Abstract
The proliferation of endovascular surgery for neurosurgical indications has resulted in the need for sincere reappraisal of the pitfalls and complications inherent in these procedures. The first step towards treating a complication is awareness and recognition of the problem. Complications during endovascular procedures can range from those occurring at the site of access to anywhere along the vascular roadmap as a result of the intravascular access. Additionally, the menu of access sites is vast, with possible puncture sites being femoral, radial or directly trans-carotid or even transcranial. This chapter provides a comprehensive list of tips and tricks to recognize, diagnose, manage and most importantly prevent complications from vascular access. The chapter is designed for easy access to material since it heavily relies on tables and figures drawn from the authors’ personal cases. Issues such as groin hematoma, pseudo aneurysm, thromboembolism and nephrotoxicity among others are described in detail along with steps towards complication avoidance. Much of the complications described are common across the spectrum of angiographic procedures in general and the chapter can serve as a resource for interventional cardiologists, radiologists and vascular surgeons.
Keywords
endovascular complications, groin hematoma, access site complications, retroperitoneal hematoma, transfemoral approach, closure device, contrast nephropathy, pseudoaneurysm
Highlights
- •
Obtaining, maintaining, and exiting the vascular portal of entry in a safe and efficient manner are essential to achieve the goal of diagnosis and treatment of cranial, spinal, and head-neck neurovascular diseases.
- •
Transfemoral/groin access represents the most common route for endovascular access in vascular neurosurgery.
- •
Access-related complications are categorized as bleeding, pseudoaneurysm, infection, and other arterial abnormalities.
- •
A standard regimental approach to complication avoidance is the secret to successful outcome.
Introduction
The field of vascular neurosurgery has been enriched by significant advances in endovascular technology and techniques. Despite rapid evolution, certain basic tenets remain sacrosanct. Chief among them is the art and science of safe vascular access. Obtaining, maintaining, and exiting the vascular portal of entry in a safe and efficient manner are essential to achieve the goal of diagnosis and treatment of cranial, spinal, and head-neck neurovascular diseases. Catastrophic complications can arise, and access-related complications should never be underestimated or viewed with hubris. The present chapter provides a concise overview of the nuances for safe access for each of the various endovascular access routes.
Access-Related Complications
Access-related complications (ARC) should be considered if related to any of the following:
- 1.
Injury at access site:
- a.
Femoral
- b.
Radial
- c.
Brachial
- d.
Carotid
- e.
Vertebral
- f.
Transorbital
- g.
Transcranial access
- a.
- 2.
Device navigation along vascular roadmap to the lesion
- a.
Thoracoabdominal aortic
- b.
Arch of aorta
- c.
Carotid arteries
- d.
Vertebral arteries
- e.
Intracranial arteries and veins
- a.
- 3.
Intracranial target lesion access
- a.
Access to aneurysm
- b.
Access to arteriovenous malformation/dural fistula
- c.
Tumor access
- a.
- 4.
Contrast-induced nephropathy
Femoral Access
Transfemoral/groin access represents the most common route for endovascular access in vascular neurosurgery. The large size of the artery that allows placement of large devices in co-axial fashion for a stable construct, location over the femoral head that allows compressibility, situation away from the fluoroscopy arms, and a long history of operator familiarity are main factors for this preference. Most devices available for intervention are configured and optimized for femoral access. Spinal angiography and intervention are almost always carried out via the transfemoral route. Complications from femoral access have been documented to occur in 1.6% to 6.0% of patients in the literature but can be minimized with proper precautions. Complications are categorized as follows:
- 1.
Bleeding
Groin hematoma
Retroperitoneal hematoma
- 2.
Pseudoaneurysm (PA)
- 3.
Other arterial abnormalities (arteriovenous fistula, acute thrombosis, dissection, distal embolism)
- 4.
Infection
Bleeding
Minor hematomas at the puncture site are common and do not necessarily represent complications. Major hematomas may occur either in the groin or retroperitoneum and represent difficulty with hemostasis. Risk factors for hematoma formation are:
- a.
