Arterial Interventions: Findings & Complications - SD

Introduction

Hi, my name is George Bjo,
and I'm director of Vascular Ultrasound Services at
Montefiore Medical Center in New York City.
Today, I will be discussing the use of duplex ultrasound
for evaluation of patients
after the various endovascular
procedures that are performed today.

Today I'll be discussing
the use of duplex ultrasound,
following various arterial interventions
and discussing some of the findings
and complications one might encounter in these patients.

Vascular Complications from Arterial Access

Vascular complications associated
with arterial access have long been recognized to occur
during cardiac catheterizations
and other percutaneous interventional procedures.

With the increase in endovascular procedures, the number
of complications we see in the vascular lab is also
increasing, and I think the vascular lab can play a major
role in terms of evaluating these patients
and predicting the types of follow up
that might be appropriate,
in this,
patient population.

The number of complications
and types of complications really is variable,
but most involve the groin area
as the femoral artery is the access site of choice,
for most interventions.

And these are some of the various,
complications
that one may encounter.

When evaluating these patients,
they can range from hematoma to psdo aneurysm,
arterial venous fistula,
dissection occlusions,
retroperitoneal hemorrhage, athero embolization,
as well as perforation.

And today we'll discuss a little bit
about,
all of these.

In addition,
although,
less common,
patients can,
experience,
complications in the venous side, including hematoma,
superficial thrombo, phlebitis,
as well
as deep vein thrombosis.

Risk Factors for Complications

I think it's,
quite important to understand some
of the risk factors and how they might contribute,
to the potential for complications in these patients.

Anticoagulation status can be an issue in these
patients,
as bleeding can occur at the puncture site
and result in some of the various complications
that have already been discussed.

Obesity,
is an issue in these patients
as accessing the,
femoral artery in an obese patient can be quite a challenge.

The position of the inguinal skin crease,
itself can be misleading due to the foss,
in the skin,
and it's essential to properly
and comfortably position the patient with full view
of the groin site to ensure an accurate puncture site.

Use of larger sheets,
can also result in,
some
of the various complications,
faulty,
puncture technique,
as well
as inadequate manual compression,
can be an issue.

Puncture or inadvertent puncture of the,
superficial femoral artery
or deep femoral artery,
can lead
to some of these complications.

Patients with hypertension,
can also be an issue,
as they're at risk for developing bleeding complications
during,
removal of the sheath.

Administration of anti-hypertensive medication may be
required to maintain a stable blood pressure,
prior,
prior to sheath removal.

To present a,
I'm sorry to prevent a potential,
hematoma,
calcified arteries,
in diabetics or,
atherosclerotic vessels,
may be an issue.

Individuals with diabetes,
typically have small,
diffusely diseased arteries, which often lead
to peripheral vascular disease,
and these patients are at risk for,
potential risk,
for infection.

Patients with extensive,
atherosclerosis have brittle
or fryable arteries that are not only difficult to access,
but can also be at risk for distal,
embolization,
due to calcification.

Simultaneous catheterization of the vein
and arteries puts patients at high risk,
for the arterial venous fistula complication.

In addition to these complications, patients
who have had multiple procedures
and multiple,
multiple femoral artery approaches,
can be a challenge with subsequent procedures
as re-accessing the groin site.

It's not only uncomfortable,
for the patient,
but it can also lead,
or be difficult for the operator
to penetrate the subcutaneous,
layer due to scar tissue,
which may cause sheets to bend or kink,
and then result in,
complications.

By far the most,
common issue is,
puncture technique,
inability
or failure to,
access the vessel at the appropriate location
or using the appropriate,
approach can sometimes lead
to puncture of an adjacent vein
or sometimes,
the need to do multiple punctures,
which in and of itself is a risk factor.

Morbid obesity, again, can be quite an issue
as accessing the femoral artery in these patients,
can be challenging.

Acquiring Patient History

I think it's important,
for the technologist
or sonographer to acquire a history prior
to the performance of the evaluation.

In terms of the type of intervention,
that was performed, was it a coronary
intervention, a peripheral intervention?

Was there access of the artery,
the vein
or a combination of these factors?

The patient's symptoms are quite important.
Is this a local complication
or is the issue remote from the area that has been accessed?

Was there difficult access during the procedure,
whether it be in the groin,
or the arm?

Was there trouble cannulating the vessel
or accessing the vessel or perhaps passing the wire?

These are all important issues.

What is the status of anticoagulation for the patient?
Or is the patient hypertensive?

Were there closure devices used?
Was the,
was there manual pressure or a patch?

