Endovascular Management of Access Site Complications

Endovascular Management of Access Site Complications

Manaf Assafin1, Robert Pyo2, Pedro Cox-Alomar3, and Miguel Alvarez-Villela1

1 Division of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, NY, USA

2 Division of Cardiology, Renaissance School of Medicine at Stony Brook University, NY, USA

3 Division of Cardiology, Louisiana State University School of Medicine, New Orleans, LA, USA


Percutaneous endovascular procedures always begin and end with the vascular access. Unfortunately, complications related to the access site are relatively common and result in additional morbidity to patients and increased costs to health systems. In the modern era of increasing procedure complexity, it is imperative for the interventional physician to be aware of these complications and understand the basic techniques to treat or mitigate them. In this chapter, we review the most common complications associated with vascular access, describe a variety of endovascular management options, and discuss the indications for escalation to surgical management.Arterial access site complications are common after cardiac or endovascular catheterization, with the incidence related to procedure complexity and vascular access bore size [1, 2], and has been cited as ranging from 1.8% for diagnostic procedures to 9% for interventional procedures [3]. Recent improvements in procedural technique and device technology, as well as the increasing utilization of mechanical support devices, have led to an increase in procedure complexity and large bore vascular access. It is therefore prudent for the practicing interventional operator to be familiar with vascular complications and their management.

Table 13.1 Common arterial access complications by access site.

Femoral artery Radial artery
Retroperitoneal Hematoma Radial artery spasm
Femoral Artery Pseudoaneurysm (FAP) Radial artery occlusion
Arteriovenous fistula formation Hematoma formation
Femoral Artery Occlusion Radial artery perforation

This chapter will focus on the practical management of common access site complications after percutaneous coronary or endovascular interventions. A list of common complications sorted by arterial access site is provided in Table 13.1.

Complications Related to Common Femoral Artery Access

The most common femoral artery (CFA) related complications include local bleeding, retroperitoneal hematomas (RPH), femoral artery pseudoaneurysms (PSA), arteriovenous fistulae (AVF), and lower extremity ischemia due to thrombosis or embolization. Although surgical treatment may be possible in nearly all cases of femoral injury, surgery has been associated with a 25% postoperative morbidity and 3.5% postoperative mortality in some series, a risk that reflects the highly comorbid profile of this subset of patients [4], while endovascular techniques have in most cases become the primary approach to the management of these complications. Table 13.2 lists some of the most common femoral arterial complications and their management options.

Access Site Bleeding

Access site bleeding in patients undergoing percutaneous coronary intervention (PCI) is the most common periprocedural complication (2–12%). Several studies have found major bleeding after PCI to be an independent predictor of mortality [57].

Risk factors for access site bleeding can be categorized into patient‐related and procedure‐related factors (Table 13.3). Patient‐related factors which increase this risk include female gender, age > 70 years, a small body surface area (<1.6 m2), history of heart failure, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, triple vessel coronary artery disease, concomitant shock, and renal failure (sCr > 2 mg/dl) [8, 9]. Procedure‐related factors include large arterial sheath size (7–8 Fr vs. 6 Fr, 23.5% vs. 13.8%; p < 0.01), [2] prolonged heparin infusion after PCI [10], delayed sheath removal [11], emergent procedures, and periprocedural use of GP IIb/IIIa inhibitors [9, 11], especially when concomitant heparin administration leads to supratherapeutic clotting times [8, 12].

Table 13.2 Most common femoral arterial complications and their management options.

Complication type Overall incidence after percutaneous coronary intervention (PCI) Treatment options
Retroperitoneal hematoma 0.4–0.74%

  • Hemostasis by prolonged balloon inflation over extravasation site
  • Covered stent placement
  • Surgery for rare selected cases
Femoral artery pseudoaneurysm (FAP) 2–6%

  • Ultrasound‐guided compression repair
  • Percutaneous thrombin injection
  • Biodegradable collagen injection
  • Covered stent placement
  • Coil embolization
  • Surgery reserved for very large aneurysms
Arteriovenous fistula formation 0.4%

  • Conservative in asymptomatic patients
  • Ultrasound‐guided compression repair
  • Arterial covered stent placement in symptomatic patients
Femoral artery occlusion <0.5%

  • Balloon angioplasty
  • Catheter‐directed thrombolysis
  • Catheter thrombectomy
  • Covered stent placement
  • Surgery for endovascular treatment failure

Management of access site bleeding is dictated by its site, severity, and hemodynamic consequences. In most cases, localized femoral bleeding and hematomas can be controlled with local manual or mechanical compression, discontinuation of anticoagulants, and in some cases reversal of therapeutic anticoagulation.

Table 13.3 Risk factors for bleeding complications after femoral arterial access.

