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Figure 12.5 (a) Occlusion of distal PT artery and
severe stenosis of distal dorsalis pedis artery. (b)
Lateral view demonstrating poor heel wound
perfusion. (c) The distal PT artery is severely calcified
and was unable to be crossed antegrade with a wire
escalation strategy using an Astato 30 (ASAHI
INTECC CO., LTD.). (d) Severe stenosis of the distal
dorsalis pedis with intact pedal arch supplying the
medial and lateral plantar arches. (e) The pedal arch
was successfully crossed with a hydrophilic Fielder XT
wire (Abbott). (f) Orbital atherectomy was performed
using a 1.25 mm crown CSI catheter. (g) Prolonged
balloon angioplasty was performed across the pedal
arch with a 2.0 mm Advance LP (Cook Medical)
balloon. (h) Final angiography demonstrating
improved perfusion through the arch into the plantar
branches.
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Case Example 2
A 67‐year‐old male with CLI and nonhealing wound of
the right hallux. Angiography demonstrated a densely
calcified long segment occlusion of the proximal AT
with unsuccessful wiring via the antegrade approach
(Figure 12.6a–d).
Figure 12.6 (a) Severe stenoses of the distal AT,
distal PT, and dorsalis pedis with an uninterrupted
pedal arch. (b) The PT stenosis and pedal arch was
wired using Runthrough wire (Terumo) and corsair
microcatheter for support. (c) Prolonged balloon
angioplasty was performed with 2.5 mm Advance LP
balloon (Cook Medical). (d) Final angiography
demonstrating improved perfusion in the PT, pedal
arch, and dorsalis pedis. The intervention enabled a
retrograde approach to the proximal AT CTO.
References
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13
Endovascular Management of
Access Site Complications
Manaf Assafin1, Robert Pyo2, Pedro Cox-Alomar3,
and Miguel Alvarez-Villela
1
1
Division of Cardiology, Albert Einstein College of
Medicine-Montefiore Medical Center, Bronx, NY,
USA
2
Division of Cardiology, Renaissance School of
Medicine at Stony Brook University, NY, USA
3
Division of Cardiology, Louisiana State University
School of Medicine, New Orleans, LA, USA
Introduction
Percutaneous endovascular procedures always begin and
end with the vascular access. Unfortunately,
complications related to the access site are relatively
common and result in additional morbidity to patients
and increased costs to health systems. In the modern era
of increasing procedure complexity, it is imperative for
the interventional physician to be aware of these
complications and understand the basic techniques to
treat or mitigate them. In this chapter, we review the
most common complications associated with vascular
access, describe a variety of endovascular management
options, and discuss the indications for escalation to
surgical management.Arterial access site complications
are common after cardiac or endovascular
catheterization, with the incidence related to procedure
complexity and vascular access bore size [1, 2], and has
been cited as ranging from 1.8% for diagnostic
procedures to 9% for interventional procedures [3].
Recent improvements in procedural technique and
device technology, as well as the increasing utilization of
mechanical support devices, have led to an increase in
procedure complexity and large bore vascular access. It
is therefore prudent for the practicing interventional
operator to be familiar with vascular complications and
their management.
Table 13.1 Common arterial access complications by
access site.
Femoral artery Radial artery
Retroperitoneal Hematoma Radial artery spasm
Femoral Artery Pseudoaneurysm
(FAP)
Radial artery
occlusion
Arteriovenous fistula formation Hematoma
formation
Femoral Artery Occlusion Radial artery
perforation
This chapter will focus on the practical management of
common access site complications after percutaneous
coronary or endovascular interventions. A list of
common complications sorted by arterial access site is
provided in Table 13.1.
Complications Related to Common
Femoral Artery Access
The most common femoral artery (CFA) related
complications include local bleeding, retroperitoneal
hematomas (RPH), femoral artery pseudoaneurysms
(PSA), arteriovenous fistulae (AVF), and lower extremity
ischemia due to thrombosis or embolization. Although
surgical treatment may be possible in nearly all cases of
femoral injury, surgery has been associated with a 25%
postoperative morbidity and 3.5% postoperative
mortality in some series, a risk that reflects the highly
comorbid profile of this subset of patients [4], while
endovascular techniques have in most cases become the
primary approach to the management of these
complications. Table 13.2 lists some of the most common
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femoral arterial complications and their management
options.
Access Site Bleeding
Access site bleeding in patients undergoing percutaneous
coronary intervention (PCI) is the most common
periprocedural complication (2–12%). Several studies
have found major bleeding after PCI to be an
independent predictor of mortality [5–7].
Risk factors for access site bleeding can be categorized
into patient‐related and procedure‐related factors (Table
13.3). Patient‐related factors which increase this risk
include female gender, age > 70 years, a small body
surface area (<1.6 m2), history of heart failure, chronic
obstructive pulmonary disease (COPD), peripheral
vascular disease, triple vessel coronary artery disease,
concomitant shock, and renal failure (sCr > 2 mg/dl) [8,
9]. Procedure‐related factors include large arterial
sheath size (7–8 Fr vs. 6 Fr, 23.5% vs. 13.8%; p < 0.01),
[2] prolonged heparin infusion after PCI [10], delayed
sheath removal [11], emergent procedures, and
periprocedural use of GP IIb/IIIa inhibitors [9, 11],
especially when concomitant heparin administration
leads to supratherapeutic clotting times [8, 12].
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