Extracardiac Complications of PCI

Christopher J. White, MDChristopher J. White, MDChairman, Department of CardiologyChairman, Department of Cardiology

Ochsner Clinic Foundation, New Orleans, LAOchsner Clinic Foundation, New Orleans, LA

Prevention, Recognition, & ManagementPrevention, Recognition, & Management

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TERMS OF USE

Avoiding ComplicationsPatient history.Patient history.Physical examination.Physical examination.Technical performance.Technical performance.

Front wall stick.Front wall stick. Pulsatile flashback.Pulsatile flashback. Reliable landmarks.Reliable landmarks. Special considerations in PVD.Special considerations in PVD.

Patient History

Signs or symptoms of PVD.Signs or symptoms of PVD.

Prior access problems.Prior access problems.

Inability to lie flat.Inability to lie flat.

Physical Examination

Examine all pulses.Examine all pulses.

Listen for bruits.Listen for bruits.

Allen’s test for radial access.Allen’s test for radial access.

Technical ElementsFront wall stick.Front wall stick.

Pulsatile blood flow before wire advancement.Pulsatile blood flow before wire advancement.

Wire exits needle without resistance.Wire exits needle without resistance.

Use of fluoroscopic guidance.Use of fluoroscopic guidance.

LandmarksGoal is access in common femoral art.Goal is access in common femoral art.

Medial inferior aspect of femoral head.Medial inferior aspect of femoral head.

Point of maximal pulse in > 90%.Point of maximal pulse in > 90%.

Confirm with fluoroscopy (if in doubt).Confirm with fluoroscopy (if in doubt).

Considerations in PVD

Known aorto-iliac disease or prior AFB.Known aorto-iliac disease or prior AFB.

Consider brachial or radial access.Consider brachial or radial access.

Review any previous angiography.Review any previous angiography.

Aorto-femoral graft may be used for Aorto-femoral graft may be used for access, avoid retrograde access into access, avoid retrograde access into blind limb of iliac artery.blind limb of iliac artery.

Considerations in PVD

Distal SFA occlusive disease is not a Distal SFA occlusive disease is not a contraindication. Enter CFA !!contraindication. Enter CFA !!

Take care NOT to compromise the Take care NOT to compromise the patent profunda femoris artery (only patent profunda femoris artery (only remaining circulation to the leg).remaining circulation to the leg).

Considerations in PVD

Beware of brachiocephalic disease in Beware of brachiocephalic disease in patients with occlusive aorto-iliac disease.patients with occlusive aorto-iliac disease.

Increased risk of stroke with catheter Increased risk of stroke with catheter manipulation in tortuous subclavian vessels.manipulation in tortuous subclavian vessels.

Femoral Access Complications

Hematoma, bleeding, & transfusion.Hematoma, bleeding, & transfusion.

Pseudoaneurysm.Pseudoaneurysm.

AV fistula.AV fistula.

Thrombosis.Thrombosis.

Infection.Infection.

Risk Factors Femoral ComplicationsFemale gender.Female gender.

Obesity.Obesity.

Low body weight.Low body weight.

Hypertension.Hypertension.

Over anticoagulation ± GP IIb/IIIa.Over anticoagulation ± GP IIb/IIIa.

Thrombolytic agents.Thrombolytic agents.

Elevated creatinine.Elevated creatinine.

Larger arterial sheath.Larger arterial sheath.

Prolonged sheath time.Prolonged sheath time.

Older age.Older age.

Low platelet count.Low platelet count.

Intra-aortic counterpulsation balloon.Intra-aortic counterpulsation balloon.

Concomitant venous sheath.Concomitant venous sheath.

Need for repeat intervention.Need for repeat intervention.

Risk Factors Femoral Complications

Femoral Access BleedingIncidence ≤ 6% (transfusion ≤ 3.0%).Incidence ≤ 6% (transfusion ≤ 3.0%).

Discontinue heparin after procedure.Discontinue heparin after procedure.

Reduce heparin with GP IIb/IIIa (70 U/KG).Reduce heparin with GP IIb/IIIa (70 U/KG).

Sheath removal with ACT < 170 sec.Sheath removal with ACT < 170 sec.

Minimize sheath size.Minimize sheath size.

