Pseudoaneurysm Risk Factors

Female > 70 yrs

Diabetes
Obesity
Low (SFA) stick

Pseudoaneurysmsurgery ?
Leg ischemia
Nerve compression
Large hematoma with skin
compromise
AV Fistula
Suspicion of infection
Anastomotic pseudoaneurysms
Bovine thrombin allergy

Hypotension post-Cath
Differential Diagnosis

Retroperitoneal
hematoma
If suspicion is high, and blood loss
significant, treat before a definitive
diagnosis is made.
Discontinue/ reverse anticoagulation.
CT Scan

Contralateral Access

Surgical Repair

Balloon Tamponade

Retroperitoneal Bleeding
Anemia

100 %

Hypotension

92 %

Abdominal tenderness

69 %

Diaphoresis

58 %

Groin pain

46 %

Low abdominal pain

42 %

Groin hematoma

31 %

Bradicardia

31 %

Back pain

23 %

dented bladder due to retroperitoneal hematoma

Retroperitoneal
Bleeding

Incidence 3.0%
Avoid highCFA arterial puncture
Front-wall puncture desirable
Treat immediately
Volume (PRBC) support
Compression
Balloon tamponade vs surgery

External Compression Devices.

Must be properly positioned
Patient must be compliant
Can make it worse
Closure Devices
Work well
Thrombotic and bleeding
complications
infection

Considerations in PVD
Known aorto-iliac disease or prior
AFB.
Consider brachial or radial access.
Review any previous angiography.
Aorto-femoral graft may be used for
access, avoid retrograde access into
blind limb of iliac artery.

Considerations in PVD
Beware of brachiocephalic
disease in patients with
occlusive aorto iliac disease.
Increased risk of stroke with
catheter manipulation in
tortuous subclavian vessels.

Radial / brachial access: Be careful

with the tortuous of subclavian
artery

Considerations in PVD
Distal SFA occlusive disease is not
contraindication. Enter CFA !!
Take care not to compromise the
patent profunda femoris artery ( only
remaining circulation to the leg.

Brachial access (1)

Cutdown or percutaneous.
Heparin is recommended (?).
Complications similar to femoral access.
* Ischemia, thrombosis, embolization.
* Brachial fossa hematoma (median
n)

Brachial access (2)

Ischemia, thrombosis, embolisation.
* Conservative therapy,
heparization.
* Surgical repair, embolectomy.
* Percutaneous lysis, mechanical
thrombectomy, or balloon
inflation to
tack-up a dissection flap.

Brachial access (3)

Median nerve injury ( 1.0 %).

* Brachial fossa hematoma

compression.
* Nerve injury during access.
* Ischemic nerve injury.

Brachial access (4)

Selective LIMA access from left arm.

Radial access
Successful access 90%.
Normal Allens test required.
Most common failure is inability to
cannulate artery.
Occlusion post PCI approximately 5
%
Associated with fewest major
complications of any access site.

RADIAL ACCESS

Pitfalls
Difficult Access
Hit it on the first try!
diminished (even if transient) pulse:
Wait
Go proximal
Give NTG IV or SL
Have the patient clench/open the hand
Go to another site

IDEAL SITE
2-3 CM proximal to the flexor
crease of the wrist
1 cm proximal to the styloid
bone
Second crease from wrist

MODIFIED ALLEN TEST

Palpate the radial and the ulnar arteries. Obliterate both
pulses with the tumbs and fingers of both hands.

Ask the patient to clench his fist

repeatedly until his palm blanches
white.

Ask the patient to open his palm

Release only the ulnar pulse and

watch
for
the
time
of
reappearance of normal palm
color.

Release only the ulnar pulse and

watch
for
the
time
of
reappearance of normal palm
color.
If color does not return or returns after 7
10 seconds, then the ulnar artery supply
to the hand is not sufficient and the
radial artery therefore cannot be safely
pricked/cannulated.

Inverse Allen Test

Determine the patency of radial
artery
Repeat procedure with the same
radial artery
Similar to Allen Test
Except that the radial pulse is
released instead of the ulnar pulse.

POTENTIAL
DISADVANTAGE
The radial artery is smaller than the
femoral (approximately 2-2.3mm)
Obtaining radial access involves a
learning curve
Smaller sheaths are required
Vessel spasm is more common
Guide placement is more challenging and
requires learning a different technique
Many physicians are not familiar with the
equipment and anatomy, and thus are
reluctant to try a new approach

ADVANTAGE
Dual blood supply which limits the
potential for limb threatening ischemia
Advantageous for patients with severe
occlusive aorto-iliac disease
Advantageous for patients with difficulty
laying/lot (back pain, obesity, CHF)
The vessel is easily compressible
Less chance for local nerve injury
earlier patient ambulation and likely will
cost less (closure devices are not
necessary)
Vascular complications are less frequent

Contraindications
Patients who have evidence of an abnormal
Allen's test
Patients who display evidence of abnormal
oximetry/ plethysmography
Patients who may require IABP.
Patients who may require devices that are not
compatible in 7F or smaller sheaths (TEC, larger
Rotoblator burrs,certain stents).
Patients with known upper extremity vascular
disease.
Patients with Buergers Disease, severe
Raynauds, or other forms of upper extremity
peripheral vascular disease

Difficult Guide Wire Movement

Tortuosity
Spasm
Radial is occluded
Guidewire is in a side branch (usually
too distal in the artery)
Abnormal take off of the radial (off of
the brachial)
Radial artery stenosis
Against the wall or subintimal

Technical Points
Rotate the needle to change the
angle of the bevel
Do a radial angiogram
Use a hydrophilic-coated wire
Try a 0.018 PTCA wire
Give vasodilators (GTN) through the
needle and then try to advance wire

Push guide wire gently/

carefully
& Watch (fluoro) !

Extravasation of contrast seen (arrow) after accidental passage of guide wire

out of small radial artery branch in a patient on eptifibatide, causing a major
arm haematoma. (br = brachial artery, r = radial artery, u = ulnar artery.)

Radial artery anomalies

A

Arrow shows radial loop which the GW was unable to negotiate (A)
Radial artery is of small caliber, making it impossible to pass a
Coronary catheter through it. (br= brachial artery, r = radial artery,
u = ulnar Artery.

Hemostasis
Manual compression.
Mechanical compression device.
Closure devices.
* Angioseal.
* Vasoseal.
* Perclose.
* ETC

Arterial Sheath Removal

(manual)

Immediately after procedure in

diagnostic cases
Delayed removal for PCI
Increased sheath size increases
complications
When ACT < 150s in case heparin
was used
In 2 hrs after stopping bivalirudin
After 6-8hrs of last enoxaparindose
Even longer after fondaparinux

Wrist splint

THANK YOU