Risk factors for bleeding related to femoral artery access
Female gender
Age > 70 yr
Body surface area < 1.6 m2
Renal failure with a serum Cr > 2 mg/dl
Prolonged indwelling sheath time
Larger sheath diameter
Emergent procedures
Larger heparin dose and prolonged heparin infusion
Use of GP IIb/IIIa inhibitors

In the case of GP IIb/IIIa inhibitors, reversal of anticoagulation requires special considerations. Reversal can be achieved with platelet transfusions when abciximab (ReoPro, Eli Lilly, Indianapolis, IN, USA) has been used, as this agent binds tightly to circulating platelets but will not affect the activity of normally functioning transfused platelets. Small molecule platelet GP IIb/IIIa inhibitors like eptifibatide (Integrilin, Cor Therapeutics, South San Francisco, CA, USA) and tirofiban (Aggrastat, Merck, West Point, PA, USA) may be harder to reverse with transfusion since they act as competitive, reversible receptor inhibitors and leave excess free circulating drug that may affect newly transfused platelets. However, their shorter half‐life will allow for the antiplatelet effect to cease after about 4 hours compared to 12 hours with abciximab.

Retroperitoneal hematoma or hemorrhage (RPH) is arguably the most grave access site bleeding complication. It has an incidence of 0.4–0.74% after PCI and is associated with significant morbidity and mortality. Besides the known risk factors for bleeding, a puncture of the CFA above the middle third of the femoral head, insertion of the sheath above the inguinal ligament, and punctures of the back wall are associated with increased risk of RPH.

It is important to note that RPH remains a clinical diagnosis and requires a high index of suspicion. Early symptoms are nonspecific and include back pain, groin pain, or ipsilateral lower quadrant abdominal tenderness, followed by relative hypotension, tachycardia, and hypovolemic shock. The majority of patients with RPH present within three hours of the index procedure; therefore, patients presenting in this window with hypotension should be promptly evaluated for RPH [1315].

In cases where bleeding is more severe or uncompressible, swift endovascular management is prudent. One of the most fundamental endovascular skills for management of femoral arterial access site complications is the “up and over” or “crossover” technique, which is the mainstay for most endovascular interventions performed on the femoral artery from the contralateral side. This will be briefly reviewed here.

Crossover Technique

Step 1. The contralateral CFA is cannulated over the femoral head using fluoroscopic and ultrasound (US) guidance, 1–2 cm above the femoral bifurcation and below the origin of the inferior epigastric artery.

Step 2. A 5 Fr diagnostic internal mammary (IMA) or Omni Flush (Angiodynamics, Latham, NY, USA) catheter is advanced over a steerable 0.035″ wire with a floppy tip – such as a Wholey (Medtronic, Dublin, Ireland) into the thoracic descending aorta.

Step 3. The steerable wire is pulled back into the catheter, which is then gently torqued and withdrawn until its tip engages the ostium of the contralateral common iliac artery. This can be confirmed by advancing the Wholey wire beyond the tip of the catheter and observing its course before removing it from the body.

Step 4. After confirming normal arterial waveform, digital subtraction angiography (DSA) of the contralateral iliofemoral system is performed with the image intensifier angulated approximately 30° contralateral to the side of interest.

Step 5. Once the area of bleeding is identified, the wire is again advanced through the iliofemoral system into the superficial femoral artery (SFA) or the profunda artery. The diagnostic catheter is then removed, and the short femoral sheath is replaced with a long 6 Fr sheath over the wire, with the tip positioned proximal to the area of interest.

Retrograde access via the “up and over” technique forms the basis for most strategies for endovascular management of access site complications.

Balloon Tamponade, Endovascular Coiling, and Covered Stent Placement

In the case of access site bleeding, balloon tamponade is often sufficient to achieve hemostasis. With a wire across the area of bleeding and a long sheath tip proximal to the area of interest, a peripheral balloon sized 1 : 1 to the vessel is advanced to the area of bleeding and inflated at 6–8 atm in five‐minute intervals, followed by brief (30‐second) periods with the balloon deflated to allow for antegrade flow and assess hemostasis. Complete occlusion of the vessel should be confirmed by DSA from the contralateral sheath.

If there is persistent bleeding after prolonged balloon tamponade, one must consider the site of bleeding to determine the appropriate next step. Bleeding involving very distal or small branch vessels may be appropriate to treat with coil embolization. This is achieved by advancing a guide catheter of appropriate shape (e.g. a multipurpose, Judkins right, or IMA catheter) to the vessel of interest, and then advancing a wire followed by a microcatheter into the vessel. The wire is then retracted, and 0.014″ or 0.018″ coils are then advanced through the microcatheter and delivered tightly into the bleeding vessel. If the bleeding vessel is collateralized, coils should be delivered both proximal and distal to the area of bleeding in order to prevent retrograde flow and continued bleeding (Figure 13.1a–d).

