Sonographic follow-up of the access site after arterial angiography: Impact on the detected complication rate

The Role of Anticoagulants and Platelet Aggregation Inhibitors in the Treatment of Pseudoaneurysms and Risk of Venous Thrombosis

Pseudoaneurysms (PSA) are one of the most common complications after arterial punctures. This retrospective study examined whether platelet aggregation inhibitors (APT) or anticoagulants (AC) lower the success rates of PSA treatment. A total of 468 patients with PSA were retrospectively analyzed between 2010 and 2018, and 238 were included in the study. Despite co-medication with APT or AC, thrombin injection (TI) was superior to compression bandage (CB) therapy in treating PSA (TIwAC 79 vs CBwAC 51%; P = .004 and TIwAPT 93 vs CBwAPT 54%; P = .001). There was no decrease in PSA-associated thrombosis in patients requiring anticoagulation after TI. The success rates of the TI and CB groups were compared in patients with and without AC therapy, and the latter was significantly lower. A reduced success rate was not observed in CB therapy patients requiring APT. In contrast, better results were seen in the TI group. Regarding PSA treatment, TI therapy is significantly superior to CB, including in patients requiring concomitant AC or APT therapy. PSA-associated thrombosis also occurs in patients requiring anticoagulation, and sonography should be performed. Concomitant medication use with APT does not significantly influence PSA therapy success or prevention of PSA-associated thrombosis.

High incidence of deep vein thrombosis during the treatment of pseudoaneurysms - a retrospective nonrandomized study

Background: Pseudoaneurysms (PSAs) are concerning complications after arterial invasive interventions. Therapeutic options include manual ultrasound-assisted compression, pressure dressings, surgical intervention and thrombin injection. Compression of neighboring veins is obvious. However, the incidence of deep vein thrombosis (DVT) in patients with PSA has not previously been investigated. Patients and methods: In this retrospective, nonrandomized study 238 patients with PSA were analyzed from 2013 to 2018. In 149 patients, all of the parameters were complete for participating. PSAs were treated according to the local standard therapy with either ultrasound-guided compression followed by compression bandage or thrombin injection. Treatment success was evaluated 24 hours later, and the venous system was examined for the presence of DVT. Results: Peripheral DVT was found in 25.4% patients after ultrasound-assisted compression and subsequent pressure bandages, but only 6.4% of patients had DVT after thrombin injection (p = 0.013). Lower leg veins, particularly veins of the crural muscles, were primarily affected. Significantly more PSAs were successfully treated without the occurrence of DVT in the thrombin injection group compared to the compression group (93.6 vs. 69.0%; p = 0.001). Conclusions: Our study revealed that the use of thrombin injections resulted in a significantly lower rate of postinterventional DVT and a higher total number of successfully treated PSAs compared to compression therapy.

Das moderne befund- und patientenadaptierte Management von peripheren Pseudoaneurysmen nach arteriellem Zugang

Pseudoaneurysmen (PSA) zählen zusammen mit den Hämatomen zu den häufigsten Komplikationen nach kathetergestützten Eingriffen.

Ziel und Methode Die narrative kompakte Kurzübersicht umreißt sowohl die Entstehung und Charakteristika von Pseudoaneurysmen sowie die Optionen der Diagnostik und Therapie als auch deren mögliche Komplikationen.

Ergebnisse Ätiopathogenese: Durch den nicht verschlossenen Stichkanal der Punktion kommt es zum kontinuierlichen Blutausstrom aus dem Gefäß, der im umliegenden Gewebe eine Pseudoaneurysmahöhle formt. Diese wird nicht wie beim wahren Aneurysma durch eine Gefäßwand begrenzt, sondern nur durch die umliegenden Gewebestrukturen eingedämmt. Dies ist aber meist nicht suffizient und es kommt zu einer raschen Ausbreitung und diffusen Einblutungen. Dadurch können umliegende Strukturen wie Nerven und Venen durch das expandierende Pseudoaneurysma komprimiert werden, woraus sich irreversible Schäden entwickeln können. Diagnostik: Die Duplexsonografie steht dominierend absolut im Vordergrund. Die CT-A, MR-A und DSA bleiben speziellen Fragestellungen oder klinischen Fallkonstellationen (z. B. Begleiterkrankungen etc.) vorbehalten – eine DSA ist stets mit Interventionsbereitschaft zu verbinden. Therapie: Mit der manuellen Kompression und der darauffolgenden Anlage eines Druckverbandes, einer ultraschallgestützten Kompression, der Thrombininjektion und der operativen Sanierung stehen mehrere Verfahren zur Auswahl. Die ultraschallgestützte Kompression sollte dabei immer sofort eingesetzt werden, da sie höchst effizient und ubiquitär verfügbar ist. Additiv zur Kompression kann die Thrombininjektion bei PSA ohne Nerven-/Gewebeirritation mit eingesetzt werden und bietet noch bessere Verschlussraten, ist jedoch anspruchsvoller in der Anwendung. Die operative Ausschaltung ist die effektivste Methode, bietet aber neben dem größten Aufwand die meisten Begleitkomplikationen wie Wundheilungsstörung bei mazeriertem Gewebe und den längsten Krankenhausaufenthalt. Alternative Verfahren zu den genannten haben sich bisher nicht durchsetzen können.

