Angiographic predictors of femoral access site complications: Implication for planned percutaneous coronary intervention

Risks and complications of coronary angiography: a comprehensive review

Coronary angiography and heart catheterization are invaluable tests for the detection and quantification of coronary artery disease, identification of valvular and other structural abnormalities, and measurement of hemodynamic parameters. The risks and complications associated with these procedures relate to the patient’s concomitant conditions and to the skill and judgment of the operator. In this review, we examine in detail the major complications associated with invasive cardiac procedures and provide the reader with a comprehensive bibliography for advanced reading.

Association between bleeding severity and long-term mortality in patients experiencing vascular complications after percutaneous coronary intervention

Vascular complications (VCs) occur in 3% to 8% of percutaneous coronary interventions (PCIs). However, only a portion of patients who experience VCs bleed significantly. The aim of this study was to assess the covariates associated with the amount of blood loss in patients experiencing postprocedural VCs as well as the effect of the degree of blood loss on long-term mortality. Overall, 7,718 unselected patients who underwent PCI through femoral access were evaluated. Those experiencing VCs were identified and stratified with regard to the degree of hematocrit (HCT) decrease after the procedure. In total, 444 patients (5.8%) had VCs. Compared to those without VCs, patients with VCs were older and had more extensive co-morbidities. Severe blood loss was most frequent in those who had vascular perforation requiring surgical repair or in those who had retroperitoneal bleeding. Overall, <25% of patients with hematoma had severe blood loss. The raw 1-year mortality was doubled in patients with minimal or moderate HCT decrease and was tripled in those with severe decreases in HCT. Similarly, the rate of definite stent thrombosis was tripled in patients with VCs and moderate or severe decreases in HCT. After adjustment, only patients with VCs and the greater HCT decreases had an increased risk for death at 1 year (hazard ratio 1.80, 95% confidence interval 1.03 to 3.14). Independent predictors of severe HCT decrease included age, female gender, glycoprotein IIb/IIIa inhibitor use, and activated clotting time peak. Bivalirudin and closure devices were independently associated with less frequent severe HCT decrease. In conclusion, VCs do not entail an increased risk for death at 1 year unless associated with severe blood loss. The use of bivalirudin and closure devices seems to reduce the risk for such complications.

Bleeding avoidance strategies. Consensus and controversy

Bleeding complications after coronary intervention are associated with prolonged hospitalization, increased hospital costs, patient dissatisfaction, morbidity, and 1-year mortality. Bleeding avoidance strategies is a term incorporating multiple modalities that aim to reduce bleeding and vascular complications after cardiovascular catheterization. Recent improvements in the rates of bleeding complications after invasive cardiovascular procedures suggest that the clinical community has successfully embraced specific strategies and improved patient care in this area. There remains controversy regarding the efficacy, safety, and/or practicality of 3 key bleeding avoidance strategies for cardiac catheterization and coronary intervention: procedural (radial artery approach, safezone arteriotomy), pharmacological (multiple agents), and technological (vascular closure devices) approaches to improved access. In this paper, we address areas of consensus with respect to selected modalities in order to define the role of each strategy in current practice. Furthermore, we focus on areas of controversy for selected modalities in order to define key areas warranting cautious clinical approaches and the need for future randomized clinical trials in this area.

Cardio-respiratory exercise testing early after the use of the Angio-Seal system for arterial puncture site closure after coronary angioplasty

AIMS

The vascular closure device (VCD) Angio-Seal is an easy-to-use system for the closure of arterial puncture sites after percutaneous coronary intervention (PCI), and allows for early mobilisation of the patient. However, little data are available about exercising early after the use of VCD's in PCI patients.

METHODS AND RESULTS

A total of 230 consecutive patients were screened. Of these, 45 (20%) were excluded due to the inability to perform exercise testing, or anatomical conditions which prevented the insertion of a VCD. The 185 remaining patients (139 male, mean age 68 ± 12 years) received Angio-Seal after PCI. After four hours, 30 patients (16%) showed a small local haematoma, 11 patients (6%) complained about minor -and one patient (0.5%) about strong- groin pain. There were no major bleeding complications, six pseudo-aneurysmata, and one arterio-venous fistula. Overall, nine patients (6%) showed moderate to severe groin problems. Patients without major complications underwent bicycle cardiopulmonary exercise testing the subsequent day. Exercise testing was performed up to 136 ± 60 W in 176 patients (94%). Maximum workload was 104 ± 33 W, peak oxygen consumption 17.6 ± 5.1 ml/min/kg, and oxygen consumption at the anaerobic threshold 15.4 ± 4.2 ml/min/kg. After exercise testing there were no cardiovascular complications noted.

