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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