Obesity
- b.
Puncture above inguinal ligament (high puncture)
- c.
Advanced atherosclerotic disease
- d.
Dual antiplatelet therapy (DAPT)
- e.
Anticoagulation
- f.
Uncontrolled hypertension
- g.
Large sheath
- h.
Rough catheterization of circumflex branch (and rupture)
- i.
Backwall puncture
- j.
Inability to deploy closure device
- k.
Inadequate rest before ambulation
A major hematoma manifests with increasing local pain, swelling, and bruising, along with declining hematocrit in the few hours post-procedure. However, a retroperitoneal hematoma is more treacherous because there is no external swelling. The only external sign sometimes is ipsilateral flank bruising. Typically with retroperitoneal hematoma, there is an initial transient episode of hypotension that improves with a fluid bolus; if left undiagnosed, it can lead to dangerous and rapid hemodynamic collapse.
Diagnosis
A high index of suspicion is needed to diagnose a retroperitoneal hematoma. Close attention to clinical examination and prompt serial hematocrit estimations are important. Ultrasound is helpful with a thigh hematoma in ruling out expanding PA. Definitive diagnosis of retroperitoneal hematoma requires computed tomography (CT) imaging.
Management
Many hematomas may not require surgical evacuation. Maintaining stable blood pressure and adequate circulatory status is paramount. Serial hematocrit estimation guides transfusion, and packed red cells should readily be available. It is prudent to obtain early vascular surgery consultation if a patient is being admitted for hematoma management. With active extravasation (which sometimes can be seen on contrast-enhanced CT) and impending cardiovascular collapse, vascular surgical intervention is indicated. Anticoagulated patients and those on DAPT pose a unique dilemma. Procedural anticoagulation usually reverses spontaneously in few hours. Reversal of chronic anticoagulation depends on the primary diagnosis for which this is indicated and should be undertaken on a case-by-case basis. DAPT patients tend to be more problematic due to difficulty in reversing platelet dysfunction and, more importantly, the fact that DAPT is indicated for recent intracranial or coronary (or other intravascular) stent. Placement of a covered stent across the site of leakage is an endovascular option in select cases.
Prevention
Though theoretically longer durations of bed rest might reduce bleeding, clinical studies have proven that a 2-hour bed rest period post sheath removal is adequate. One study used manual compression for hemostasis after use of 5 Fr sheaths in the majority of the 295 patients evaluated. Close attention to steps involved in femoral access is mandatory to prevent complications (see “ Complication avoidance ”).
Pseudoaneurysms
A hematoma that occurs in the vessel wall and is in communication with the arterial lumen can become PA. Clinical presentation is with an enlarging firm mass that is pulsatile and may have a bruit on auscultation. Some degree of pain/discomfort may be seen. PA typically becomes evident after 48 hours. Some authors describe simple (one lobe) and complex (more than one lobe) PA. Whether use of a closure device in lieu of manual compression increases PA risk is debatable based on recent metaanalyses versus those from a decade ago. Other risk factors include high puncture, large sheath, and puncture below bifurcation in superficial femoral artery.
Diagnosis
Duplex ultrasound (US) is the imaging modality of choice. PA neck, lobe(s), dimensions, and parent artery lumen communication are clearly visualized.
Management
Small PAs frequently do not require treatment, but occasional lesions progressively enlarge. Treatment modalities are delineated in Table 39.1 .
| Treatment | Advantages | Concerns |
|---|---|---|
| Ultrasound-guided manual compression |
|
|
| Ultrasound-guided thrombin injection |
|
|
| Covered stent |
|
|
| Open surgical repair |
| Major surgical procedure |
The most common technique (including at our center) is thrombin injection because it is quick, highly effective, a bedside procedure, and largely safe. It may be prudent to repeat a US in 1 to 2 weeks to rule out recurrence.
