complications of endovascular procedures - department of surgery … of... · 2016-11-01 ·...
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Complications of Endovascular Procedures
Kate McNamara October 27, 2016
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case presentation
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HPI 66yo Puerto Rican F with several year h/o bilateral claudication p/w worsening LLE rest pain and cool LLE.
PMHx: HTN, HLD, DM, COPD, PVD, schizophrenia
PSHx: flank sebaceous cyst removal
Meds: risperidone, sertraline, lantus, metformin, glucatrol,
enalapril, cardizem, lipitor, singulair, atrovent, aspirin, prilosec
All: sulfa
SocHx: +tob >30pk yrs; lives alone with HHC in AM and children alternate care in afternoons
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VS HR 78 BP 163/81 RR 18
PE LLE cooler than RLE, <1cm dry ulcer lateral left 5th metatarsal, delayed capillary refill L>R pulses b/l DP/PT/pop nonpalpable, palpable b/l fem
Labs 9.29 > 10.8/32.2 < 341 140/5.3/101/19/38/1.18/234 PT 11.2/ INR 1.1
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HD#4 (7/11) bilateral lower extremity angiogram ● severe diffuse disease in left external iliac and common femoral arteries ● severe disease in bilateral superficial femoral arteries
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HD#7 (7/14) cannulation of right femoral artery, attempted recanalization of left external iliac artery ● failed recanalization of left external iliac artery; procedure aborted
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HD#8 (7/15) retrograde angioplasty of left common and external iliac arteries ● stent placement in left common and external iliac arteries • sBP drop following sheath removal • angiogram demonstrated contrast blush at puncture site
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• manual compression • heparin reversed with protamine
• CTA-pelvis no contrast extravasation or retroperitoneal hematoma iliac stent occlusion
• upgraded to SICU
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HD#11 (7/18) left external iliac catheter-directed thrombolysis • 1mg/hr tPA and 3000U/hr heparin • overnight monitoring in SICU
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HD#12 (7/19) thrombectomy of occluded left common and external iliac stents; attempted recanalization of occluded superficial femoral artery • angio jet mechanical thrombectomy of left common and
external iliac arteries • sub-intimal dissection of chronic total occlusion of SFA without
re-entry into true lumen
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• hypotensive (sBP 70s-90s) at induction and persistent
throughout procedure • received 1700cc crystalloid, 1U pRBC without response • started on levophed and brought to SICU
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• CT-head negative for intracranial bleed
• CTA-pelvis negative for extravasation or hematoma
• troponemia cardiology consult; NSTEMI likely demand ischemia
• pan-culture UTI, klebsiella pneumoniae sensitive to ceftriaxone
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HD#13 (7/20)
• weaned off levophed
• extubated
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HD#14 (7/21)
• PE notable for loss of motor/sensation b/l LE
• MRI-spine spinal cord infarct T5 to conus medullaris
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HD#15 (7/22) left AKA • monitored postoperatively in SICU • downgraded to floor Monday 7/25
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HD#19 (7/26) on floor noted with altered mental status;
hypoxic , tachycardic and tachypneic • EKG sinus tachycardia
• CT-head negative for intracranial bleed
• CTA-chest negative for PE
• upgraded to SICU
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• psychiatry consult
– delirium of multifactorial etiology – hold psychiatric meds; haldol prn agitation
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HD#22 (7/29) • downgraded to surgical floor
• persistent leukocytosis (WBC 14-18) • repeat pan-culture UTI; enterococcus faecalis
• CT-abd/pelvis and LLE foci of air in urinary bladder, heterogeneous fluid
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HD#35 (8/11) • code 66 for altered mental status • stroke code for left facial droop
• neurology consult no facial droop, +left NLF flattening
• CT-head negative for bleed or infarct
• upgraded to SICU
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HD#36 (8/12) • code 88 for desaturation intubated
HD#40 (8/16) • palliative consult
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HD#48 (8/24) • terminally extubated and expired
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Questions…??
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endovascular interventions in peripheral arterial occlusive disease
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lower extremity arterial disease
General principles indications for intervention • intermittent claudication • critical limb ischemia
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General principles medical management • risk factor modification
smoking cessation, anti-platelet therapy, BP control, lipid-lowering agents, glucose control
• exercise therapy • pharmacologic therapy for claudication
cilostazol, pentoxifylline
limb amputation versus revascularization endovascular versus surgical revascularization
lower extremity arterial disease www.downstatesurgery.org
General principles endovascular versus surgical revascularization
Lancet. 2005 Dec 3;366(9501):1925-34. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H; BASIL trial participants.
