Pseudoaneurysm Risk Factors

Female > 70 yrsDiabetesObesityLow (SFA) stick

Pseudoaneurysm-surgery ?Leg ischemia Nerve compression Large hematoma with skin compromise AV Fistula Suspicion of infection Anastomotic pseudoaneurysms Bovine thrombin allergy

Hypotension post-CathDifferential Diagnosis

Retroperitoneal hematoma

If suspicion is high, and blood loss significant, treat before a definitive diagnosis is made. Discontinue/ reverse anticoagulation.

CT Scan

Surgical RepairContralateral Access

Balloon Tamponade

Retroperitoneal Bleeding

Anemia100 %Hypotension92 %Abdominal tenderness69 %Diaphoresis58 %Groin pain46 %Low abdominal pain42 %Groin hematoma31 %Bradicardia31 %Back pain23 %

dented bladder due to retroperitoneal hematoma

Incidence 3.0%Avoid highCFA arterial punctureFront-wall puncture desirable

Treat immediately Volume (PRBC) support Compression Balloon tamponade vs surgery

Retroperitoneal Bleeding

External Compression Devices. Must be properly positioned Patient must be compliant Can make it worse

Closure Devices Work well Thrombotic and bleeding complications infection

Considerations in PVDKnown aorto-iliac disease or prior AFB.Consider brachial or radial access.Review any previous angiography.Aorto-femoral graft may be used for access, avoid retrograde access into blind limb of iliac artery.

Considerations in PVDBeware of brachiocephalic disease in patients with occlusive aorto iliac disease.

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

Radial / brachial access: Be careful with the tortuous of subclavian artery

Considerations in PVDDistal SFA occlusive disease is not contraindication. Enter CFA !!

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

Brachial access (1)Cutdown or percutaneous.

Heparin is recommended (?).

Complications similar to femoral access. * Ischemia, thrombosis, embolization. * Brachial fossa hematoma (median n)

Ischemia, thrombosis, embolisation. * Conservative therapy, heparization. * Surgical repair, embolectomy. * Percutaneous lysis, mechanical thrombectomy, or balloon inflation to tack-up a dissection flap.Brachial access (2)

Median nerve injury ( 1.0 %).

* Brachial fossa hematoma compression.

* Nerve injury during access.

* Ischemic nerve injury.Brachial access (3)

Selective LIMA access from left arm.Brachial access (4)

Radial accessSuccessful access 90%.Normal Allens test required.Most common failure is inability to cannulate artery.Occlusion post PCI approximately 5 %Associated with fewest major complications of any access site.

RADIAL ACCESS

PitfallsDifficult Access

Hit it on the first try! diminished (even if transient) pulse: Wait Go proximal Give NTG IV or SL Have the patient clench/open the hand Go to another site

IDEAL SITE2-3 CM proximal to the flexor crease of the wrist

1 cm proximal to the styloid bone

Second crease from wrist

MODIFIED ALLEN TESTPalpate the radial and the ulnar arteries. Obliterate both pulses with the tumbs and fingers of both hands.

Ask the patient to clench his fist repeatedly until his palm blanches white.

Ask the patient to open his palm

Release only the ulnar pulse and watch for the time of reappearance of normal palm color.

Release only the ulnar pulse and watch for the time of reappearance of normal palm color.If color does not return or returns after 710 seconds, then the ulnar artery supply to the hand is not sufficient and the radial artery therefore cannot be safely pricked/cannulated.

Inverse Allen TestDetermine the patency of radial arteryRepeat procedure with the same radial arterySimilar to Allen TestExcept that the radial pulse is released instead of the ulnar pulse.

POTENTIAL DISADVANTAGEThe radial artery is smaller than the femoral (approximately 2-2.3mm) Obtaining radial access involves a learning curve Smaller sheaths are required Vessel spasm is more common Guide placement is more challenging and requires learning a different technique Many physicians are not familiar with the equipment and anatomy, and thus are reluctant to try a new approach

ADVANTAGEDual blood supply which limits the potential for limb threatening ischemia Advantageous for patients with severe occlusive aorto-iliac disease Advantageous for patients with difficulty laying/lot (back pain, obesity, CHF) The vessel is easily compressible Less chance for local nerve injury earlier patient ambulation and likely will cost less (closure devices are not necessary) Vascular complications are less frequent

Contraindications

Patients who have evidence of an abnormal Allen's test Patients who display evidence of abnormal oximetry/ plethysmography Patients who may require IABP. Patients who may require devices that are not compatible in 7F or smaller sheaths (TEC, larger Rotoblator burrs,certain stents). Patients with known upper extremity vascular disease. Patients with Buergers Disease, severe Raynauds, or other forms of upper extremity peripheral vascular disease

Difficult Guide Wire Movement

Tortuosity Spasm Radial is occluded Guidewire is in a side branch (usually too distal in the artery) Abnormal take off of the radial (off of the brachial) Radial artery stenosis Against the wall or subintimal

Technical PointsRotate the needle to change the angle of the bevelDo a radial angiogram Use a hydrophilic-coated wire Try a 0.018 PTCA wire Give vasodilators (GTN) through the needle and then try to advance wire

Push guide wire gently/ carefully & Watch (fluoro) !Extravasation of contrast seen (arrow) after accidental passage of guide wireout of small radial artery branch in a patient on eptifibatide, causing a majorarm haematoma. (br = brachial artery, r = radial artery, u = ulnar artery.)

Radial artery anomaliesArrow shows radial loop which the GW was unable to negotiate (A)Radial artery is of small caliber, making it impossible to pass a Coronary catheter through it. (br= brachial artery, r = radial artery, u = ulnar Artery.AB

HemostasisManual compression.Mechanical compression device.Closure devices. * Angioseal. * Vasoseal. * Perclose. * ETC

Arterial Sheath Removal (manual)Immediately after procedure in diagnostic cases Delayed removal for PCI Increased sheath size increases complications When ACT < 150s in case heparin was usedIn 2 hrs after stopping bivalirudinAfter 6-8hrs of last enoxaparindose Even longer after fondaparinux

Wrist splint

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