CONCLUSIONS

In patients receiving VCD after PCI, exercise testing above the anaerobic threshold was feasible after Angio-Seal deployment in those patients with no complications after the use of the device.

Percutaneous management of inferior epigastric artery injury after cardiac catheterization

Inferior epigastric artery injury after cardiac catheterization and percutaneous coronary intervention is sporadically reported in the literature, yet it is a serious complication that can lead to life-threatening retroperitoneal hemorrhage and poor clinical outcomes after percutaneous coronary intervention. We present two cases of inferior epigastric artery injury from inadvertent puncture during cardiac catheterization and a discussion in the management and prevention of this potentially fatal complication.

Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial)

OBJECTIVES

The aim of this study was to compare the procedural and clinical outcomes of femoral arterial access with ultrasound (US) guidance with standard fluoroscopic guidance.

BACKGROUND

Real-time US guidance reduces time to access, number of attempts, and complications in central venous access but has not been adequately assessed in femoral artery cannulation.

METHODS

Patients (n = 1,004) undergoing retrograde femoral arterial access were randomized 1:1 to either fluoroscopic or US guidance. The primary end point was successful common femoral artery (CFA) cannulation by femoral angiography. Secondary end points included time to sheath insertion, number of forward needle advancements, first pass success, accidental venipunctures, and vascular access complications at 30 days.

RESULTS

Compared with fluoroscopic guidance, US guidance produced no difference in CFA cannulation rates (86.4% vs. 83.3%, p = 0.17), except in the subgroup of patients with CFA bifurcations occurring over the femoral head (82.6% vs. 69.8%, p < 0.01). US guidance resulted in an improved first-pass success rate (83% vs. 46%, p < 0.0001), reduced number of attempts (1.3 vs. 3.0, p < 0.0001), reduced risk of venipuncture (2.4% vs. 15.8%, p < 0.0001), and reduced median time to access (136 s vs. 148 s, p = 0.003). Vascular complications occurred in 7 of 503 and 17 of 501 in the US and fluoroscopy groups, respectively (1.4% vs. 3.4% p = 0.04).

CONCLUSIONS

In this multicenter randomized controlled trial, routine real-time US guidance improved CFA cannulation only in patients with high CFA bifurcations but reduced the number of attempts, time to access, risk of venipunctures, and vascular complications in femoral arterial access. (Femoral Arterial Access With Ultrasound Trial [FAUST]; NCT00667381).

Quantitative impact of cardiovascular risk factors and vascular closure devices on the femoral artery after repeat cardiac catheterization

BACKGROUND

We evaluated the exact quantitative long-term impact of repeated catheterizations, vascular closure devices, and cardiovascular risk factors on the femoral artery after cardiac catheterization.

METHODS

A total of 2,102 available femoral angiograms from 827 consecutive patients were analyzed using caliper-based quantitative vascular analysis. These patients underwent coronary interventions between January 2005 and April 2007 and had at least one additional catheterization procedure through the ipsilateral femoral access site from December 2001 until January 2008. Multivariate analysis was performed to control for confounding variables. The primary outcome was change in artery size.

RESULTS

The average punctured artery diameter was 6.5 +/- 2.1 mm. The average time between the first case and last follow-up was 349 days. There was no significant change of the punctured artery size over time after the index procedure (P = .15) and no change associated with the use of vascular closure devices (P = .25) after multivariate analysis. Smaller arteries were associated with female gender (-1.22 mm, P < .0001), presence of angiographic peripheral vascular disease (PVD, -1.19 mm, P < .0001), and current (-0.48 mm, P = .001) or former (-0.23 mm, P = .01) smoking status, whereas previous statin therapy was associated with an increase in artery size (+0.47 mm, P < .0001). Vascular closure devices were used less often compared with manual compression in cases preceding the first detection of angiographic PVD (P < .001).

CONCLUSION

Vascular closure devices are not associated with a change in the artery size or progression of PVD. Overall, there is no change in vessel size over time after repeat catheterizations, with a decrease in vessel size associated with current and former smoking and an increase with previous statin therapy.

Strategies to reduce bleeding among patients with ischemic heart disease treated with antiplatelet therapies

Antiplatelet therapy is the cornerstone of management in acute coronary syndromes (ACS) and percutaneous coronary intervention. Combination therapy with aspirin and clopidogrel reduces the risk of death, myocardial infarction, or stroke in ACS but increases the risk of major bleeding, which studies indicate is 1%-4% higher when clopidogrel is added to aspirin. Given the association between bleeding and adverse outcomes, minimizing bleeding risk is a clinical priority. This review outlines strategies to reduce both acute and chronic bleeding risk with aspirin and clopidogrel and focuses on dosing of concomitant therapies, vascular access techniques, and mitigating the bleeding risk associated with coronary artery bypass grafting surgery.