In this setting, I think it's very important,
to have a conversation with the nurse
or with the tech indie cat suite in the interventional
suite, or with the physician
to elucidate all of these findings.

I think it's quite critical,
to have all of the,
relevant,
relevant information available to you
before you go in to do that study,
because it will allow you to get all the information
that you need,
to pass on
to the referring physician in order for them
to make the appropriate decisions.

Hematoma

Hematoma is probably the most common,
finding we see
after an interventional procedure.

These patients will often present with matic areas
and discoloration,
secondary,
to bleeding into the subcutaneous tissue,
removing the sheath prior to proper hand positioning.

And,
timely compression can lead,
to the formation
of hematoma, which is simply a collection
of blood within the soft tissues of the upper thigh.

If the bleeding,
from the hematoma is controlled
with manual compression, the hematoma will usually resolve,
very quickly, and as the blood is reabsorbed,
into the soft tissues,
sono graphically, they appear
as in,
encapsulated,
structures.

They,
and again, they typically tend
to resolve spontaneously.

However, when they're large enough,
occasionally surgical drainage,
will be needed,
especially,
when these,
hematomas are infected.

And these are just a couple of sonographic images,
showing the very well-defined
and encapsulated structures,
full
of blood doppler silent,
and this is the typical presentation of a hematoma.

Occasionally, they can be quite large
and much more diffused, covering a much,
larger area of the groin.

As you can see in this image, this is not very well defined
in all and really not encapsulated
again when they're too large.

Occasionally, they will require a surgical drainage.

Pseudoaneurysm

Pseudo aneurysm is the most common injury,
after catheterization,
and especially more common
after interventional procedures,
more common
after interventional procedures than diagnostics,
because larger sheets are used.

What happens here is
that the puncture site does not heal,
and it allows blood into the surrounding tissue,
resulting in a false aneurysm.

In this image here, you can see the native artery
and a fluid,
blood filled sac,
with an extravascular tract that communicates,
with the adjacent artery.

By definition, a pseudo aneurysm patients will often
present with pain and a pulsitile,
groin mass.

Occasionally, you can hear a bruery if you put a
stethoscope,
over the groin site.

It's,
critically important for you to be aware that,
at times, especially in obese patients, you may need
to uncover,
the area where the pseudo aneurysm,
in fact does lie, and you might actually have to lift,
some of the belly in order to access the groin
and get the transducer in the right space.

These,
pseudo aneurysms,
can be treated als
as well as diagnosed in the vascular lab, either
with duplex guided manual compression,
or thrombin injection.

Occasionally if the patient is refractory to those types
of treatments, they'll require surgery.

Some patients can be followed conservatively
as there is a small percentage of these pseudo aneurysms
that will go on to thrombosis,
spontaneously.

As you can see in this image here, here is the native,
femoral artery with a relatively wide neck,
in this case, communicating with an adjacent fluid fill sac.

This type of patient probably would not be a candidate
for thrombin injection and probably not
for duplex guided manual compression based on the
size of the neck itself.

In this case, there really is no discernible neck.

And again, this patient might not be amenable to either
of the,
less invasive procedures.

It might require a surgery,
for treatment.

Arteriovenous Fistula

Arterial venous fistulas are,
not uncommon,
typically resulting from needle punctures to both the artery
and the vein, or when there is right and left.

Catheterization,
bleeding from the arterial puncture may track
into the adjacent venous structures forming in
arterial venous fistula.

These patients,
also at higher risk if there have been multiple femoral
punctures,
a low femoral puncture
or a high SFA stick,
AV fistula,
tend to be small and often resolve spontaneously.

Some of these will present with a continuous murmur.
If you put the stethoscope over the groin or,
or an audible bruery.

If you put your hand over the groin,
you may feel a palpable thrill.

When they're large enough,
they can result in significant arterial
insufficiency or swelling of the limb.

However, in my experience,
we don't see this very often.

Here's an example of a patient
who had a brachial artery stick.

Here we see the brachial artery and the adjacent vein,
and you can see the direct communication
between the artery and the vein.

One of the things that you don't see from this image is the
color flow brew that we often see in patients with fistulas.

But keep in mind, I'll point you here to the fact
that the PRF is is set quite high at 153,
and the reason for that was because we wanted
to identify the communication site.

As you can see now from this image in the same patient,
the PRF has been dropped to 67,
and you can now see the,
color flow brewed
that is often seen in patients,
with arterial venous fistulas.

In addition,
doppler evaluation
of the j the adjacent artery reveals this,
continuous,
forward flow,
throughout the cardiac cycle.

We know that in normal patients in the periphery,
we should see aphasic waveform,
and this finding confirms the presence
of the arterial venous fistula.

