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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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Table 13.2 Most common femoral arterial
complications and their management options.
Complication
type
Overall
incidence after
percutaneous
coronary
intervention
(PCI)
Treatment
options
Retroperitoneal
hematoma
0.4–0.74% Hemostasis by
prolonged
balloon
inflation over
extravasation
site
Covered stent
placement
Surgery for
rare selected
cases
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Complication
type
Overall
incidence after
percutaneous
coronary
intervention
(PCI)
Treatment
options
Femoral artery
pseudoaneurysm
(FAP)
2–6% Ultrasound‐
guided
compression
repair
Percutaneous
thrombin
injection
Biodegradable
collagen
injection
Covered stent
placement
Coil
embolization
Surgery
reserved for
very large
aneurysms
Complication
type
Overall
incidence after
percutaneous
coronary
intervention
(PCI)
Treatment
options
Arteriovenous
fistula formation
0.4% Conservative
in
asymptomatic
patients
Ultrasound‐
guided
compression
repair
Arterial
covered stent
placement in
symptomatic
patients
Femoral artery
occlusion
<0.5% Balloon
angioplasty
Catheter‐
directed
thrombolysis
Catheter
thrombectomy
Covered stent
placement
Surgery for
endovascular
treatment
failure
Management of access site bleeding is dictated by its site,
severity, and hemodynamic consequences. In most cases,
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localized femoral bleeding and hematomas can be
controlled with local manual or mechanical compression,
discontinuation of anticoagulants, and in some cases
reversal of therapeutic anticoagulation.
Table 13.3 Risk factors for bleeding complications after
femoral arterial access.
Risk factors for bleeding related to femoral
artery access
Female gender
Age > 70 yr
Body surface area < 1.6 m
2
Renal failure with a serum Cr > 2 mg/dl
Prolonged indwelling sheath time
Larger sheath diameter
Emergent procedures
Larger heparin dose and prolonged heparin infusion
Use of GP IIb/IIIa inhibitors
In the case of GP IIb/IIIa inhibitors, reversal of
anticoagulation requires special considerations. Reversal
can be achieved with platelet transfusions when
abciximab (ReoPro, Eli Lilly, Indianapolis, IN, USA) has
been used, as this agent binds tightly to circulating
platelets but will not affect the activity of normally
functioning transfused platelets. Small molecule platelet
GP IIb/IIIa inhibitors like eptifibatide (Integrilin, Cor
Therapeutics, South San Francisco, CA, USA) and
tirofiban (Aggrastat, Merck, West Point, PA, USA) may
be harder to reverse with transfusion since they act as
competitive, reversible receptor inhibitors and leave
excess free circulating drug that may affect newly
transfused platelets. However, their shorter half‐life will
allow for the antiplatelet effect to cease after about 4
hours compared to 12 hours with abciximab.
Retroperitoneal hematoma or hemorrhage (RPH) is
arguably the most grave access site bleeding
complication. It has an incidence of 0.4–0.74% after PCI
and is associated with significant morbidity and
mortality. Besides the known risk factors for bleeding, a
puncture of the CFA above the middle third of the
femoral head, insertion of the sheath above the inguinal
ligament, and punctures of the back wall are associated
with increased risk of RPH.
It is important to note that RPH remains a clinical
diagnosis and requires a high index of suspicion. Early
symptoms are nonspecific and include back pain, groin
pain, or ipsilateral lower quadrant abdominal
tenderness, followed by relative hypotension,
tachycardia, and hypovolemic shock. The majority of
patients with RPH present within three hours of the
index procedure; therefore, patients presenting in this
window with hypotension should be promptly evaluated
for RPH [13–15].
In cases where bleeding is more severe or
uncompressible, swift endovascular management is
prudent. One of the most fundamental endovascular
skills for management of femoral arterial access site
complications is the “up and over” or “crossover”
technique, which is the mainstay for most endovascular
interventions performed on the femoral artery from the
contralateral side. This will be briefly reviewed here.
Crossover Technique
Step 1. The contralateral CFA is cannulated over the
femoral head using fluoroscopic and ultrasound (US)
guidance, 1–2 cm above the femoral bifurcation and
below the origin of the inferior epigastric artery.
Step 2. A 5 Fr diagnostic internal mammary (IMA) or
Omni Flush (Angiodynamics, Latham, NY, USA) catheter
is advanced over a steerable 0.035″ wire with a floppy tip
– such as a Wholey (Medtronic, Dublin, Ireland) into the
thoracic descending aorta.
Step 3. The steerable wire is pulled back into the
catheter, which is then gently torqued and withdrawn
until its tip engages the ostium of the contralateral
common iliac artery. This can be confirmed by advancing
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the Wholey wire beyond the tip of the catheter and
observing its course before removing it from the body.
Step 4. After confirming normal arterial waveform,
digital subtraction angiography (DSA) of the
contralateral iliofemoral system is performed with the
image intensifier angulated approximately 30°
contralateral to the side of interest.
Step 5. Once the area of bleeding is identified, the wire
is again advanced through the iliofemoral system into
the superficial femoral artery (SFA) or the profunda
artery. The diagnostic catheter is then removed, and the
short femoral sheath is replaced with a long 6 Fr sheath
over the wire, with the tip positioned proximal to the
area of interest.
Retrograde access via the “up and over” technique forms
the basis for most strategies for endovascular
management of access site complications.