Schlussfolgerung Das diagnostische und therapeutische Management von Pseudoaneurysmen stellt eine Herausforderung im interdisziplinären befund- und patientenadaptierten Vorgehen dar, das den erfahren Gefäßmediziner erfordert.

Pseudoaneurysm

Pseudoaneurysms (PSAs) are commonly known as complications associated with invasive interventions. Because of the pulsatile in- and outflow of blood through the neck of PSAs, they tend to grow and, in the worse cases, can rupture. Therapeutic options are compression therapy, using a compression bandage and ultrasound-guided compression, and thrombin injection. Manual ultrasound-guided compression is widely performed and is successful in most cases. In general, it is combined with a subsequently applied compression bandage. Thrombin injection is a more difficult technique, but it has a higher success rate. This article gives an overview of the characteristics of PSAs, their diagnostic characteristics and the therapeutic methods used to treat them. Complications associated with compression or thrombin injection are also explained in detail.

Complications of Transbrachial Arterial Access for Peripheral Endovascular Interventions

Purpose: To prospectively assess current limitations and complication rates of the transbrachial access technique for endovascular treatment of peripheral vascular pathologies. Methods: In total, 150 patients (112 men; mean age 66.3±10.0 years) with arterial occlusive disease underwent endovascular therapy via a transbrachial access. Periprocedure data (sheath size, dose area product, fluoroscopy time, and procedure duration) were analyzed. Postprocedure complications of the puncture sites were categorized as minor (local hematoma, pseudoaneurysm, embolization, dissection, minor bleeding) and major (thrombotic occlusion, hematoma requiring surgery, major bleeding, nerve injury). Results: The minor and major complication rates were 14.0% (n=21) and 2.7% (n=4). The most frequent major complication was thrombotic occlusion of the brachial artery requiring surgical treatment (3/150, 2%). There was only one temporary palsy of the median nerve and no stroke. Local hematoma (15, 10%), pseudoaneurysm (3, 2%), or a combination of both (3, 2%) dominated the minor complications. The average dose area product and fluoroscopy time were 12,752.1±9524.5 cGy*cm2 and 24.3±18.4 minutes, respectively, though procedure duration was acceptable (121.8±48.9 minutes). Conclusion: Complication rates of the transbrachial access for endovascular treatment of peripheral or visceral artery occlusive disease are tolerably low, making it a safe and an important alternative to the transfemoral access in selected cases, though the radiation exposure is rather high.

Access site-related complications after transradial catheterization can be reduced with smaller sheath size and statins

The aim of this study was to investigate the risk factors for access site-related complications after transradial coronary angiography (CAG) or percutaneous coronary intervention (PCI). Transradial PCI has been shown to reduce access site-related bleeding complications compared with procedures performed through a femoral approach. Although previous studies focused on risk factors for access site-related complications after a transfemoral approach or transfemoral and transradial approaches, it is uncertain which factors affect vascular complications after transradial catheterization. We enrolled 500 consecutive patients who underwent transradial CAG or PCI. We determined the incidence and risk factors for access site-related complications such as radial artery occlusion and bleeding complications. Age, sheath size, the dose of heparin and the frequency of PCI (vs. CAG) were significantly greater in patients with than without bleeding complications. However, body mass index (BMI) was significantly lower in patients with than without bleeding complications. Sheath size was significantly higher and the frequency of statin use was significantly lower in patients with than without radial artery occlusion. Multiple logistic analysis revealed that sheath size [odds ratio (OR) 5.5; P < 0.05] and BMI (OR 0.86; P < 0.01) were risk factors for bleeding complications; and sheath size (OR 5.2; P < 0.05) and the lack of statin pretreatment (OR 0.50; P < 0.05) were risk factors for occlusive complications. In conclusion, these findings indicate that down-sizing of the devices used in transradial procedures might attenuate access site-related complications after transradial CAG or PCI. Statin pretreatment might also be a strategy that could prevent radial artery occlusion after transradial procedures.

[The patient with pulmonary embolism or vascular emergency requiring intensive care]

Acute pulmonary embolism requires ICU management only for patients with hemodynamic instability who need artificial ventilation, or for hemodynamically stable patients with significant right ventricular dysfunction. For both patient groups, echocardiography is the most relevant diagnostic method. The main therapeutic consideration is on systemic thrombolysis. It is indicated in almost all patients with hemodynamic instability but only in selected cases of right ventricular dysfunction. All other patients receive standard anticoagulation only. A second vascular emergency scenario is type 2 heparin-induced thrombocytopeniae (HIT II) which may cause venous as well as arterial complications. Alternative anticoagulation has to be established from the first moment of clinical suspicion. It has to be continued in a therapeutic dosage if HIT II is confirmed, and has to be stopped if the diagnosis is refuted. The latter case is by far more frequent. Regarding arterial occlusions (acute limb ischemia, acral gangrene, iatrogenic vascular trauma) hints are given for the management in the setting of intensive care.