Angiographic access site complications in the era of arterial closure devices

Infectious complications of endoarterial interventional radiology: protocol for an observational study of a longitudinal national cohort of patients assessed in the French hospital discharge database (MOEVA study)

Around seven million patients undergo endoarterial interventional radiology procedures (EAIRP) annually worldwide. These procedures have become part of the standard repertoire of vascular surgery. However, the healthcare-associated infections related to these procedures are relatively unknown. Prevalence and adverse outcome of infectious complication (IC) post-EAIRP may be underestimated. We aim to provide national trend estimation of EAIRP incidence and outcome in France. METHODS AND ANALYSIS: From the French Common Classification of Medical Acts, we will define four categories of EAIRP. We will collect procedures via the French nationwide hospital discharge database, called Programme de Médicalisation des Systèmes d'Information (PMSI) and derived from the Diagnosis Related Group system. Various combinations to identify the numerator will be employed according to a pre-established algorithm. Technical data wrangling tools facilitating the use of PMSI will be developed to obtain a clean and well-structured database ready for statistical analysis. This protocol will require competences in medicine, epidemiology, statistics, data processing and techniques through various stages of the study. The cohort will contain the denominator (the first act of the first stay of each patient) and the corresponding numerator (the IC which will occur during the first stay). ETHICS AND DISSEMINATION: No nominative, sensitive or personal data on patients have been collected. The study of the MOrtality and infectious complications of therapeutic EndoVAscular interventional radiology (MOEVA) study does not involve humans, and falls within the scope of the French Reference Methodology MR-004 according to 2016-41 law dated 26 January 2016 on the modernisation of the French health system. Our study involves the reuse of already recorded data, which require neither information or non-opposition of the included individuals. Access to linked ANOnymous (ANO) file in the PMSI databases was approved by the French National Commission for Data Protection and Liberties (CNIL number 1564135). The results will be disseminated through a peer-reviewed publication.

MOrtality and infectious complications of therapeutic EndoVAscular interventional radiology: a systematic and meta-analysis protocol

BACKGROUND

Endovascular interventional radiology (EIR) is an increasingly popular, mini invasive treatment option for patient with symptomatic vascular disease. The EIR practiced by qualified hands is an effective, well-tolerated procedure that offers relief of patient's symptoms with a low risk of complications. During acute post procedural period, immediate complications may relate to vascular access, restenosis, thromboembolic events, uterine ischemia, infection, necrosis, sepsis, ICU stay, surgical recovery, pain management, treatment failure, and death. Moreover, additional non-life-threatening complications exist, but they are not well described and represent disparate information.

METHODS/DESIGN

A range of databases will be screened consulted to identify the relevant studies: PubMed, EMBASE, The Cochrane Library, NosoBase, and Google Scholar (to identify articles not yet indexed). Scientist librarian used Medical Subject Headings (MeSH) and free terms to construct the search strategy in PubMed. This search strategy will be adapted in other databases. Two coauthors will independently select the relevant studies, extract the relevant data, and assess the risk of bias in the included studies. Any disagreements between the two authors will be solved by a third author.

DISCUSSION

This systematic review will provide a synthesis of EIR complications. The spotlighted results will be analyzed in order to provide a state-of-knowledge synopsis of the current evidence base in relation to the epidemiology of the infectious complications after EIR. In the event of conclusive results, our findings will serve as a reference background to assess guidelines on reality of the problem of the infections linked to endovascular interventional radiology and to formulate of assumptions and propose preventive measures, based on the results of our investigations. These propositions will aim to reduce the risk and/or the severity of these complications in the concerned population in favor a positive medical economics report. It will also aim to decrease the antibio-resistance and in fine will improve health status and security of patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015025594.

Clinical and Subclinical Femoral Vascular Complications after Deployment of two Different Vascular Closure Devices or Manual Compression in the Setting of Coronary Intervention

BACKGROUND

In the past two decades vascular closure devices (VCD) have been increasingly utilized as an alternative to manual compression after percutaneous femoral artery access. However, there is a lack of data confirming a significant reduction of vascular complication in a routine interventional setting. Systematic assessment of puncture sites with ultrasound was hardly performed.