ADP inhibitors instead of coumadin.ADP inhibitors instead of coumadin.

Retroperitoneal HematomaIncidence ≤ 3.0%.Incidence ≤ 3.0%.

Avoid “high” CFA arterial puncture.Avoid “high” CFA arterial puncture.

Front-wall puncture desirable.Front-wall puncture desirable.

Suspect when:Suspect when: Blood loss, hypovolumia, hypotension.Blood loss, hypovolumia, hypotension. Supra-inguinal fullness, tenderness.Supra-inguinal fullness, tenderness. Flank pain.Flank pain.

Retroperitoneal HematomaIf suspicion is high, and blood loss significant, If suspicion is high, and blood loss significant, treattreat before a definitive diagnosis is made. before a definitive diagnosis is made.

Discontinue/reverse anticoagulation.Discontinue/reverse anticoagulation.

CT Scan

Surgical Repair

Contralateral Access

Balloon Tamponade

HYPOTENSION POST-CATHDifferential DiagnosisDifferential Diagnosis

Retroperitoneal Bleeding

6 Fr IMA6 Fr IMA

CoilsCoils

PSEUDOANEURYSMIncidenceIncidence

Duplex ultrasound ≤ 6.0 %.Duplex ultrasound ≤ 6.0 %. Clinical detection 1 - 3.0 %.Clinical detection 1 - 3.0 %.

Risk factorsRisk factors Female > 70 yrs.Female > 70 yrs. Diabetes.Diabetes. Obesity.Obesity. Low (SFA) stick.Low (SFA) stick.

PSEUDOANEURYSMSmall (≤ 2 cm) may be observed and Small (≤ 2 cm) may be observed and

are likely to close spontaneously.are likely to close spontaneously.

Larger aneurysms may be closed with:Larger aneurysms may be closed with:

Ultrasound guided compression.Ultrasound guided compression.

Thrombin injection.Thrombin injection.

Surgical repair.Surgical repair.

A-V FISTULAIncidence ≤ 0.4%.Incidence ≤ 0.4%.

Associated with low (SFA/Profunda) access Associated with low (SFA/Profunda) access and a venous branch.and a venous branch.

Small fistula may be observed and many will Small fistula may be observed and many will spontaneously close or remain stable.spontaneously close or remain stable.

Larger fistula may cause signifcant AV Larger fistula may cause signifcant AV shunts, swelling and tenderness.shunts, swelling and tenderness.

A-V FISTULASurgical repair.Surgical repair.

Ultrasound guided compression.Ultrasound guided compression.

Balloon tamponade.Balloon tamponade.

Stent graft.Stent graft.

Ischemia/Thrombosis/EmboliIncidence ≤ 1.0 %.Incidence ≤ 1.0 %.

Risk factors:Risk factors:

Large access catheter/small artery.Large access catheter/small artery.

Presence of peripheral arterial disease.Presence of peripheral arterial disease.

Iatrogenic dissection.Iatrogenic dissection.

Thrombus within sheath.Thrombus within sheath.

Ischemia/Thrombosis/EmboliSigns and symptoms:Signs and symptoms:

PainPain PallorPallor ParesthesiaParesthesia PulselessPulseless Polar (cold).Polar (cold).

Ischemia/Thrombosis/EmboliContralateral access and angiography.Contralateral access and angiography.

Selective lysis below access site.Selective lysis below access site.

Mechanical thrombectomy.Mechanical thrombectomy.

Suction thrombectomy.Suction thrombectomy.

SHEATH EMBOLISM

POPLITEAL UK LACING FINAL

Surgical RepairDependent on facility with catheter-Dependent on facility with catheter-

based repair techniques.based repair techniques. Bleeding.Bleeding. Thrombosis.Thrombosis. Pseudoaneurysm.Pseudoaneurysm.

Incidence ranges from 1% to 3%.Incidence ranges from 1% to 3%.

Groin InfectionIncidence ≤ 0.2%.Incidence ≤ 0.2%.

Risk factors:Risk factors: Reintervention at same site.Reintervention at same site. Hematoma formation.Hematoma formation. Prolonged sheath placement.Prolonged sheath placement.

N.B. Future series will include infections secondary to closure devices such as angioseal and perclose.