Balloon Tamponade, Endovascular
Coiling, and Covered Stent
Placement
In the case of access site bleeding, balloon tamponade is
often sufficient to achieve hemostasis. With a wire across
the area of bleeding and a long sheath tip proximal to the
area of interest, a peripheral balloon sized 1 : 1 to the
vessel is advanced to the area of bleeding and inflated at
6–8 atm in five‐minute intervals, followed by brief (30‐
second) periods with the balloon deflated to allow for
antegrade flow and assess hemostasis. Complete
occlusion of the vessel should be confirmed by DSA from
the contralateral sheath.
If there is persistent bleeding after prolonged balloon
tamponade, one must consider the site of bleeding to
determine the appropriate next step. Bleeding involving
very distal or small branch vessels may be appropriate to
treat with coil embolization. This is achieved by
advancing a guide catheter of appropriate shape (e.g. a
multipurpose, Judkins right, or IMA catheter) to the
vessel of interest, and then advancing a wire followed by
a microcatheter into the vessel. The wire is then
retracted, and 0.014″ or 0.018″ coils are then advanced
through the microcatheter and delivered tightly into the
bleeding vessel. If the bleeding vessel is collateralized,
coils should be delivered both proximal and distal to the
area of bleeding in order to prevent retrograde flow and
continued bleeding (Figure 13.1a–d).
Bleeding involving larger vessels not responding to
balloon occlusion should prompt consideration of a
covered stent‐graft placement. After appropriate
anticoagulation is administered, a covered stent with a
diameter 1 mm larger than the native vessel should be
advanced under fluoroscopy from the contralateral
sheath, with enough proximal and distal landing zones to
ensure adequate sealing. However, careful attention
should be paid to avoid crossing the CFA bifurcation in
order to prevent obstruction of the ostia of the deep
femoral artery (DFA) or SFA. Self‐expanding nitinol‐
framed stent‐grafts are preferred in areas such as the hip
joint near the flexion point of the inguinal ligament, as
they have been shown to have increased fatigue
resistance to bending, crushing, and stretching [16];
however, their longer lengths and less precise
deployment can make their use challenging. Balloon‐
expandable stent‐grafts are available in shorter lengths
and can be more precisely deployed; however, stent
deformation is a concern when they are used near flexion
points.
A completion angiogram should always be performed to
ensure there is cessation of bleeding and patency of the
SFA and DFA, keeping in mind that postdilation of the
stent‐graft may be necessary if there is continued
extravasation. In cases where covered stent‐graft
placement is unsuccessful, or not feasible due to
anatomy (tortuous/calcified iliac arteries, or bleeding
directly at the bifurcation of the CFA), surgical
consultation for open repair should be pursued.
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Femoral Pseudoaneurysms
A femoral PSA forms when a breach of all three layers of
the arterial wall results in a hematoma that remains in
continued communication with the arterial lumen.
Similar to a hematoma, the hemorrhage and resulting
blood collection is contained by the adventitia or
perivascular soft tissue; but unlike a hematoma, there is
continued flow of blood into the PSA sac in systole and
out of the sac in diastole.
Figure 13.1 Bleeding and contrast extravasation (red
arrow) of a small vessel originating from the CFA after
cardiac catheterization (a). Selective cannulation and
angiography of the vessel with a Judkins right catheter
from the contralateral femoral artery (b), followed by
advancement of a coronary wire and microcatheter (c),
and finally 0.14″ coil placement (Axium detachable coils,
Medtronic) (white arrows) (d) with final angiography
showing no residual bleeding.
The reported incidence of femoral PSA ranges from 2%
to 6% after peripheral or coronary interventions, and less
than 0.5% after diagnostic angiography [17, 18]. Larger
bore access, more aggressive anticoagulant and
antiplatelet therapy use, simultaneous ipsilateral femoral
vein and artery catheterization, and lower punctures,
especially when they result in SFA cannulation, are all
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associated with increased risk of PSA formation [19].
PSAs are also more common in women, patients over the
age of 70 years, diabetics, and those with obesity [20].
Clinically, femoral PSAs present with pain, swelling, and
bruising at the site of a recent arterial puncture, and
examination often reveals a palpable thrill or pulsatile
mass. The gravest complication related to femoral PSAs
is rupture, but other complications include persistent
local pain, infection, embolization of thrombus from the
PSA to the distal circulation, or issues resulting from
compression of adjacent structures (e.g. femoral nerve
palsy with femoral nerve compression, or deep venous
thrombosis [DVT] with femoral vein compression).
Duplex US is the preferred modality for diagnosis and
serial evaluation of arterial PSA. The study should seek
to identify the site of origin of the aneurysm from the
parent vessel, the waveform pattern of the inflow and
outflow arterial tree, the size of the aneurysm including
the number of loculations, and the length and diameter
of the aneurysm neck. These anatomic features are
crucial in dictating the appropriate treatment strategy.
Although there is some discrepancy in the published
literature regarding the threshold to undergo treatment,
it is generally accepted that femoral PSAs less than 2 cm
in diameter are excepted to resolve spontaneously and
could be reasonably managed conservatively, though
close follow‐up with serial arterial duplex US should be
performed to confirm resolution.
PSAs larger than 2 cm generally require treatment.
Although traditionally treated surgically, minimally
invasive techniques have become the initial treatment
strategy since 1991 when Fellmeth and colleagues
introduced a minimally invasive approach to thrombose
iatrogenic PSAs by externally compressing the PSA with
US guidance, with a success rate of 93% [21].
Ultrasound‐guided compression repair (UGCR) has
become a widely adopted initial strategy in stable
patients with simple femoral PSAs. Modern series report
technical success rates between 75% and 98% [22–25];
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