METHODS

620 consecutive patients undergoing elective or urgent percutaneous coronary intervention were randomly allocated to either Angioseal (AS; n = 210), or Starclose (SC; n = 196) or manual compression (MC; n = 214). As an adjunct to clinical evaluation vascular ultrasonography was used to assess the safety of each hemostatic method in terms of major and minor vascular complications. The efficacy of VCDs was assessed by achievement of puncture site hemostasis.

RESULTS

No major complications needing transfusion or vascular surgery were observed. Furthermore, the overall incidence of clinical and subclinical minor complications was similar among the three groups. There was no differences in the occurrence of pseudoaneurysmata (AS = 10; SC = 6; MC = 10), arteriovenous fistula (AS = 1; SC = 4; MC = 2) and large hematoma (AS = 11; SC = 10; MC = 14). The choice of access site treatment had no impact in the duration of hospital stay (AS = 6.7; SC = 7.4; MS = 6.4 days).

CONCLUSIONS

In the setting of routine coronary intervention AS and SC provide a similar efficacy and safety as manual compression. Subclinical vascular injuries are rare and not related to VCD use.

Animal experimental evaluation of a new sealing device for indwelling arterial catheters

BACKGROUND

Hematoma is a common complication following arterial puncture. To date no device that allows sealing of an arterial puncture site with in-situ catheter has been developed.

PURPOSE

To evaluate a newly developed arterial sealing device for endovascular catheters in an in-vivo experimental setting.

MATERIAL AND METHODS

A peelable collagen-based vascular sealing device for endovascular catheters was tested in acute (follow-up: 4 h; n = 2) and chronic (follow-up: 1 week; n = 4) settings in the femoral artery (FA) of sheep. After implantation correct position of the device as well as patency of the FA were verified angiographically. In the chronic group, hematoma was excluded and patency of FA was assured using color Doppler ultrasound 1 and 3 days after the procedure. After 1 week a final ultrasound and an angiography were performed for final evaluation. Thereafter, the animals were sacrificed and the puncture site was dissected and analyzed macroscopically.

RESULTS

Sufficient sealing of the puncture site could be observed in all animals. In acute and chronic experiments, neither a hematoma at the puncture site nor other complications were observed after positioning the sealing device. Follow-up color Doppler ultrasounds (CDUS) and final angiography revealed patent FAs in all animals. Macroscopic evaluation of dissection material proved collagen plug and catheter being in place.

CONCLUSION

Our preliminary in-vivo results demonstrate a safe and convenient vascular sealing system for endovascular catheters. No acute or chronic complications were observed.

Development of four different devices to turn over introducer sheaths

INTRODUCTION

We developed four prototype sheath-turning auxiliary devices (STADs) and evaluated them in an in vitro study setup designed to enable the change of catheter direction in endovascular interventions.

METHODS

Four different prototypes, A through D, of STADs were designed and created by modifying commercially available dilators and catheters. All STADs work with different anchor-like tips to ensure fixation inside the vessel at the puncture site. The STAD is loaded into the introducer sheath, retracted with the introducer sheath, and turned at the puncture site. The STADs were tested in an in vitro vascular study setup using bovine veins. Success rates and procedure times were calculated, and the handling, reliability, and overall performance were evaluated. The maximum soft tissue thickness (STTmax) applicable was tested using bovine vessels with 7-mm thickness surrounded by a soft tissue phantom consisting of chicken breast. A retrospective cross-sectional observation in 108 patients from our center was performed to provide mean STTmax at the common femoral artery in patients for comparison.