Figure 3: All-cause mortality after bypass surgery and balloon angioplasty Figure 2: Amputation-free survival after bypass surgery and balloon angioplasty
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lower extremity arterial disease
General principles endovascular versus surgical revascularization preoperative considerations • Trans-Atlantic Inter-Society Consensus (TASC)
Guidelines endovascular therapy preferred for type A and B lesions
surgery preferred for type D lesions and
good-risk patients with type C lesions • surgical risk, life expectancy, conduit availability
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lower extremity arterial disease
endovascular therapy • balloon angioplasty
• stenting
• mechanical thrombectomy
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lower extremity arterial disease
complications access site related (1-3%) • arteriovenous fistula • pseudoaneurysm • bleeding/hematoma • thrombosis • dissection • distal embolization
angioplasty site related (1-5%) • arterial rupture • thrombosis • dissection • distal embolization • stent fracture or migration
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lower extremity arterial disease
complications • systemic (<0.5%) renal failure; contrast-related nephropathy (0.2%) cardiovascular (0.2%)
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arteriovenous fistula • incidence
0.006-0.88% • risk factors
female gender, obesity, advanced age, hypertension, anticoagulation/antifibrinolytic, left-sided puncture, low site of puncture, multiple punctures, larger sheath size
• clinical features
symptom onset in few days to few months abnormal vibration sensation, fatigue, new onset or worsened lower extremity
ischemia, high-output heart failure
• diagnosis PE: pulsatile mass, bruit, lower extremity edema duplex US: low resistance flow, mosaic color pattern; arterialization of venous signal
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arteriovenous fistula
management • observation • surgical repair
dissection proximal to distal, division of arteriovenous connection, suture closue of arterial and venous wall defects
• endovascular repair
covered stent or embolization
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pseudoaneurysm • incidence
0.05-8%
• risk factors inadequate compression age >65yrs, obesity, hypertension, hemodialysis, large sheaths,
anticoagulation/antiplatelet, cannulation of SFA
• clinical features symptom onset usually within 24-72hrs pulsatile mass, tenderness, neuropathy, skin necrosis
• diagnosis PE: tender pulsatile mass duplex-US: echolucent pulsatile sac with swirling to-and-fro flow pattern
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pseudoaneurysm treatment
• observation • US-guided compression • US-guided injection of thrombin • open surgical or endovascular repair
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hematoma • risk factors
female gender, age >65yrs, anticoagulation/antiplatelet
• etiology unsuccessful access attempt(s), back wall injury
• clinical features swelling, ecchymosis, pain, neuropathy, hypotension/shock
• management conservative; manual compression, transfusion, hold anticoagulation, bed rest exploration with evacuation
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dissection
balloon angioplasty dissection • high risk lesions are bulky calcified plaque especially proximal SFA, external iliac • overdistention of balloon in normal vessel wire, catheter, or device dissection
arteriography • demonstrates luminal flap with contrast on both sides of dissection
management • low-pressure angioplasty • self-expandable or balloon-expandable stent
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therapeutic subintimal dissection • propagation too far distally results in two lumens
loss of side branches or outflow vessel or potential future surgical anastomotic site • failure to recognize extraluminal position
vessel occlusion or perforation
management • re-entry devices • rarely open surgical correction
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embolization
• prevention by early anticoagulation, identifying high-risk lesions, minimizing manipulation across high-risk lesions
• endovascular rescue with aspiration catheters, embolectomy, mechanical
thrombectomy, or thrombolysis • open surgical thromboembolectomy or bypass warranted for acute ischemia
and unsuccessful endovascular intervention
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perforation wire perforation • risk higher with stiffer wires and small highly diseased vessels • fluoroscopy demonstrates travel outside normal course; wire tip curling;
angiography demonstrates extravasation of contrast • withdraw wire; usually seal with conservative management
angioplasty perforation • overdistension of calcified low compliance vessel atherectomy perforation sheath-related perforation • angiography demonstrates extent of rupture based on extravasation • endovascular options include balloon tamponade, covered stents, coil
embolization • surgical options include interposition grafts, patch closure, bypass
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stent/graft infection • incidence
aortic stent-graft 0.1-0.2% peripheral stent <0.1%
• pathogenesis perioperative contamination, bacteremia, mechanical erosion, contiguous spread
• risk factors procedure-related: emergent operation, extended length, re-operation patient-related: malnutrition, DM, ESRD, malignancy, autoimmune disease, etc
• microbiology S.aureus (25-50%); S. epidermidis and gram negative bacteria
• clinical features extracavitary: inflammation/cellulitis, sinus tract, pseudoaneurysm intracavitary: unexplained sepsis, abdominal distension, ileus
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stent/graft infection diagnosis • ultrasonography, CT/MRI, arteriography
management • device explantation with ex situ bypass • in situ replacement with femoral vein or prosthetic graft • endovascular repair • graft preservation with parenteral antibiotics
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device fracture or embolization
early device fracture/malfunction • fragment retrieval with endovascular snares or forceps • balloon expansion
late device fracture/malfunction • re-intervention
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thrombolysis
• puncture site bleeding/hematoma • retroperitoneal hematoma • intracerebral bleeding • distal embolization
• monitor serial Hct and coagulation studies • CT a/p for drop in Hct and/or hypotension • CT-head for change in mental status and/or hypotension • concurrent heparinization to prevent embolization and rethrombosis • surgical embolectomy or bypass for embolization with persistent ischemia
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Vasc Endovascular Surg. 2011 Jul;45(5):467-9.
