37.1.1 Clinical Presentation

Traditionally, the common femoral artery (CFA) has been used for arterial access in interventional neuroradiology, both for diagnostic and therapeutic procedures. However, particularly for acute stroke treatment (AIS) treatment, where patients are elderly, vasculopaths, or both, femoral artery access may present challenges. Aortic arch anatomy may influence the approach strategy, since a femoral approach may be not favorable and other routes of access such as the radial or brachial artery may be required. Regardless of the site of access, complications can occur related to the puncture as well as the methods used to obtain hemostasis following completion of the procedure. Hemorrhagic complications are the most common, and in cardiac catheterization patients, the risk has been shown to be increased with the administration of antithrombotic agents, clopidogrel, and postprocedural heparin. It stands to reason that hemorrhagic complications are also likely to be more common in patients receiving tissue plasminogen activator (tPA) in combination with intra-arterial therapy. Other complications include arterial dissection, and thrombotic and embolic complications. These complications can be a source of significant morbidity and mortality despite successful neurointerventional therapy; therefore, it is imperative that the interventionalist is capable of recognizing and managing these complications should they occur.

The following cases present a range of complications that can occur at the arterial puncture site.

37.1.2 Mini-Case A: Active Extravasation Round the Vascular Sheath

The CFA was punctured and a 6-Fr sheath was inserted. Active bleeding was noted around the sheath, so the sheath was upsized to 8 Fr. The amount of bleeding slowed but did not abate. The patient received a therapeutic dose of tPA which was thought to contribute to the bleeding. At the conclusion of the procedure, an 8-Fr Angio-Seal was inserted. This resulted in complete hemostasis.

Contrast was seen surrounding the sheath adjacent to the entry point into the CFA (Fig. 37.1), demonstrating active extravasation.

37.1.3 Mini-Case B: Femoral Artery Pseudoaneurysm

Arterial access was obtained with a right femoral artery puncture and insertion of a 6-Fr sheath. Following the procedure, hemostasis was achieved with manual compression. Later that day, the patient was noticed to have a palpable lump in the right groin in the region of the puncture. Arterial vascular ultrasound (US) was performed and demonstrated a large pseudo aneurysm. Initial attempts were made to treat this with US-guided compression; however, this was not successful due to the large size of the pseudoaneurysm. US-guided thrombin injection procedure was performed with resultant thrombosis of the pseudoaneurysm.

Duplex US demonstrated an arterialized jet (Fig. 37.2) projecting away from the CFA. Immediately superior to the visualized jet, a bilobed pseudoaneurysm was identified with the classic yin-yang appearance.

37.1.4 Mini-Case C: Hematomas in Anticoagulated Patients

Patient 1

A patient underwent bilateral CFA punctures with insertion of bilateral 6-Fr sheaths earlier in the day. The patient was entirely anticoagulated with a heparin infusion and was taking clopidogrel and aspirin. He felt unwell in the evening after the procedure and was found to experience a sudden drop in blood pressure. Hemoglobin had dropped from 100 g/L pre procedure to 70 g/L. CTA demonstrated bilateral hematomas at the puncture sites (Fig. 37.3) as well as a retroperitoneal hematoma involving the right iliopsoas muscle (Fig. 37.3b).

The heparin infusion was discontinued and the patient was managed with supportive measures including fluid resuscitation as well as blood transfusion. The patient had a prolonged admission because of the hematomas; however, he ultimately made a full recovery.

Stay updated, free articles. Join our Telegram channel

Join