RESULTS

The success rate ranged between 75% for prototype D and 90% for prototypes A and C. The procedure time averaged 60 seconds (range, 25-165 seconds). The mean handling was rated 2.4 (good) for prototype A, 2.0 (good) for prototype B, 2.6 (satisfactory) for prototype C, and 3.5 (poor) for prototype D. Mean reliability was rated 3.4 (satisfactory) for prototype A, 2.0 (good) for prototype B, 1.6 (good) for prototype C, and 2.4 (good) for prototype D. Mean overall performance was rated 2.0 (good) for prototype C, 2.6 (satisfactory) for prototype B, 3.3 (poor) for prototype D, and 3.4 (poor) for prototype A. In the cross-sectional patient observation, the mean STTmax was 3.3 cm (range, 0,5-13 cm) with a 95% confidence interval of the distribution including an STTmax of up to 8 cm. The STTmax was ≤ 5 cm in 100 of 108 patients (93%). The applicable STTmax for prototype A was 1 cm (8 of 10 successful cases), 3 cm for prototype B (9 of 10 successful cases), 5 cm for prototype C (8 of 10 successful cases), and 3 cm for prototype D (7 of 10 successful cases).

CONCLUSIONS

All four STAD prototypes offered the ability of turning the sheaths at the puncture site in an in vitro vascular study setup. In the future, this concept may allow routine clinical performance of turning maneuvers at the groin vascular access site.

Impact of Preoperative 64-Slice CT Scanning on Mini-Maze Atrial Fibrillation Surgery

BACKGROUND

: Multidetector computed tomography (MDCT) is emerging as a powerful noninvasive diagnostic tool. The appropriate role of this technique in the preoperative evaluation of cardiovascular disease has yet to be fully defined. Atrial fibrillation is the most common sustained cardiac arrhythmia, and novel minimally invasive surgical techniques have been developed to treat this condition by electrically isolating the pulmonary veins. The ideal methodology to preoperatively evaluate these patients remains debatable. We hypothesized that 64-slice CT could significantly affect perioperative planning.

METHODS

: Thirty-six consecutive patients who consented to undergo minimally invasive pulmonary vein isolation at our institution underwent a preoperative 64-slice cardiac CT scan. All cardiac and noncardiac abnormalities were recorded, and modifications to the initial surgical plan were documented.

RESULTS

: The mean patient age was 64.4 ± 11.9 years [26 men (72.2%), 17 with known coronary artery disease (47.2%)]. Preoperative CT scanning detected 12 patients with abnormal pulmonary venous anatomy (33.3%), 3 with left atrial thrombus (8.3%), and 17 with significant coronary artery disease (47.2%). Furthermore, 20 studies (55.6%) detected pulmonary abnormalities (including 11 nodules). Preoperative scanning significantly altered surgical planning in 10 cases (27.8%). Alterations in patient treatment included preoperative invasive angiography, conversion of the mini-maze to an open chest procedure, alteration of surgical approach, and postponement/cancellation.

CONCLUSIONS

: Sixty-four-slice CT scanning is a safe, rapid, and accurate procedure with important ramifications for surgical planning. This methodology could become an alternative approach to screen preoperative cardiac surgical patients.

Radioembolization complicated by dissection of the common femoral artery

The common femoral artery is the most frequently used access site for angiographic procedures in interventional radiology. Potential complications of common femoral arteriotomy include hematoma formation, pseudoaneurysm, uncontrolled groin or retroperitoneal bleeding, acute arterial occlusion, dissection, and arteriovenous fistula formation. In a case such as the one described here, with a common femoral artery dissection with intraluminal thrombus and vessel occlusion, the complication may have occurred at the time of access or at the time of closure, with both procedure-associated and patient-specific risk factors affecting the overall risk of complications. Though some studies have shown an increased risk of complications with the use of arterial closure devices, others have found no increase. In any patient with symptoms following a femoral arteriotomy, rapid diagnosis and treatment is necessary to avoid further complications. Both patient-specific and procedure-associated risk factors should be considered prior to arteriotomy and usage of an arterial closure device.

Strategies for decreasing vascular complications in diagnostic cardiac catheterization patients

Vascular complications are the most common type of complication after a cardiac catheterization. These include hematoma, pseudoaneurysm, arteriovenous fistula, peripheral artery occlusion and dissection, and retroperitoneal bleeding. The Pennsylvania Patient Safety Authority reports that nearly half the medical errors that occurred between June 2004 and December 2006 were cardiac catheterization complications, many of which were vascular related. The American College of Cardiology's National Cardiovascular Data Registry benchmark for vascular complications incidence is less than 1% for diagnostic catheterizations and less than 3% for percutaneous coronary intervention. The need to search for strategies to decrease vascular complication in diagnostic cardiac catheterization patients was a priority.