Bleeding involving larger vessels not responding to balloon occlusion should prompt consideration of a covered stent‐graft placement. After appropriate anticoagulation is administered, a covered stent with a diameter 1 mm larger than the native vessel should be advanced under fluoroscopy from the contralateral sheath, with enough proximal and distal landing zones to ensure adequate sealing. However, careful attention should be paid to avoid crossing the CFA bifurcation in order to prevent obstruction of the ostia of the deep femoral artery (DFA) or SFA. Self‐expanding nitinol‐framed stent‐grafts are preferred in areas such as the hip joint near the flexion point of the inguinal ligament, as they have been shown to have increased fatigue resistance to bending, crushing, and stretching [16]; however, their longer lengths and less precise deployment can make their use challenging. Balloon‐expandable stent‐grafts are available in shorter lengths and can be more precisely deployed; however, stent deformation is a concern when they are used near flexion points.

A completion angiogram should always be performed to ensure there is cessation of bleeding and patency of the SFA and DFA, keeping in mind that postdilation of the stent‐graft may be necessary if there is continued extravasation. In cases where covered stent‐graft placement is unsuccessful, or not feasible due to anatomy (tortuous/calcified iliac arteries, or bleeding directly at the bifurcation of the CFA), surgical consultation for open repair should be pursued.

Femoral Pseudoaneurysms

A femoral PSA forms when a breach of all three layers of the arterial wall results in a hematoma that remains in continued communication with the arterial lumen. Similar to a hematoma, the hemorrhage and resulting blood collection is contained by the adventitia or perivascular soft tissue; but unlike a hematoma, there is continued flow of blood into the PSA sac in systole and out of the sac in diastole.

Photos depict bleeding and contrast extravasation (red arrow) of a small vessel originating from the CFA after cardiac catheterization (a). Selective cannulation and angiography of the vessel with a Judkins right catheter from the contralateral femoral artery (b), followed by advancement of a coronary wire and microcatheter (c), and finally 0.14″ coil placement (Axium detachable coils, Medtronic) (white arrows) (d) with final angiography showing no residual bleeding.

Figure 13.1 Bleeding and contrast extravasation (red arrow) of a small vessel originating from the CFA after cardiac catheterization (a). Selective cannulation and angiography of the vessel with a Judkins right catheter from the contralateral femoral artery (b), followed by advancement of a coronary wire and microcatheter (c), and finally 0.14 coil placement (Axium detachable coils, Medtronic) (white arrows) (d) with final angiography showing no residual bleeding.

The reported incidence of femoral PSA ranges from 2% to 6% after peripheral or coronary interventions, and less than 0.5% after diagnostic angiography [17, 18]. Larger bore access, more aggressive anticoagulant and antiplatelet therapy use, simultaneous ipsilateral femoral vein and artery catheterization, and lower punctures, especially when they result in SFA cannulation, are all associated with increased risk of PSA formation [19]. PSAs are also more common in women, patients over the age of 70 years, diabetics, and those with obesity [20].

Clinically, femoral PSAs present with pain, swelling, and bruising at the site of a recent arterial puncture, and examination often reveals a palpable thrill or pulsatile mass. The gravest complication related to femoral PSAs is rupture, but other complications include persistent local pain, infection, embolization of thrombus from the PSA to the distal circulation, or issues resulting from compression of adjacent structures (e.g. femoral nerve palsy with femoral nerve compression, or deep venous thrombosis [DVT] with femoral vein compression).

Duplex US is the preferred modality for diagnosis and serial evaluation of arterial PSA. The study should seek to identify the site of origin of the aneurysm from the parent vessel, the waveform pattern of the inflow and outflow arterial tree, the size of the aneurysm including the number of loculations, and the length and diameter of the aneurysm neck. These anatomic features are crucial in dictating the appropriate treatment strategy.

Although there is some discrepancy in the published literature regarding the threshold to undergo treatment, it is generally accepted that femoral PSAs less than 2 cm in diameter are excepted to resolve spontaneously and could be reasonably managed conservatively, though close follow‐up with serial arterial duplex US should be performed to confirm resolution.

PSAs larger than 2 cm generally require treatment. Although traditionally treated surgically, minimally invasive techniques have become the initial treatment strategy since 1991 when Fellmeth and colleagues introduced a minimally invasive approach to thrombose iatrogenic PSAs by externally compressing the PSA with US guidance, with a success rate of 93% [21]. Ultrasound‐guided compression repair (UGCR) has become a widely adopted initial strategy in stable patients with simple femoral PSAs. Modern series report technical success rates between 75% and 98% [2225]; however, in patients on anticoagulation a failure rate as high as 30–40% has been documented [26].

Ultrasound‐Guided Compression Repair

Oct 25, 2023 | Posted by in CARDIOLOGY | Comments Off on Endovascular Management of Access Site Complications

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