NEUROPATHYRare complication.Rare complication.

Due to nerve injury:Due to nerve injury: Retroperitoneal hematoma with compression of Retroperitoneal hematoma with compression of

lumbar plexus.lumbar plexus. Femoral hematoma with nerve compression.Femoral hematoma with nerve compression. Femoral nerve injury during access.Femoral nerve injury during access.

BRACHIAL ACCESSCutdown or percutaneous.Cutdown or percutaneous.

Heparin is recommended.Heparin is recommended.

Complications similar to femoral access.Complications similar to femoral access.

Ischemia, thrombosis, embolization.Ischemia, thrombosis, embolization.

Brachial fossa hematoma (median n.)Brachial fossa hematoma (median n.)

BRACHIAL ACCESSIschemia, thrombosis, embolisation.Ischemia, thrombosis, embolisation.

Conservative therapy, heparization.Conservative therapy, heparization.

Surgical repair, embolectomy.Surgical repair, embolectomy.

Percutaneous lysis, mechanical Percutaneous lysis, mechanical thrombectomy, or balloon inflation to tack-thrombectomy, or balloon inflation to tack-up a dissection flap.up a dissection flap.

BRACHIAL COMPLICATION

PTAPTA

BRACHIAL ACCESSMedian nerve injury (≤ 1.0 %).Median nerve injury (≤ 1.0 %).

Brachial fossa hematoma compression.Brachial fossa hematoma compression.

Nerve injury during access.Nerve injury during access.

Ischemic nerve injury.Ischemic nerve injury.

BRACHIAL ACCESS

Selective LIMA access from left arm.Selective LIMA access from left arm.

RADIAL ACCESSSuccessful access ≥ 90%.Successful access ≥ 90%.

Normal “Allens” test required.Normal “Allens” test required.

Most common failure is inability to cannulate Most common failure is inability to cannulate artery.artery.

Occlusion post-PCI approx 5%.Occlusion post-PCI approx 5%.

Associated with fewest major complications of Associated with fewest major complications of any access site.any access site.

Randomized TrialAttempted PTCA (n = 900)Attempted PTCA (n = 900)

93

95.7

99.7

88

90

92

94

96

98

100

Cannulation Success

Radial Brachial Femoral

%After successful cannulation, there was no difference in successful PCI.

Kiemeneij F. et al. JACC 1997;29:1269.

Randomized Trial2.3

2.0

0.0

0.5

1.0

1.5

2.0

2.5Percent

Radial Brachial Femoral

Major Complications at PCI

0.0

Kiemeneij F. et al. JACC 1997;29:1269.

P = 0.035P = 0.035

Asymptomatic radial artery occlusion in 3%.

NBNB

HEMOSTASISManual compression.Manual compression.

Mechanical compression device.Mechanical compression device.

Closure devices.Closure devices. Angioseal.Angioseal. Vasoseal.Vasoseal. Perclose.Perclose.

DEVICESMechanical compression.Mechanical compression.

Equal or superior to manual compression Equal or superior to manual compression for safety.for safety.

Pressure dressings do not decrease Pressure dressings do not decrease complications and may obscure bleeding.complications and may obscure bleeding.

Require constant attention, patient cannot Require constant attention, patient cannot be left unattended.be left unattended.

Patient at bedrest 4 to 6 hrs.Patient at bedrest 4 to 6 hrs.

DEVICESClosure devices:Closure devices:

Have not demonstrated any reduction in Have not demonstrated any reduction in major complications.major complications.

Offer less intensive needs for monitoring Offer less intensive needs for monitoring and personnel post-procedure.and personnel post-procedure.

Significant disposable cost.Significant disposable cost. Offer early ambulation.Offer early ambulation.

HEMOSTASISReverse heparin with protamine (10 mg Reverse heparin with protamine (10 mg

/ 1000 U of heparin). N.B. protamine / 1000 U of heparin). N.B. protamine excess can also cause anticoagulation.excess can also cause anticoagulation.

IIb/IIIa platelet inhibitors.IIb/IIIa platelet inhibitors. Abciximab - platelet transfusion.Abciximab - platelet transfusion. Eptifibatide/tirofiban - renal clearance.Eptifibatide/tirofiban - renal clearance.