Unusual complications of arterial closure devices: a word of warning

The authors describe two patients who underwent transfemoral endovascular procedures followed by the use of the Angio-seal arterial percutaneous closure device. In the first patient, distal migration of the device occurred with consequent occlusion of the ipsilateral popliteal artery 2 days post procedure. In the second patient, thrombotic occlusion of the femoral artery occurred and the patient presented with acute leg ischaemia 3 weeks post procedure. Surgical removal of the closure device with consequent revascularisation of the affected leg was achieved in both patients. This report aims to alert clinicians to the possibility of device-induced arterial occlusion, dislodgment and their sequelae.

A new kaolin-based haemostatic bandage compared with manual compression for bleeding control after percutaneous coronary procedures

OBJECTIVE

Bleeding and vascular access site complications are an important cause of morbidity after percutaneous femoral procedures. New haemostatic dressings have been developed to control heavy bleeding. To evaluate the efficacy of a new kaolin-based haemostatic bandage for femoral artery closure after diagnostic or interventional procedures compared with manual compression.

METHODS

The first pilot European trial using this haemostatic bandage was performed at the in Milan, Italy. Two-hundred patients (71% male, mean age 66 ± 11 years) undergoing angiography or PCI via a femoral approach were randomised to the haemostatic bandage (n = 100) or manual compression (n = 100) following sheath removal. The mean active clotting time (ACT) at haemostasis was 146 ± 24 s (range 98-198 s). Haemostasis was achieved in 5.4 ± 1.5 min with the bandage vs 25 ± 15 min after manual compression, p < 0.001. No haemostasis failure occurred in either group. No differences in oozing, minor and major haematomas and pseudoaneurysms were observed. All patients ambulated at 4 h. Major bleeding, re-bleeding or haematoma did not occur after early (4 h after the procedure) ambulation following use of the bandage.

CONCLUSIONS

The haemostatic bandage obtained prompt and significantly shorter haemostasis than controls. This novel haemostatic device allowed for early ambulation without clinical complications.

Successful reduction of surgeries secondary to arterial access site complications: a retrospective review at a single center with an extravascular closure device

BACKGROUND

Access site complications requiring emergent surgery following femoral catheterization expose patients to additional morbidities and mortality. We observed a significant decrease in such surgeries after the Mynx device was introduced.

METHODS

A retrospective review of surgeries performed as a complication of 6F & 7F femoral cardiac and peripheral catheterization was done. Rates of surgeries among 3 closure methods were compared during the study period July 2006 to July 2008 (Mynx, AngioSeal, and manual/mechanical compression).

RESULTS

Of 11 006 6F &7F transfemoral catheterization procedures, 26 (0.24%) surgeries secondary to access complications resulted. Surgeries were done in 14 (0.61%) AngioSeal patients, 10 (0.19%) manual/mechanical compression, and 2 (0.06%) Mynx patients (P < .0001 vs AngioSeal, P = .14 vs compression).

CONCLUSIONS

Significant reduction in surgeries was seen in the Mynx vs Angioseal patients, no difference was noted in compression subset. Further analysis is warranted to prospectively evaluate these findings.

Management of vascular involvement in extremity soft tissue sarcoma

Advances in adjuvant treatment protocols and improvements in imaging techniques have helped improve the limb-salvage rate for extremity soft tissue sarcomas to approximately 95%. Moreover, improvements in operative techniques have enabled successful limb-salvage surgery to be performed even in the face of vascular invasion or encasement by tumor. En bloc resection of major vascular structures with the tumor and reconstruction with reversed saphenous vein grafts, femoral venous grafts, or synthetic grafts has proved to be a feasible option in limb-salvage surgery. However, the surgical oncologist and patient should be aware that although overall function is only slightly worse after these procedures, individual functional results are less predictable. In addition, procedures requiring vascular resection and reconstruction are associated with an increased risk of complications, including amputation.

