VASCULAR ACCESS COMPLICATIONS

Natalia Fendrikova Mahlay, MD, RPVI

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TYPICAL ARTERIAL COMPLICATION PROTOCOLIndications• Prior vascular access• Pulsatile mass• Access site pain• Bruit • Expanding hematoma

or drop in hematocrit

Arteries are examined for the presence of:• Pseudoaneurysm• Stenosis/occlusion• Dissection• True aneurysm• AV Fistula

Veins are examined for the presence of thrombusIncidental findings (i.e hematoma, fluid collection) are recorded

ARTERIAL EXAMINATION: NORMAL FINDINGS

• Antegrade flow• Triphasic signal with

brisk upstroke, open acoustic window

• Assessing for arterial stenosis

VENOUS EXAMINATION: NORMAL FINDINGS

• Compressible vein • Flow is with antegrade,

spontaneous, respirophasic, augmentable

B-mode cannot differentiate vascular from non-vascular structure

• ?Complex cyst• ?Hematoma• ?Seroma• ?Aneurysm• ?Pseudoaneurysm

• ?Complex cyst• ?Hematoma• ?Seroma• ?Aneurysm• ?Pseudoaneurysm

CASE: 49yoM ESRD with groin pain s/p left heart catheterization and PCI

Vascular, “yin-yang” sign

“To and Fro” Flow

• Color Dopper Sn 94%, Sp 97%

• Vascular structure• “To and Fro” flow within the

tract • Connection with an artery

should be established • Length of the tract and width of

the neck needs to be measured• Evaluate for additional

chambers• Rule out arteriovenous fistula

PSEUDOANEURYSM:

AACC/AHA PAD Guidelines, 2005

J Am Coll Cardiol. 2006;47:e1– e192

US-GUIDED COMPRESSION (USGC)• Success rate of 75-98%. In patients on

anticoagulation 30-73%• Selective compression is importantUS-GUIDED THROMBISN INJECTION (UGTI)• Off label use of thrombin• Cumulative success rate of 97%• Complications rate 0-4 %• Distal arterial embolization 0-2%• Recurrence rate 0-9%.

Nonoperative intervention:

Surgical treatment:• Symptomatic PSA• PSA at the site of the vascular

anastomosis• Spontaneous

Edgerton JR et al. Ann Thorac Surg 2002;74:S1413-5Olsen DM et al.. J VascSurg 2002;36:779-82La Perna L et al, Circulation 2000;102:2391-5Webber et al,Circulation.2007;115:2666-2674

CASE: 82yoF with severe aortic stenosis s/p TAVR undergoes VDU to rule out DVT

• Negative for DVT• Turbulent venous flow

ARTERIOVENOUS FISTULA• Artery proximal to AVF: may see low

resistance flow• Artery distal to AVF: normal or

dampened (if significant steal)• Fistulous tract: increased velocities

and low resistance flow pattern• Venous flow proximal to fistula:

“arterialized” and/or turbulent flow

• 33% resolve spontaneously within 1 yr• Observation in asymptomatic patients• Surgical or endovascular treatment

reserved for symptomatic patients (distal ischemia, high output heart failure, venous hypertension)

Courtesy of Heather Gornik, MD

51yoF with ILD, respiratory failure, s/p ECMO is referred for an incidental finding on abdominal CT

Two-flow channels

Dissection flap Dissection flap

ARTERIAL DISSECTION

• Echogenic dissection flap on grey scale images

• Parallel two flow channels on color Doppler images

• Manage conservatively for non-flow limiting dissection

• Interventional management for flow limiting dissection/ limb ischemia

74yoM with severe AS planned for TAVR who is referred for postprocedure evaluation

74yoM with severe AS planned for TAVR who is referred for postprocedure evaluation

Image courtesy of Alia Grattan, RVT

Wall based filling defect :_ plaque?_ dissection?

_ thrombus?

Found it!

Patient underwent recent preoperative LHC

Finding is related to closure device

Need clinical correlation to patient’s history

CLOSURE DEVICESDevice On the market Mechanism DisadvantageActive arterialal closure devicesAngioSeal 1997 to present Collagen and suture Collagen an

mediatedIntraarterialal component Possible Possible

thromboembolic thromboembolic complications, infection complications, inrelated to wick

Perclose 1997 to present Suture mediated Intraarterialal component Device failure may Device failure may require surgical repair

StarClose 2005 to present Nitinolol clip No o intraarterialNoo ntraarteriincomponent

Adequate skin contact is Adequate skin contacneeded to prevent needed tfailure

Passivee closuree devicesMynx 20077 to present PEGG-G-hydrogel plug No o intraarterialNoo ntraarteriin

componentPossible e intraarterialPossiblee ntraarterialininjection of sealant

Kern M. The Cardiac Catheterization Handbook, 5th ed

CLOSURE DEVICE ASSOCIATED ARTERIAL STENOSIS

Image courtesy of Susan Whitelaw, RVT

PSV 585 cm/sTAKE HOME POINTS

• Ultrasound is a great modality of choice for evaluation of postprocedural complications

• Dedicated protocol allows consistency of evaluation and prevents missing a diagnosis

• Clinical correlation is important in diagnosis and management

THANK YOU