Spinal cord ischemia following external iliac artery angioplasty: a case report. Bani-Hani MG1, Friere V, Byrne BE, Plant GR, Moawad MR.
systemic complications www.downstatesurgery.org
spinal cord infarction: anatomy
• anterior spinal artery • posterior spinal artery • radicular arteries
artery of Adamkiewicz
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endovascular intervention in the thoracic and abdominal aorta
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abdominal aortic aneurysms
General principles indications for intervention • symptomatic aneurysm • asymptomatic aneurysm diameter > 5.5cm • asymptomatic aneurysm enlarging ≥ 0.5cm within 6mo
medical management • therapies to limit aortic expansion
smoking cessation, exercise, antihypertensives, statin
• aneurysm surveillance annual ultrasound if <4.5cm and more frequent if larger
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General principles endovascular versus open surgical repair DREAM trial • perioperative morbidity and mortality significantly less for EVAR
(4.6% vs 1.2% and 9.8% vs 4.5%) EVAR1 trial • perioperative mortality significantly less for EVAR (1.8% vs 4.3%) • no difference in overall survival • more frequent graft-related complications with EVAR
OVER Trial • no mortality difference • similar rates of secondary intervention
majority of secondary procedures in EVAR group due to endovascular revisions compared with repair of incisional hernia in open group
abdominal aortic aneurysms www.downstatesurgery.org
General principles endovascular versus open repair preoperative considerations • aneurysm neck
15mm length
• neck angulation ≤ 60 degrees
• iliofemoral access 15mm length CFA diameter ≥ 6mm
abdominal aortic aneurysms www.downstatesurgery.org
descending thoracic aortic aneurysms and thoracoabdominal aortic aneurysms
General principles indications for intervention • symptomatic aneurysm • aneurysm diameter > 6-7cm • aneurysm in setting of genetic syndrome diameter > 5-6cm • aneurysm expansion rate >1cm/yr if <5cm and >5mm/yr if >5cm medical management • risk factor reduction
smoking cessation, anti-hypertensive therapy, statin therapy • surveillance
4-5cm: annual CT or MR angiography 5-6cm: biennial CT or MR angiography
endovascular versus open surgical repair
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Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP; Gore TAG Investigators. J Vasc Surg. 2008 May;47(5):912-8.
• mortality
• major adverse events
Fig 1: freedom from aneurysm-related mortality at 5yrs
Fig 2: freedom from all-cause mortality at 5yrs
Fig 3: Freedom from major adverse events over time
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General principles endovascular versus open surgical repair preoperative considerations • proximal and distal seal zones 20mm length • sufficient arterial access size (≥ 7-8mm)
• preoperative cardiopulmonary evaluation
endovascular repair of thoracic aorta www.downstatesurgery.org
EVAR complications
access site and delivery (9-16%) • dissection • thrombosis • pseudoaneurysm • arteriovenous fistula • hematoma • embolization
endograft (11-30%) • graft deployment and retrieval • graft limb kink or thrombosis • migration • component separation • endoleak
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endoleak
Type I • graft attachment leak; proximal (IA) or distal (IB)
Type II • retrograde blood flow from patent branches (inferior mesenteric, lumbar)
Type III • graft defect; junctional leak/modular defect (IIIA) or fabric defect (IIIB)
Type IV • graft fabric porosity
Type V (endotension) • sac pressurization without direct evidence of endoleak
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aortoenteric fistula
graft enteric fistula versus graft enteric erosion etiology: infection, pulsatile pressure, technical error clinical presentation: hemorrhage, sepsis; herald bleed diagnosis: CT, EGD, angiography versus exploratory laparotomy management: graft excision, in-situ replacement, graft excision and reconstruction with autogenous vein, extra-anatomic revascularization and graft repair, endovascular repair with lifelong antibiotics
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EVAR complications
systemic (3-12%) • cardiac (2-5%) • pulmonary (3%) • contrast-related nephropathy (1-2%) or allergy • ischemic (9%) intestinal, lower extremity, pelvic, spinal dissection, thrombosis, embolism, impingement of vessel origin
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early complications
Category TEVAR, % (No.) Open, % (No.) P
Cardiovascular 15.6 (25/160) 44.3 (31/70) <.01
Pulmonary 15.6 (25/160) 44.3 (31/70) <.01
Renal 8.8 (14/160) 14.3 (10/70) 0.24
Gastrointestinal 6.9 (11/160) 7.1 (5/70) >.99
Neurologic 8.1 (13/160) 14.3 (10/70) .15
Vascular 22.5 (36/160) 40 (28/70) .01
Wound 6.3 (10/160) 4.3 (3/70) .75
Table VI: Morbid events (by category) occurring ≤30 days.
