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Access Site Complications Management
Jennifer R. Buckley, MD; Brandt C. Wible, MD
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KEY FACTS

  • Terminology

    • Procedure

      TERMINOLOGY

      • Definitions

        • Hematoma: Extravascular blood collection from continued bleeding at access site
          • Concern for active bleed → apply pressure
          • Most common minor complication
            • Incidence of up to 5% (but < 1% severe)
          • Extremity: Involving common femoral, brachial, or axillary arteries
            • Small: Subcutaneous perivascular soft tissues
              • Mild discomfort, ecchymosis
              • Self-limited, conservative treatment
            • Large: Extensively involves subcutaneous tissues
              • Severe groin/arm pain, massive swelling
              • May cause limb ischemia, nerve compression, or skin necrosis
              • Drainage vs. endovascular or surgical treatment
          • Retroperitoneal: Extension into retroperitoneal soft tissues of pelvis/abdomen
            • Associated with double wall and high punctures
            • May cause hemodynamic compromise and death
            • Exclude/address possible active bleed
              • Arterial bleed → angiography and embolization
              • Venous bleed → reverse anticoagulants, consult surgery
        • Pseudoaneurysm (PSA): Contained arterial "rupture" at access site
          • Most common major complication
            • Incidence: 0.05-2.00% after diagnostic catheterization
            • Increases to 2-6% when intervention performed
          • Occurs when arterial puncture does not adequately seal
            • Pulsatile blood tracks into and is contained in perivascular space; assumes sac-like configuration
              • Does not contain all 3 layers of arterial wall
            • Connecting tract persists between PSA and feeding vessel (usually common femoral artery)
          • Variable size and severity
            • < 1 cm: May resolve spontaneously
            • > 1 cm: Usually require treatment
              • US-guided compression: 1-4 cm
              • US-guided thrombin injection: 1-6 cm
              • Surgical repair: > 6 cm or after rupture
        • Arteriovenous fistula (AVF): Direct abnormal communication between artery and vein
          • Incidence of up to 0.9%
          • May be isolated or associated with PSA
          • Variable size and severity
            • Small: Up to 1/3 of AVFs may spontaneously close
            • Large: May cause hemodynamically significant left-to-right shunt with associated side effects
              • Surgical repair
              • Endovascular coiling if adequate length
              • Arterial covered stent occlusion for nonsurgical candidates
        • Arterial dissection: Tear in arterial intima, creating false passage for blood
          • Incidence of < 0.5%
          • Variable severity
            • Focal, nonflow limiting: Usually self-resolve
              • Observation, systemic anticoagulation
            • Flow limiting: Can cause arterial occlusion/limb ischemia; require treatment
              • Focal: Prolonged endovascular balloon occlusion
              • Extensive (involving iliac arteries): Endovascular stent placement
        • Vessel thrombosis: Can occur due to dissection, embolization, or in situ thrombus formation
          • Incidence of < 0.5%
          • Variable severity
            • Nonocclusive: Systemic anticoagulation
            • Occlusive: Endovascular thrombolysis vs. open thrombectomy

      PREPROCEDURE

      • Indications

        • Contraindications

          • Preprocedure Imaging

            • Getting Started

              PROCEDURE

              • Procedure Steps

                • Alternative Procedures/Therapies

                  OUTCOMES

                  • Complications

                    • Expected Outcomes

                      Selected References

                      1. Gabrielli R et al: Thrombin injection and compression with removable guidewire in the treatment of postcatheterization femoral pseudoaneurysm. J Cardiovasc Surg (Torino). 57(4):510-3, 2016
                      2. Bechara CF et al: Access site management with vascular closure devices for percutaneous transarterial procedures. Erratum in: J Vasc Surg. 54(5):1556, 2011
                      3. Brueck M et al: Percutaneous transluminal dilatation of inadvertent partial or complete occlusion of the femoral artery caused by Angio-Seal deployment for puncture site closure after cardiac catheterization. J Invasive Cardiol. 22(8):353-7, 2010
                      4. Fornaro J et al: Percutaneous balloon fenestration of flow-limiting iatrogenic dissection of the common femoral artery: report of two cases. J Vasc Interv Radiol. 21(7):1115-8, 2010
                      5. Tsetis D: Endovascular treatment of complications of femoral arterial access. Cardiovasc Intervent Radiol. 33(3):457-68, 2010
                      6. Chan YC et al: Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery? Int J Clin Pract. 62(10):1604-13, 2008
                      7. Webber GW et al: Contemporary management of postcatheterization pseudoaneurysms. Circulation. 115(20):2666-74, 2007
                      8. Krueger K et al: Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients. Radiology. 236(3):1104-10, 2005
                      9. Tsutsumi K et al: Pseudoaneurysm of the brachiocephalic artery. Jpn J Thorac Cardiovasc Surg. 53(2):88-92, 2005
                      10. Onal B et al: Postcatheterization femoral arteriovenous fistulas: endovascular treatment with stent-grafts. Cardiovasc Intervent Radiol. 27(5):453-8, 2004
                      11. Kelm M et al: Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment. J Am Coll Cardiol. 40(2):291-7, 2002
                      12. Ruebben A et al: Arteriovenous fistulas induced by femoral arterial catheterization: percutaneous treatment. Radiology. 209(3):729-34, 1998
                      13. Do DD et al: Unusual pseudoaneurysms after catheterization: successful treatment by ultrasound-guided compression. Ultrasound Med Biol. 23(3):377-80, 1997
                      Related Anatomy
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                      Related Differential Diagnoses
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                      References
                      Tables