Trends in vascular complications after diagnostic cardiac catheterization and percutaneous coronary intervention via the femoral artery, 1998 to 2007

OBJECTIVES

This study sought to evaluate trends in vascular complications after diagnostic cardiac catheterization (CATH) and percutaneous coronary intervention (PCI) from the femoral artery from 1998 to 2007.

BACKGROUND

Vascular complications have been recognized as an important factor in morbidity after CATH and PCI. Whether strategies to reduce vascular complications performed from the femoral artery in the past decade have improved the safety of these procedures, however, is uncertain.

METHODS

A total of 35,016 consecutive diagnostic cardiac catheterization (n = 20,777) and percutaneous coronary intervention procedures (n = 14,239) performed via a femoral access at a single site (Wake Forest University Baptist Medical Center) between 1998 and 2007 were evaluated. Annual rates of vascular complications were evaluated. Covariate effects on the risk of vascular complications were evaluated by logistic regression and risk-adjusted trend analysis.

RESULTS

Overall, the incidence of any vascular complication decreased significantly for CATH, 1.7% versus 0.2%, and PCI, 3.1% versus 1.0%, from 1998 to 2007, both p < 0.001 for trend. Favorable trends in procedural covariates affecting vascular complications were mainly responsible for the decrease in the incidence of vascular complications, including fewer closure device failures and use of smaller sheath sizes.

CONCLUSIONS

In this large, single-center, contemporary observational study, the safety of CATH and PCI performed from the femoral artery improved significantly from 1998 to 2007. Reductions in the prevalence of adverse procedural factors contributed to the decrease in the incidence of vascular complications, suggesting that strategies to reduce vascular complications can be effective in improving the safety of these procedures.

Risk predictors of retroperitoneal hemorrhage following percutaneous coronary intervention

Retroperitoneal hemorrhage (RPH) is a potentially catastrophic complication after percutaneous coronary intervention (PCI). Previous studies identified female gender, body surface area, and high arterial puncture location as independent risk factors for RPH. There have been conflicting reports regarding the association with vascular closure devices (VCDs). Chronic renal insufficiency (CRI) and diabetes mellitus have been associated with both peripheral vascular disease and vascular access-site complications. The putative association of VCDs, CRI, and diabetes mellitus with RPH in the contemporary PCI era was investigated. A total of 3,062 consecutive patients undergoing 3,482 PCIs at Brigham and Women's Hospital from January 2005 to April 2007 were evaluated for the study. All 3,311 patients with femoral angiography underwent hand-caliper-based quantitative vascular analysis and were included in this analysis. Multivariate analysis was performed using a backwards selection algorithm, and a propensity adjustment was developed to control for possible confounding variables regarding VCD use. The incidence of RPH was 0.49% (17 of 3,482 patients). After multivariate and propensity analyses, covariates that significantly influenced the risk of RPH were CRI, glycoprotein IIb/IIIa inhibitors, and high arterial puncture (p < or =0.007). VCD use was not independently associated with the development of RPH (p = 0.74). In conclusion, this large prospective cohort study identified CRI, but not VCD use, as an independent predictor for RPH and peripheral vascular disease.

Managing the femoral artery in coronary angiography

Vascular access and subsequent methods to obtain haemostasis are commonly overlooked components of coronary angiography, yet most complications related to diagnostic coronary angiography and percutaneous coronary interventions come from groin bleeds. Most of these complications are minor, leading to bruising and patient discomfort. However, major vascular complications such as retroperitoneal bleeding are life threatening. A number of devices are now available to ensure the arteriotomy can be closed immediately at the end of the procedure. These devices have advantages but are in themselves the source of additional complications, which are not seen without them. The mechanisms related to the use of these devices and the potential complications that they may cause should be understood by all cardiologists performing coronary angiography.

Immediate catheterization laboratory management of acute femoral artery occlusion due to a vascular closure device

Acute limb ischemia due to vascular closure devices is an infrequent complication. However, its incidence is increasing because the use of these devices has become commonplace after cardiac catheterization and coronary angioplasty. It is therefore important for interventional cardiologists to be acquainted with the knowledge and cognitive skills of managing this complication in the catheterization laboratory. The present report describes a strategy to manage this complication in a cardiac catheterization laboratory that is not equipped with standard fluoroscopic equipment for peripheral interventions.