Other Femoral Artery Complications
Arterial thrombosis, dissection, and distal embolism are rare complications that present with pain, paresthesias, and diminished or absent pedal pulses. Thrombosis risk is strongly correlated with leaving the sheath in for prolonged duration post procedure. Risk factors include puncture below bifurcation of common femoral artery, large sheath placement, inadequate flush of heparinized saline, severe atherosclerosis, and rough technique. Arteriovenous fistula is recognized by characteristic thrill and bruit and usually presents in a delayed fashion. US guidance to avoid the femoral vein and tributaries during arterial puncture and avoiding a simultaneous femoral vein puncture (when required) on the same side may help avoid this complication. It is imperative to recognize these potentially limb-threatening complications early and involve vascular surgery expeditiously for open or endovascular intervention. The imaging modality of choice to document these complications is duplex US. Early recognition and management leads to good outcomes.
Complication Avoidance
At our institution, all diagnostic angiography–related access is treated with a “nuclear launch code” protocol. Fluoroscopic confirmation of femoral head location is performed with a localizer (hemostat), and puncture occurs over this site ( Fig. 39.1A–C ). We use ultrasound to mark the bifurcation of the common femoral artery (into superficial femoral and profunda femoris artery), and we puncture above this point but still over the femoral head ( Fig. 39.2D–G ). Continuous heparinized saline flush is run through the sheath for the duration of the procedure. Invariably we endeavor to remove the femoral sheath on the table after the conclusion of the procedure. Femoral arteriography is performed before sheath removal. Particular attention is paid to puncture site vis-a-vis the bifurcation, location of puncture site (= sheath entry site) with respect to the femoral head, dissection, or thrombosis. Decision regarding closure device deployment proceeds as described later, after ensuring that the puncture is above the bifurcation.
Closure Device Use
Vascular closure devices are approved for femoral access closure and are currently available under various categories:
- i.
Collagen plug–based (Angio-Seal, Terumo, Somerset, NJ)
- ii.
Suture based (Perclose Abbott, Abbott Park, IL)
- iii.
Clip based (StarClose Abbott, Abbott Park, IL)
The advantages and disadvantages of using a closure device for femoral access are described in Table 39.2 .
| Advantages | Disadvantages |
|---|---|
| Shortens bed rest | Potential vessel occlusion/thrombosis |
| Less intense physician/nurse involvement | Dissection/PA risk may be greater |
| Cost benefit by reducing stay and personnel requirement | Infection |
| Potentially less incidence of hematoma formation | Cost |
Closure device deployment also follows a strict set of rules:
- i.
Confirm location of puncture above common femoral artery bifurcation ( Fig. 39.3 )
Fig. 39.3
Ideal puncture site (horizontal arrow) is over the femoral head (asterisk) and above the bifurcation (vertical arrow) for deployment of closure device.
(Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved.)
- ii.
Repeat prep and draping of groin site
- iii.
Change of gloves by team
- iv.
Prophylactic antibiotics before insertion
- v.
Confirmation of intravascular placement
- vi.
Avoidance of closure device deployment in certain situations:
- a.
Puncture at/below bifurcation (higher risk of dissection)
- b.
Severe calcified atherosclerotic disease
- c.
Small artery size
- d.
Immunocompromised patient (infection risk)
- e.
Access through bypass graft
- a.
Infection of a closure device can be a severe complication and most commonly occurs in immunocompromised populations. It can potentially lead to vessel rupture in addition to bacteremia and sepsis. Treatment often involves open surgical resection and grafting and prolonged IV antibiotic therapy, but outcomes may not be satisfactory.
Related posts:
Medical Complications in Neurosurgery
Cerebral Vasospasm: Complications and Avoidance
Complications of Surgery for Pineal Region Tumors
Thalamic and Insular Tumors : Minimizing Deficits
Complications of Surgery for Peripheral Nerve Injuries and Tumors
Complications of Surgery for Intrinsic Spinal Cord Tumors
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