                      Tables

                      KEY FACTS

                      • Terminology

                        • Procedure

                          TERMINOLOGY

                          • Definitions

                            • Hematoma: Extravascular blood collection from continued bleeding at access site
                              • Concern for active bleed → apply pressure
                              • Most common minor complication
                                • Incidence of up to 5% (but < 1% severe)
                              • Extremity: Involving common femoral, brachial, or axillary arteries
                                • Small: Subcutaneous perivascular soft tissues
                                  • Mild discomfort, ecchymosis
                                  • Self-limited, conservative treatment
                                • Large: Extensively involves subcutaneous tissues
                                  • Severe groin/arm pain, massive swelling
                                  • May cause limb ischemia, nerve compression, or skin necrosis
                                  • Drainage vs. endovascular or surgical treatment
                              • Retroperitoneal: Extension into retroperitoneal soft tissues of pelvis/abdomen
                                • Associated with double wall and high punctures
                                • May cause hemodynamic compromise and death
                                • Exclude/address possible active bleed
                                  • Arterial bleed → angiography and embolization
                                  • Venous bleed → reverse anticoagulants, consult surgery
                            • Pseudoaneurysm (PSA): Contained arterial "rupture" at access site
                              • Most common major complication
                                • Incidence: 0.05-2.00% after diagnostic catheterization
                                • Increases to 2-6% when intervention performed
                              • Occurs when arterial puncture does not adequately seal
                                • Pulsatile blood tracks into and is contained in perivascular space; assumes sac-like configuration
                                  • Does not contain all 3 layers of arterial wall
                                • Connecting tract persists between PSA and feeding vessel (usually common femoral artery)
                              • Variable size and severity
                                • < 1 cm: May resolve spontaneously
                                • > 1 cm: Usually require treatment
                                  • US-guided compression: 1-4 cm
                                  • US-guided thrombin injection: 1-6 cm
                                  • Surgical repair: > 6 cm or after rupture
                            • Arteriovenous fistula (AVF): Direct abnormal communication between artery and vein
                              • Incidence of up to 0.9%
                              • May be isolated or associated with PSA
                              • Variable size and severity
                                • Small: Up to 1/3 of AVFs may spontaneously close
                                • Large: May cause hemodynamically significant left-to-right shunt with associated side effects
                                  • Surgical repair
                                  • Endovascular coiling if adequate length
                                  • Arterial covered stent occlusion for nonsurgical candidates
                            • Arterial dissection: Tear in arterial intima, creating false passage for blood
                              • Incidence of < 0.5%
                              • Variable severity
                                • Focal, nonflow limiting: Usually self-resolve
                                  • Observation, systemic anticoagulation
                                • Flow limiting: Can cause arterial occlusion/limb ischemia; require treatment
                                  • Focal: Prolonged endovascular balloon occlusion
                                  • Extensive (involving iliac arteries): Endovascular stent placement
                            • Vessel thrombosis: Can occur due to dissection, embolization, or in situ thrombus formation
                              • Incidence of < 0.5%
                              • Variable severity
                                • Nonocclusive: Systemic anticoagulation
                                • Occlusive: Endovascular thrombolysis vs. open thrombectomy

                          PREPROCEDURE

                          • Indications

                            • Contraindications

                              • Preprocedure Imaging

                                • Getting Started

                                  PROCEDURE

                                  • Procedure Steps

                                    • Alternative Procedures/Therapies

                                      OUTCOMES

                                      • Complications

                                        • Expected Outcomes

                                          Selected References

                                          1. Gabrielli R et al: Thrombin injection and compression with removable guidewire in the treatment of postcatheterization femoral pseudoaneurysm. J Cardiovasc Surg (Torino). 57(4):510-3, 2016
                                          2. Bechara CF et al: Access site management with vascular closure devices for percutaneous transarterial procedures. Erratum in: J Vasc Surg. 54(5):1556, 2011
                                          3. Brueck M et al: Percutaneous transluminal dilatation of inadvertent partial or complete occlusion of the femoral artery caused by Angio-Seal deployment for puncture site closure after cardiac catheterization. J Invasive Cardiol. 22(8):353-7, 2010
                                          4. Fornaro J et al: Percutaneous balloon fenestration of flow-limiting iatrogenic dissection of the common femoral artery: report of two cases. J Vasc Interv Radiol. 21(7):1115-8, 2010
                                          5. Tsetis D: Endovascular treatment of complications of femoral arterial access. Cardiovasc Intervent Radiol. 33(3):457-68, 2010
                                          6. Chan YC et al: Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery? Int J Clin Pract. 62(10):1604-13, 2008
                                          7. Webber GW et al: Contemporary management of postcatheterization pseudoaneurysms. Circulation. 115(20):2666-74, 2007
                                          8. Krueger K et al: Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients. Radiology. 236(3):1104-10, 2005
                                          9. Tsutsumi K et al: Pseudoaneurysm of the brachiocephalic artery. Jpn J Thorac Cardiovasc Surg. 53(2):88-92, 2005
                                          10. Onal B et al: Postcatheterization femoral arteriovenous fistulas: endovascular treatment with stent-grafts. Cardiovasc Intervent Radiol. 27(5):453-8, 2004
                                          11. Kelm M et al: Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment. J Am Coll Cardiol. 40(2):291-7, 2002
                                          12. Ruebben A et al: Arteriovenous fistulas induced by femoral arterial catheterization: percutaneous treatment. Radiology. 209(3):729-34, 1998
                                          13. Do DD et al: Unusual pseudoaneurysms after catheterization: successful treatment by ultrasound-guided compression. Ultrasound Med Biol. 23(3):377-80, 1997