Kissing stents in the aortic bifurcation--a valid reconstruction for aorto-iliac occlusive disease

OBJECTIVE

To evaluate outcome and patency predicting factors of kissingstent treatment for aorto iliac occlusive disease (AIOD).

METHODS

Patients treated with kissingstents for AOID between 1995 and 2004 at a tertiary referral center were identified through local databases. Chart review and preoperative images were used for TASC and Fontaine classification. Follow-up consisted of clinical exams, ABI and/or duplex. Patency rates were estimated by Kaplan-Meier analysis, and Cox multivariate regression was used to determine factors associated with patency.

RESULTS

173 consecutive patients (46% male, mean 64 years) were identified. TASC distribution was: A 15%, B 34%, C 10%, D 41%. Mean follow-up was 36 months (range: 1-144). 30-day mortality was 1% (2 patients), and 1-year survival was 91% (157 patients). 2 patients underwent late, open conversion and 13 patients suffered minor puncture site complications. Primary, assisted primary and secondary patency was: 97%, 99% and 100%, and 83%, 90% and 95% at twelve and 36 months respectively. There was no significant difference in patency between the TASC groups. Patency was significantly worse for patients in Fontaine class III.

CONCLUSIONS

Aortoiliac kissing stents is a valid alternative to open repair for TASC A-D lesions. The procedure has low mortality and morbidity and good patency at 3 years.

Incidence and Treatment of Arterial Access Dissections Occurring during Cardiac Catheterization

BACKGROUND

Arterial access dissections may complicate cardiac catheterization and can often be treated percutaneously. The goal of this study was to examine the incidence, consequences, and the treatment of arterial access dissections at a tertiary referral hospital with an active training program.

METHODS

Patients experiencing arterial access dissection during coronary angiography or intervention at our institution between October 1, 2004, and January 31, 2007, were identified and their records were retrospectively reviewed.

RESULTS

Thirteen of the 3,062 consecutive patients (0.42%) had arterial access dissection during the study period. The location of the dissection was in the common femoral artery (CFA) (n = 6), the external iliac artery (EIA) (n = 6), or in an aortobifemoral graft (n = 1). Three of the six patients with CFA dissection were diagnosed during coronary angiography, and because of significant comorbidities were treated with self-expanding stents. After a mean follow-up of 7 months, they experienced no stent fracture or other complication. Six patients had EIA dissections. In one such patient, the dissection was not flow limiting and was treated conservatively. The remaining five patients underwent successful implantation of self-expanding stents, and during a mean follow-up of 9.6 months, no patient had any symptoms or events related to lower extremity ischemia. Finally, one patient had an aortobifemoral graft dissection. Due to the patient's critical condition, secondary to sepsis, his family elected to withdraw care, and he subsequently expired.

CONCLUSIONS

Arterial access dissections occur infrequently during cardiac catheterization. Routine femoral artery angiography may help identify vascular access complications, often allowing simultaneous endovascular treatment, with excellent short-term outcomes.

Ischemic complications of percutaneous femoral artery catheterization

Ischemic injuries following percutaneous femoral artery catheterization are uncommon but have been associated with vascular closure devices (VCDs). The purpose of this study was to retrospectively compare ischemic and hemorrhagic complications of femoral artery catheterization and to identify factors associated with ischemic injuries. The operative registries of the attending vascular surgeons at one academic and two community hospitals were retrospectively reviewed to identify all complications of femoral artery catheterization requiring operative intervention. Demographic, clinical, procedural, operative, and outcome data were compared between patients who sustained ischemic and hemorrhagic complications. From January 2001 to December 2006, 95 patients required operative management of complications related to femoral artery catheterization including 40 patients who experienced ischemic (group 1) and 55 patients who experienced hemorrhagic (group 2) complications. Compared to those sustaining hemorrhagic complications, ischemic complications were more frequently associated with younger age, smoking, VCD deployment, and, when controlling for VCD use, female gender. Time to presentation was also significantly longer in patients experiencing ischemic complications. Ischemic complications are increasingly recognized following femoral artery catheterization. Vascular surgeons should anticipate a new pattern of injury following femoral artery catheterization, one that often requires complex arterial reconstruction.

Access site complications with carotid angioplasty and stenting

BACKGROUND

Carotid angioplasty and stenting is a relatively new therapeutic alternative to CEA for treatment of carotid stenosis. The percutaneous transfemoral approach, the standard technique for angioplasty and stent deployment, may not be feasible in all patients. We present our experience with access site complications that occurred with CAS.