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.

Postinterventional percutaneous closure of femoral artery access sites using the Clo-Sur PAD device: initial findings

The purpose of this study was to evaluate a percutaneous hemostatic device in patients to achieve immediate hemostasis at the vascular access site as well as early ambulation after vascular interventional procedures. In a randomized trial, a hemostatic device (Clo-Sur PAD, Medtronic AVE, Inc., Santa Rosa, CA, USA; n=60) was compared with manual compression (n=60) in patients after endoluminal intervention through an inguinal access (sheath sizes: 5-7 French). Device safety was evaluated by assessing complications within 24 h and 14 days. System efficacy was measured by the percentage of achieved immediate hemostasis and early ambulation. Device application was possible in 57 cases (95.0%), with 93.3% (56/60) of the patients rising 2 h after application. Hemostasis time was 10.15+/-1.96 min (control group: 16.20+/-1.79 min), with a pressure bandage time of 3.47+/-5.53 h (control group: 13.8+/-4.32 h). Ambulation was possible after 2.13+/-0.50 h (control group: 8.57+/-3.47 h). Complications encountered were access-site bleeding with hematoma (device: n=3; control: n=9). All complications were managed conventionally without blood transfusion or surgical intervention. The system is an easy to use device permitting early ambulation without additional pressure bandaging in the majority of patients. Preliminary data show that hemostasis does not depend on the level of anticoagulation.

Vascular Closure Devices

This article summarizes the vascular closure device technologies that are available to physicians who perform percutaneous catheter-based procedures.

Evaluation of risk factors associated with femoral pseudoaneurysms after cardiac catheterization

BACKGROUND

Femoral pseudoaneurysm (FPA) is one of the common complications of percutaneous catheterization procedures performed via the femoral artery. The aim of this research was to evaluate factors associated with FPA of sufficient clinical significance that they required surgical treatment after diagnostic or interventional cardiac catheterization.

METHODS

We evaluated 41,322 transfemoral catheterization procedures performed in our center within 7 years. Among all procedures, 630 FPAs developed that required surgical repair. Eighty-five cases were managed by compression with duplex guidance. As a case-control group, 1260 patients were selected from the patients who had been catheterized during the same time period but did not develop FPA. Two controls were selected for each study patient, matched according to age, sex, and catheterization day. Body mass index, hypertension, diabetes mellitus, catheter diameter, coronary artery disease, atherosclerosis, and number of cases performed per day in a particular room were evaluated as risk factors by using multivariate techniques.

RESULTS

Femoral pseudoaneurysm required operative repair in 1.1% (n = 398) of patients who underwent cardiac catheterization for diagnostic purposes and in 4.7% (n = 232) of patients after cardiac interventional procedures. Factors found to be independently predictive of FPA were hypertension (P = .011; odds ratio, 1.52), diabetes mellitus (P = .035; odds ratio, 1.11), coronary artery disease (P = .022; odds ratio, 1.21), larger (> or = 28 kg/m2) body mass index (P < .001; odds ratio, 2.21), larger number of cases (> or = 18) performed per day in a particular room (P < .001; odds ratio, 2.39), and larger (> or = 7F) catheter diameter (P < .001; odds ratio, 2.82).

CONCLUSIONS

Due to the development of technology and experience, more and more diagnostic and interventional catheterization procedures are performed on a daily basis. In our study, a high volume of cases in a particular room and use of large catheters were important risk factors for FPA complications. When these situations are combined with other risk factors (such as obesity, diabetes mellitus, hypertension, and arteriosclerosis), giving particular attention to local compression therapy would be more crucial to decrease the FPA rate.

Arterial Puncture Site Management After Percutaneous Transluminal Procedures Using a Hemostatic Wound Dressing (Clo-Sur P.A.D.) Versus Conventional Manual Compression:A Randomized Controlled Trial

PURPOSE

To investigate the efficacy and safety of a novel hemostatic wound dressing designed for rapid hemostasis at arterial puncture sites.

