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Complications in the cath lab and what the team learned from it
Peter A. Schneider, MD
Kaiser Foundation Hospital
Honolulu, Hawaii
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Disclosure
Peter A. Schneider
.................................................................................
I have the following potential conflicts of interest to report:
Scientific Advisory Board (non-paid): Cardinal, Abbott, Medtronic
Royalty (modest): Cook
Co-founder and Chief Medical Officer: Intact, Cagent
Enter patients into studies: NIH, Bard, Gore, Medtronic, BSI,
Silk Road (no financial relationship).
VIVA Board member (nonprofit)
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Complications During Vascular Interventions
Acute Mechanical Complications
• Access site
• Treatment site
• Runoff bed
What Can Happen at These Sites?
• Vessel Rupture/Hemorrhage
• Dissection
• Thrombosis
• Spasm
• Embolization
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XX
xxxx
Access Site: Femoral Artery Pseudoaneurysm
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Femoral Pseudoaneurysm
• Duplex guided thrombin injection
• Duplex guided compression
• Open surgical repair
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Guidance of Puncture Site Placement
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Avoid Retroperitoneal Hematoma
Obtain a Spot Film with the Needle in Place
Puncture site:must be inferior tothe top of the femoral head
Avoid retroperitoneal hematoma
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Half way through the case, she developed severe right leg
ischemic pain. This resolved after removing sheath.
Avoid Puncture Site Thrombosis
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Open Repair: Femoral Artery Dissection
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Lower Extremity Intervention
Causes of Sudden Failure
At the target site
• Dissection/Thrombosis– Clues from angiographic image
• Filling defect
– Check anticoagulation status
– Re-inflate balloon
– Mix TPA
– Aspiration catheter, nitroglycerine
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Anterior tibial artery
dissection after long
segment recanalizationAbove knee popliteal artery
dissection at re-entry site
SFA dissections
Treatment Site: Dissection
Achilles heal of balloon angioplasty=dissection
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Dissection: Rx Options
• Propagation of subintimal tear– Occurs with all angioplasties– Not always clinically significant
• Identify the origin point• How:
– Angiography –• Use Multiple Views• Selective catheter injection• Pull back angiography• Add vasodilators to increase flow• IVUS
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Dissection: Imaging• Intravascular Ultrasound
– Volcano (Volcano Therapeutics, Medtronic)
• 4 French 0.014” probe
– Galaxy 2 (Boston Scientific)
• 40 mHz 0.014” monorail probe
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Treatment Site: Extravasation or Rupture
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When Did Failure Occur?When Did It Fail? Why?
Before PTA Failure to cross
Immediatelyafter PTA
At the PTA site: Usually dissection occasionally thrombosis or perforation
Immediatelyafter PTA
Distal runoff: Could be embolization, spasm, flow phenomenon
After the procedure Could be technical or antiplatelet
Much later Restenosis
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Treatment Site: Rupture
• How bad is it?
Not all perforations are the same
Adventitial staining
Small Perforation
Substantial flow to extravascular tissues
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Treatment Site Rupture: Balloon Tamponade
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Rupture
• First Line Therapy
• Gentle balloon inflation to tamponade
– Consider reversal of anticoagulation
• Second Line Therapy
– In flow balloon occlusion
– Covered Stents (depends on vessel size)
– Balloon Expandable, Self Expanding, Stent-graft limb
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Covered Stents
• EVAR Limbs
• Viabahn
• Icast (Advanta V12)
• Fluency
•
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Iliac Artery Rupture
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Aortic Occlusion Balloon Options
Q 50 Balloon Reliant Balloon Coda Balloon
Max diameter 50 mm 46 mm 32 mm 40 mm
Profile 12 Fr 12 Fr 14 Fr 14 Fr
Shaft 8 Fr 8 Fr 10 Fr 10 Fr
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Rupture of Access Vessel
• Artery on a Stick
J Vasc Surg 2009;49:524-7
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Embolic Agents• Useful for branch
perforations
• Options:
• Platinum coils
• Polymer coated coils
• Plugs
• Gelfoam
• Glue
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Runoff Vessels: Embolization
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This is the case that convinced
me that embolization occurs
more often than we think.
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Embolization
• Embolization with SFA intervention using Doppler
• 60 patients
– 10 PTA alone
– 40 PTA and stenting
– 10 SilverHawk or laser atherectomy
• Emboli noted in every patient during wire crossing, angioplasty, stent deployment and atherectomy
• Embolization was statistically higher during stent deployment vs wire crossing or balloon angioplasty but equivalent to atherectomy
• Clinically significant in only one case
• Findings do not support the routine use of protection devices
J Vasc Surg. 2007 Dec;46(6):1155-9
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EmbolizationTreatment
• Aspiration
– MPA 110 cm 6 & 7F guide
– Export Catheter 6F, 7F (Medtronic)
– Diver Catheter 6F (ev3)
– Rinspiration (ev3)
– Angiojet (Possis)
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Aspiration CatheterExport
6 Monorail
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AngioJet
• Percutaneous mechanical thrombectomy
• Removal of acute clot
• Can be used to delivery pulse spray of thrombolytic agents
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Rescue After Failure
Thrombolytics• No approved drug for thrombolysis in PAD
• TPA most commonly used
– Immediate 4-8 mg
– Infusion 0.5-1.0mg/hr
• Single or dual level infusions
• Concomitant low dose heparin 300-500u/hr via sheath –prevents pericatheter clot
– Retevase, TNKase
– Urokinase
– IIb/IIIa inhibitors
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Embolectomy
Sean Lyden, MD
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• Prevention Emboli Protection
– Percusurge
– Emboshield
– EPI Filterwire
– Accunet
– Angioguard
– SpideRx
EmbolizationAngioguard
AccunetEPI filter
wire
Percusurge
Guardwire
Emboshield
SpideRx
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This is the case that convinced
me to use a filter when
performing atherectomy.
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No flowfull distal filter
Filter
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Lower Extremity Angioplasty:
Causes of Sudden Failure
Distal to the PTA site
• Embolization
– Check anticoagulation status
– Finish work at PTA site
– Place wire across
– Aspiration catheter
– Administer nitroglycerine, thrombolytic
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Runoff Vessels: Thrombosis
• Prevention is key
• Adequate anticoagulation
– Heparin 100units/kg
• Check ACT’s
• Keep >250-300
– IIb/IIIa inhibitors (abciximab, integrilin)
– Thrombolysis-chemical or mechanical
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Vasospasm
• May be difficult to distinguish from emboli and dissection
– Nitroglycerine
• 50-600 mcg– Can give more if delivered infrageniculate
– Papaverine
• 30-60 mg
– Calcium channel blockers
• Verapamil etc
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Complications in the cath lab and what the team learned from it
Peter A. Schneider, MD
Kaiser Foundation Hospital
Honolulu, Hawaii