantly high incidence of local vascular complications than pure diagnostic procedure complications than pure diagnostic procedure ― ― 1 to 2%1 to 2%

Use of larger sheathUse of larger sheath

The intensity and duration of anticoagulationThe intensity and duration of anticoagulation

Removal of the sheaths only after an overnight dwellRemoval of the sheaths only after an overnight dwell

Various approaches for collagen plugging or Various approaches for collagen plugging or percutaneous suture-mediated closure have been usedpercutaneous suture-mediated closure have been used

Avoid the discomfort of prolonged manual or mechanical Avoid the discomfort of prolonged manual or mechanical compressioncompression

Allow early even immediate ambulationAllow early even immediate ambulation

Failed to demonstrate significant reduction of major vascular Failed to demonstrate significant reduction of major vascular complications compared with compressioncomplications compared with compression

Catheterization via the femoral artery and veinCatheterization via the femoral artery and veinSelection of puncture siteSelection of puncture site

Perform the puncture at the correct levelPerform the puncture at the correct level ― ― 1 or 2 cm below the 1 or 2 cm below the inguinal ligamentinguinal ligament (runs from the anterior superior iliac spine to the (runs from the anterior superior iliac spine to the pubic bone)pubic bone)

Skin nick in reference to the skin crease may be misleading in obese patientsSkin nick in reference to the skin crease may be misleading in obese patientsInferior border of femoral neckInferior border of femoral neck by fluoroscopy by fluoroscopy

Most difficulties in entering the femoral artery and vein arise as a Most difficulties in entering the femoral artery and vein arise as a result of inadequate identification of these landmarksresult of inadequate identification of these landmarksPuncture above inguinal ligamentPuncture above inguinal ligament

Catheter advancement difficultCatheter advancement difficultPredispose to inadequate compressionPredispose to inadequate compressionHematoma formation or retroperitoneal bleeding following catheter removalHematoma formation or retroperitoneal bleeding following catheter removal

Puncture at more 3 cm below the inguinal ligamentPuncture at more 3 cm below the inguinal ligamentFailed to enter the vessel lumenFailed to enter the vessel lumenIncrease the risk of false aneurysm or thrombotic occlusion due to smaller Increase the risk of false aneurysm or thrombotic occlusion due to smaller calibercaliberExcessive bleeding Excessive bleeding AV-fistulaAV-fistula

Femoral artery punctureFemoral artery punctureAs 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 punctureFemoral 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 Control of the puncture site following sheath removalremoval

ACT < 160 sec → removing sheathThree 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 blockersMechanical device (Compressar or FemoStop) to apply similar local pressureAdequate control of puncture site bleeding and not compromising distal perfusionInspection for hematoma or active oozing and assessed distal pulseBed rest for 4 to 6 hours with a sandbag (and pressure bandage in hypertension, obesity, or AR) in place over the puncture siteElevation of the head and chest to 30° to 45°

Orthostatic hypotension → Lie completely flatReinspection for recurrent bleeding, hematoma formation, a bruit of pseudoaneurysm or A-V fistula formation, or loss of distal pulses

Percutaneous entry of the axillary Percutaneous entry of the axillary arteryartery

Axillary fossa exposure and local anesthesia, needles Axillary fossa exposure and local anesthesia, needles puncture and guidewire techiniques as prescribed puncture and guidewire techiniques as prescribed earlier earlier ― ― enter over the head of the humerusenter over the head of the humerus

Left axillary artery is generally preferred to allow use Left axillary artery is generally preferred to allow use of performed Judkins catheter and avoid the of performed Judkins catheter and avoid the brachicephalic trunkbrachicephalic trunk

Effective control of the puncture site after catheter Effective control of the puncture site after catheter removal is critical removal is critical ― ― accumulation of even modest accumulation of even modest amounts of hematoma around the artery can cause amounts of hematoma around the artery can cause nerve compressionnerve compression

Percutaneous entry of the brachial Percutaneous entry of the brachial aeteryaetery

Surgical cut-down or using percutaneous Surgical cut-down or using percutaneous techniques techniques ― ― shorter procedure time and no shorter procedure time and no increase in complicationsincrease in complications

A 21-gauge arterial needle, a special 0.021 A 21-gauge arterial needle, a special 0.021 heavy-duty guide-wire and a 5F or 6F sheathheavy-duty guide-wire and a 5F or 6F sheath

Compressed manually or proximal occlusion Compressed manually or proximal occlusion obtained by inflation of a blood pressure cuff for obtained by inflation of a blood pressure cuff for 20 to 25 minutes20 to 25 minutes

Percutaneous entry of the radial arteryPercutaneous entry of the radial artery

Adapted to the performance of diagnostic Adapted to the performance of diagnostic angiography and many types of percutaneous angiography and many types of percutaneous coronary interventioncoronary interventionLiberal use of lidocaine, nitroglycerin, calcium Liberal use of lidocaine, nitroglycerin, calcium channel blocker to control local spasm channel blocker to control local spasm ““wrist-band” compression devices to control wrist-band” compression devices to control bleedingbleedingPatients can get up and walk immediatelyPatients can get up and walk immediatelyRadial artery thrombosis Radial artery thrombosis ―― 5% 5%Allen testAllen test

Percutaneous entry of the radial arteryPercutaneous entry of the radial artery

A preferred access in many labA preferred access in many labRapid ambulationRapid ambulation

Availability of stents or other devices that can be Availability of stents or other devices that can be used through current large-lumen guiding catheterused through current large-lumen guiding catheter

Paucity of entry-site complicationsPaucity of entry-site complications

Percutaneous entry of the lumbar aortaPercutaneous entry of the lumbar aorta

A technique of radiologists to study extensive A technique of radiologists to study extensive vascular diseasevascular disease

Adapted to the performance of coronary Adapted to the performance of coronary angiography and stent placement recentlyangiography and stent placement recently

Prone positionProne positionComplicates angiographic viewsComplicates angiographic views

Limits resuscitative effortsLimits resuscitative efforts

Inability to apply direct pressure over the arterial Inability to apply direct pressure over the arterial entry site entry site ― ― limits aggressive anticoagulationlimits aggressive anticoagulation

complicatii locale cateterism

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