METHODS

One hundred thirty-two CAS procedures were performed at our institution in the past 5 years for symptomatic (62.1%) or asymptomatic (37.9%) carotid stenosis. Mean age of patients was 70.72 +/- 6.53 years and the mean degree of stenosis of the treated carotids was 80.74% +/- 11.83%. The transfemoral approach was the access route in 126 CAS, the transbrachial approach was used in 2 CAS procedures, and direct carotid exposure was used in 5 patients.

RESULTS

All CAS procedures were done successfully; 4 (3%) access site complications were detected, 3 (2.4%) groin hematomas with transfemoral approach and 1 hematoma on the left side of the neck, in patients treated with direct carotid cutdown. Surgical repair of FSA was successfully performed for the patients with groin hematoma, whereas surgical wound exploration in the neck for the remaining patient revealed no identifiable cause. All patients received blood transfusion for correction of associated hypovolemia or hemorrhagic anemia. No patients had experienced access site-related additional cardiac, systemic, or neurologic events.

CONCLUSIONS

The authors' experience demonstrates that access site complications are rare events with CAS despite the large diameter of implantable devices and liberal anticoagulant and antiplatelet therapy. Transbrachial and direct carotid approaches are relatively safe, accepted alternatives in the setting of contraindicated femoral access.

Renal perforation and retroperitoneal hematoma: an unusual complication following cardiac catheterization

Retroperitoneal hematoma (RPH) is a well-recognised, albeit rare complication of percutaneous transfemoral cardiac catheterization. We describe an unusual case of renal perforation and RPH following transfemoral cardiac catheterization for endomyocardial biopsy. Diagnosis was made based on multidetector computed tomography (MDCT) which clearly depicted active renal hemorrhage in short acquisition time. The case expands the spectrum of possible complications of percutaneous transfemoral cardiac catheterization and illustrates the usefulness MDCT in quickly and adequately detecting RPH.

Early mobilization after diagnostic cardiac catheterization with the use of a hemostatic bandage containing thrombin

The aim of the present study was to assess the efficacy and safety of a thrombin-containing bandage for local hemostasis after femoral sheath removal in patients undergoing diagnostic cardiac catheterization. Forty-one patients undergoing diagnostic coronary angiography using a 6-F femoral sheath were included. The sheath was removed immediately after the procedure using the bandage according to a prespecified protocol. Mean compression time was 7.3+/-1.7 min and mean time from sheath removal to mobilization was 132+/-34 min. None of the patients suffered recurrent bleeding or any in-hospital and 7-day vascular complications. We conclude that in patients undergoing femoral-access diagnostic cardiac catheterization, the use of a hemostatic bandage containing thrombin was associated with short time to hemostasis with the ability for early patient mobilization without vascular complications.

Correlates and outcomes of retroperitoneal hemorrhage complicating percutaneous coronary intervention

BACKGROUND

Retroperitoneal hemorrhage (RPH) is an infrequent but occasionally fatal complication of percutaneous coronary intervention (PCI). Therefore, it has been studied in relatively small numbers of patients.

METHODS

Prospectively collected data on 28,378 consecutive patients treated between 1992 and 2003 were examined, supplemented by a date-based case control cohort study (76 RPH and 76 non-RPH patients) to examine elements not routinely recorded prospectively. Independent correlates of RPH were determined using logistical regression analysis.

RESULTS

One hundred sixty-three patients (0.57%) developed RPH; of these 73.5% required blood transfusions and 10.4% expired during hospitalization (P < 0.001 for both compared with patients without RPH). RPH was independently associated with femoral artery sheath placement superior to the inferior epigastric artery (P < 0.001), female sex (P < 0.001), use of Angioseal Device (P < 0.001), glycoprotein IIb/IIIa inhibitor use (P = 0.001), and patient presentation with the acute myocardial infarction (P = 0.035), and was inversely related to patient weight (P = 0.014). Of the 17 patient deaths, 6 were directly related to RPH, 2 of which occurred in association with delays in resuscitation efforts consequent to attempts to obtain diagnostic confirmation with CT imaging.

CONCLUSIONS

RPH remains an infrequent but serious complication of PCI. Appropriate management of the femoral access site and the patient once this complication is suspected may minimize adverse outcomes.

Retroperitoneal hemorrhage from inferior epigastric artery: Value of femoral angiography for detection and management

Laceration of the inferior epigastric artery during cardiac catheterization is under-reported in the literature, but it is a serious complication leading to retroperitoneal hemorrhage and even death. We report on two cases of retroperitoneal bleeding from unintentional puncture of the inferior epigastric artery during cardiac catheterization. Femoral angiography is a valuable tool to promptly recognize this complication.