Anastomotic Pseudoaneurysms

Occasionally you'll see patients who present with,
anastomotic pseudo aneurysms.

Here's a patient,
who had,
catheterization
with access through the groin, who had previously had,
previously had a,
distal bypass graft.

The patient presented to the vascular lab
with groin pain and swelling,
and this is the image that we acquired at the level of the,
proximal,
anastomosis,
where you can see this large outpouching here.

In fact, the pseudo aneurysm really enveloped,
most
of the proximal anastomosis.

This patient went out to have surgical
repair of that lesion.

Infected Hematomas or Pseudoaneurysms

Patients can sometimes,
present
with infected hematomas or pseudo aneurysms.

The typical presentation is pain
and swelling at the puncture site
with erythema, fever and chills.

This is a patient who had an infected,
hematoma in the groin.

You can see here this pretty,
gnarly looking groin.

This is the corresponding,
duplex image in that patient.

The patient in fact, had to go on,
to the operating room to have that hematoma evacuated.

And this is what,
this is all the,
blood and
and clot that was evacuated from that groin.

False Aneurysms in Dialysis Access

False aneurysms are not uncommon in patients,
with dialysis access.

This is a patient who, in fact,
had a percutaneous transluminal angioplasty
of a subclavian vein with access through,
the dialysis access itself.

The patient presented with pain
and swelling at the puncture site.

This is the duplex image, 2D without color,
and,
you really can't appreciate it.

But what you're seeing here is the,
dialysis access itself with this,
large surrounding,
fluid fill mass.

When you turn the color on, you can see
that some thrombus has formed within the sac itself.

Again, this is the dialysis axis,
and you can see that there's color flow still.

The important thing here is to realize that you can get,
issues not just remote,
from the access site,
but also at the access site itself.

This pulsitile mass over the access site really was the
clue,
in this patient.

Relatively straightforward study,
patients can present
with retroperitoneal hematomas,
typically occurs when there's puncture above the level
of the inguinal ligament.

Retroperitoneal Hematomas

And adequate pressure cannot be applied,
to the puncture site.

In this case, you'll put the transducer down in the groin.

These patients are often referred,
because the hematocrit is dropping, or
because there's been a drop in pressure.

You put the transducer down in the groin,
and the groin appears to be normal.

Keep in mind with the,
with these high puncture sites,
that the,
issue may not be at the puncture site itself.

It could be higher. The bleed could be,
anywhere,
and you'll have to look up higher.

Typically the diagnosis,
for retroperitoneal,
hematoma should be a,
a CT scan.

But occasionally you'll get lucky.

In this case, there's a patient with an,
iliac,
really a,
an iliac artery puncture with a contained,
bleed,
at that level.

And this patient actually went on to thrombosis
with a little bit of duplex guided manual compression.

But again, the diagnosis in these patients,
the preferred diagnostic,
method is a CT scan.

Dissection

Dissection,
can be an issue in these patients.

Some of the predisposing factors include tortuosity,
and the atherosclerosis,
introduction
of the wire can cause sib,
subintimal,
disruption.

And you can have a wire
or a needle that extends into the subintimal space.

In some cases, this is,
very obvious,
although in this,
in these,
two images, really it's not,

you can see here from the,
color flow image
that it appears as if this is just a stenosis at the level
of the puncture site.

So I would caution you in these patients,
where the predisposing factors point toward the possibility
of dissection to just turn the color off
and evaluate the patient with just the 2D.

In this case, you can see this linear structure that
although it's not,
an obvious dissection should point you in
that direction if the risk factors are appropriate.

The key,
question here,
to ask would have been,
did the interventionalist have trouble passing the
wire here?

Really,
another case, same patient,
where the dissection is much more obvious,
based on the two,
the image in this case,

the patient went on,
to get a stent to placate
that dissection and to restore flow in a patient who is,
ischemic thrombotic occlusion,
can sometimes occur.

Thrombotic Occlusion

And this will happen in patients who are under,
I'm sorry, under anticoagulated,
prior,
to their interventional procedures.

It can occur in patients who are receiving larger sheets
or long,
manual compression times
or other occlusive procedures
as the flow in these patients is compromised.

This is,
an image of a patient
who had a femoral popliteal prosthetic bypass graft.

And you can see in this to the image,
that the,
flow
or the presentation is quite normal.

This patient actually had a c clamp placed,
for occlusion after his interventional procedure,
became ischemic.

After the procedure, we went on
to examine this patient afterwards, and there was no doppler
or visual evidence of active blood flow demonstrated within
the lumen of this prosthetic graft, probably
because of the compression from the C clamp.