METHODS

Over a 15-month period, 209 consecutive patients were randomized to conventional manual compression (n=105) or the use of the Clo-Sur P.A.D. hemostatic device (n=104) after removal of the sheath. Puncture-related and device-related complications, time to hemostasis, time to ambulation, and patient and physician discomfort were recorded.

RESULTS

In 209 patients, 21 (10.0%) puncture-related complications were observed, including 11 (5.3%) pseudoaneurysms, 9 (4.3%) hematomas, and 1 (0.5%) major bleeding complication. There was no significant difference (p=0.36) in complications between the hemostatic device (9/104, 8.7%) and the conventional group (12/105, 11.4%). In the hemostatic device group compared to the conventional group, respectively, the average time to hemostasis (13.6 versus 20.3 minutes; p<0.001), time to ambulation (6.5 versus 17.4 hours, p<0.001), patient discomfort (VAS 2.1 versus 4.7, p<0.001), and physician discomfort (VAS 3.8 versus 5.2, p<0.001) were significantly lower. Twenty (19%) sheath removals in the hemostatic device group were classified as a technical failure of the device.

CONCLUSION

The use of this hemostatic wound dressing for arterial access site management after percutaneous vascular procedures significantly reduced the time to hemostasis, enabled early mobilization, and reduced patient discomfort without increasing the risk for complications compared to conventional manual compression. A high rate of technical failures, however, warrants further improvement before routine use can be recommended.

Status of Femoral Closure Devices

Both sealing and suturing closure devices have been shown to shorten hemostasis time, reduce the discomfort of manual or mechanical compression, and allow for earlier ambulation after cardiac catheterization and percutaneous coronary interventions without increasing vascular complications compared with conventional compression techniques. Several studies now report a reduction in vascular complications for percutaneous coronary intervention patients treated with closure devices compared with manual compression with pronounced benefit seen in patients receiving glycoprotein IIb/IIIa receptor inhibitors. Adoption of a simple predeployment femoral angiogram is now standard practice for use of a closure device. In an attempt to develop devices that are safer and more "user friendly," considerable modifications and improvements have been made in newer generation devices. Ultimately, the acceptance of femoral closure devices will depend on which device provides a simple approach with reliable hemostasis and a cost that can justify their incorporation into routine practice.

Embolização uterina para tratamento de mioma sintomático: experiência inicial revisão da literatura

OBJETIVO: Apresentar os resultados da experiência clínica inicial de 100 casos de mulheres portadoras de miomatose sintomática que foram submetidas a embolização das artérias uterinas como forma de tratamento principal. Apresenta-se, também, extensa revisão bibliográfica sobre o tema, para determinar as indicações e contra-indicações, bem como as eventuais complicações do método. MATERIAL E MÉTODO: Cem pacientes com miomatose sintomática foram submetidas a embolização das artérias uterinas como única forma de tratamento. O principal sintoma que indicou a intervenção foi o aumento do fluxo menstrual em 79 pacientes e dor associada à miomatose em 21. O diagnóstico de miomatose foi realizado por meio de ultra-sonografia em 75 pacientes, e pela associação de ultra-sonografia e ressonância magnética em 25 pacientes. O volume uterino médio avaliado por esses métodos de imagem resultou em 487 cm³. Os procedimentos foram realizados em duas instituições hospitalares: uma pública, onde foram atendidas 56 pacientes dependentes do Sistema Único da Saúde (SUS), e outra particular, onde foram atendidas 46 pacientes com plano de assistência médica. Setenta e seis pacientes foram avaliadas clinicamente após 12 semanas da realização da embolização uterina. RESULTADOS: O procedimento foi completado com sucesso em 97% dos casos, utilizando-se técnica convencional. O acompanhamento e a avaliação clínica após 12 semanas evidenciou que houve melhora dos sintomas em mais de 90% das pacientes. Verificou-se, ainda, redução de volume uterino de 52%. Não foram observadas complicações técnicas ou clínicas relevantes. CONCLUSÃO: A técnica de embolização uterina para tratamento da miomatose sintomática é um método simples, eficiente e seguro.