TEVAR complications www.downstatesurgery.org
spinal cord ischemia
• thoracic/thoracoabdominal aortic aneurysm repair is the most common cause
• incidence usually reported 10%
• risk factors include advanced age, cerebrovascular disease, renal insufficiency, prior aortic surgery, more extensive disease, postoperative bleeding, intraoperative hypotension, sacrifice of intercostal vessels
• management strategies to reduce risk include lumbar drainage, reimplantation
of intercostal arteries, intraoperative neurophysiologic monitoring, arterial blood pressure augmentation
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References Rutherford, Robert , Jack Cronenwett, and K. Wayne Johnston. Rutherford's Vascular Surgery. Philadelphia, PA: Elsevier Saunders, 2014. Cameron, John L.. Current Surgical Therapy. Philadelphia, PA: Elsevier Saunders, 2014. Wolf GL1, Wilson SE, Cross AP, Deupree RH, Stason WB. Surgery or balloon angioplasty for peripheral vascular disease: a randomized clinical trial. Principal investigators and their Associates of Veterans Administration Cooperative Study Number 199. J Vasc Interv Radiol. 1993 Sep-Oct;4(5):639-48. Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H; BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005 Dec 3;366(9501):1925-34. Ihnat DM1, Duong ST, Taylor ZC, Leon LR, Mills JL Sr, Goshima KR, Echeverri JA, Arslan B. Contemporary outcomes after superficial femoral artery angioplasty and stenting: the influence of TASC classification and runoff score. J Vasc Surg. 2008 May;47(5):967-74. Rand T1, Lammer J, Rabbia C, Maynar M, Zander T, Jahnke T, Müller-Hülsbeck S, Scheinert D, Manninen HI. Percutaneous transluminal angioplasty versus turbostatic carbon-coated stents in infrapopliteal arteries: InPeria II trial. Radiology. 2011 Nov;261(2):634-42. Rastan A1, Krankenberg H, Baumgartner I, Blessing E, Müller-Hülsbeck S, Pilger E, Scheinert D, Lammer J, Gißler M, Noory E, Neumann FJ, Zeller T. Stent placement versus balloon angioplasty for the treatment of obstructive lesions of the popliteal artery: a prospective, multicenter, randomized trial. Circulation. 2013 Jun 25;127(25):2535-41. Laird JR1, Katzen BT, Scheinert D, Lammer J, Carpenter J, Buchbinder M, Dave R, Ansel G, Lansky A, Cristea E, Collins TJ, Goldstein J, Cao AY, Jaff MR; RESILIENT Investigators. Nitinol stent implantation vs. balloon angioplasty for lesions in the superficial femoral and proximal popliteal arteries of patients with claudication: three-year follow-up from the RESILIENT randomized trial. J Endovasc Ther. 2012 Feb;19(1):1-9. Bani-Hani MG1, Friere V, Byrne BE, Plant GR, Moawad MR. Spinal cord ischemia following external iliac artery angioplasty: a case report. Vasc Endovascular Surg. 2011 Jul;45(5):467-9. Makaroun MS, Dillavou ED, Wheatley GH, Cambria RP; Gore TAG Investigators. Five-year results of endovascular treatment with the Gore TAG device compared with open repair of thoracic aortic aneurysms. J Vasc Surg. 2008 May;47(5):912-8. Schermerhorn ML1, O'Malley AJ, Jhaveri A, Cotterill P, Pomposelli F, Landon BE. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med. 2008 Jan 31;358(5):464-74. Karthikesalingam A1, Holt PJ, Hinchliffe RJ, Nordon IM, Loftus IM, Thompson MM. Risk of reintervention after endovascular aortic aneurysm repair. Br J Surg. 2010 May;97(5):657-63.
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