Atheroembolism

Athero embolism can be an issue,
in these patients,
often happening if a catheter,
because of catheter
or wire induced trauma,
of a fireable plaque,
which leads to distal embolization
and then arterial ischemia, patients may sometimes,
present with bluto syndrome as the small emboli dis,
the small emboli,
pass on
to the very small distal vessels.

There's an increased incidence
of this phenomenon in patients with atherosclerotic aortas
or when curved catheters,
are used.

And this is an image of a posterior tibial artery
with a little bit of athero emboli,
which you can see here is compromising the lumen.

Arterial Perforation

Arterial perforation,
can occur in a subset
of patients and can range from a very minor bleed,
to sometimes major hemorrhage.

I have not really seen this very
often in the vascular lab.

However, if you have occasion to spend a lot of time,
within the interventional suite,
you might in fact encounter this,
complication.

You should be suspicious when the patient complains
of acute severe pain with passing of the wire,
the catheter or the balloon.

But again, in most cases it's the contrast arteriogram,
which will,
cinch the diagnosis.

As contrast injection shows extravasation of blood
outside of the artery.

And again, this is rarely,
diagnosed
by duplex ultrasound.

Closure Devices

Some patients,
will receive closure devices,
and these are being increasingly used,
in order
to shorten length of stay
and minimize the need for,
manual compression.

However, we've seen both short
and long-term complications in these patients,
including infection,
thrombosis and bleeding.

These devices come in various,
different configurations
and,
different occlusion,
techniques from clips
to sutures,
to collagen plugs,
and they'll present,
differently sono graphically.

Here's a patient who actually has a collagen plug,
inserted,
at a puncture site.

And you can see the plug here on the near wall
and also a shadow that's resulting from that.

Here's the color flow image in the same patient.

You can see the intraluminal plug,
really extravascular collagen.

You can see also that there's a little bit
of a slight flow disturbance here generated by the fact
that the lumen has been compromised
and has resulted in an increased velocity here in this case,

in a different kind of a closure device,
a suture type closure device.

Nothing really appreciated by the 2D image.

The flow really has,
been maintained.

No norm, no abnormalities, no significant flow disturbances,
no increases in velocity.

We have experienced complications in these patients.

You can see here thrombus,
by the 2D image forming
around,
the closure device.

And then the color flow image,
really just confirming the suspicion of the 2D image.

You can see that the,
the lumen has been significantly narrowed in this patient.

Venous Complications

Let's talk a little bit about some
of the venous complications that one might experience.

Deep Vein Thrombosis

Deep vein thrombosis is a complication
that can occur in patients who have,
right heart catheterization.

Occasionally we'll see this in patients
after undergoing IVC filter placement
or some of the other various,
venous interventions
that require access into the venous or arterial system.

I located this,
paper,
recently,
and it's the title Thrombosis
of common Femoral Vein After left heart catheterization
and Unusual Complication resulting from application
of a compression device,
a case report
and a review, a review of the literature.

And in fact, this,
particular patient had a fem stop use,
in lieu
of manual compression,
which resulted in,
significant partially obstructive,
deep vein thrombosis.

You have to be careful not only
to look at the arterial structures in the groin,
but also take a quick peek at the venous structures as well.

Thrombo Phlebitis

Currently,
we're offering,
endo venous ablation procedures for the treatment,
the varicose veins.

And one of the,
major complications associated
with this procedure is the potential,
for thrombus formation.

After,
the,
procedure has been completed in this case, you can see here,
thrombus peeking out into the very distal common femoral
vein at the level of the saphenofemoral junction.

And again, you should be,
clued to the potential
for these issues in these patients
and look for them,
on your,
post-procedure studies.

Thrombo phlebitis can be an issue in this patient.

We see a,
thrombosis of the cephalic vein.

In fact, this patient is,
status post thrombolytic therapy of the subclavian vein
through a PICC line
and presented with arm swelling, fever,
and chills
and pain along the cephalic vein distribution.

A duplex scan revealed,
occlusion
and,
dilation of the cephalic vein at the level of the,
puncture site as well
as throughout the level of the upper arm.

Conclusion

So in conclusion,
with the increase in endovascular,
procedures, the number of complications
that we see in the vascular lab,
is also increasing.

I believe that the vascular lab can play a significant
and major role in terms of,
diagnosis of these lesions
as well as,
and follow up in treatment.

I believe the familiarity with the risk factors
and the potential complications is key to the diagnosis,
and always a conversation
with the referring physician will allow you
to better care for your patients.

I'd like to thank you very much for your time and attention,
and I hope this has been helpful.