Management of Vascular Complications following Femoral Artery Catheterization with and without Percutaneous Arterial Closure Devices

Percutaneous arterial closure devices allow earlier mobilization and discharge of patients after arterial catheterization than with manual compression for puncture site hemostasis. We reviewed our recent experience managing the complications of femoral artery catheterization with and without these devices on the vascular surgery service at a tertiary hospital. Thirty-one patients presenting over an 18-month period with complications after femoral artery catheterization with manual compression (n = 21) or percutaneous arterial closure devices (n = 10) were retrospectively reviewed.     

The use of closure devices

The use of arterial closure devices offers significant benefits over manual compression in achieving groin hemostasis following catheter-based procedures. Several currently available devices provide rapid puncture site closure with complication rates similar to that of manual compression. Closure devices allow for early times to ambulation and hospital discharge, and have a high degree of patient satisfaction. Their use may be of particular benefit inpatients that are anticoagulated. We believe that their use should be strongly considered in all patients following femoral artery catheterization.     

Infectious complications resulting from use of hemostatic puncture closure devices

BACKGROUND: Femoral access site complications have increased as the fields of invasive cardiology, radiology, and endovascular surgery have emerged. In order to address one of these complications, hemorrhage, the hemostatic puncture closure devices were developed. METHODS: Retrospective review of cardiac catheterizations performed at a single institution to investigate infectious groin complications related to use of the Perclose Prostar and Techstar devices. RESULTS: Infectious groin complications were significantly higher in the Perclose group as compared with manual compression. Three patients had clinical and laboratory evidence of arterial infection whereas 2 had soft tissue infections. All 5 required operative intervention ranging from incision and drainage to arterial reconstruction. Hemorrhagic complications were not significantly different between the two groups. CONCLUSIONS: The Perclose devices provide hemostasis after femoral artery catheterization similar to manual compression. However, infectious groin complications appear to be more common with these devices.     

Femoral artery infections associated with percutaneous arterial closure devices

Hemostasis obtained by manual compression after femoral artery catheterization results in consistently low rates of major complications. A rare complication of femoral artery catheterization is arterial infection. Its occurrence after diagnostic angiography using manual compression has not been reported. We report two cases of femoral arterial infection after uneventful diagnostic catheterization in nonimmunocompromised patients using the Perclose percutaneous arterial closure device. Our cases are representative of Perclose associated infections, with delayed presentation of a staphylococcal arterial infection requiring arterial debridement and reconstruction. This article indicates that Perclose use carries a risk of severe arterial infection. Surgeons should be aware of the potential infectious complications associated with Perclose use and the need for aggressive treatment.     

Complications associated with the arterial puncture closure device--Angio-Seal

BACKGROUND: Arterial puncture closure devices (APCD) are frequently used after cardiac catheterization. Here, the diagnosis and therapy of femoral artery complications after the use of the Angio-Seal APCD is reported. PATIENTS AND METHODS: The Angio-Seal APCD was deployed in 1600 patients undergoing transfemoral catheterization. RESULTS: In 7 of 1600 cases (0.4%) vascular complications occurred following Angio-Seal deployment. Diagnosis was made by duplex sonography. Intraoperative findings consisted of a complete occlusion with dissection of the femoral artery in all patients. In 6 cases, the femoral bifurcation had to be reconstructed after endarterectomy. Follow-up is complete with a mean of 6 months. CONCLUSION: The Angio-Seal device should not be used for closure of the superficial femoral artery and in patients with severe arteriosclerosis. The application of arteriography as well as the use of ultrasound-guided puncture is advisable. In all cases, surgical intervention was successful and an adequate therapy for management of complications.     

Groin Infection Caused by a Percutaneous Femoral Artery Closure Device: Report of a Case

Hemostasis after femoral artery catheterization is generally achieved by manual compression, which results in a low incidence of infection at the puncture site. Percutaneous femoral artery closure devices have recently been used to prevent bleeding complications, shorten the hospital stay, and reduce the patient's discomfort. However, they have been associated with infectious complications, necessitating surgical intervention, such as patch angioplasty or arterial bypass; the treatment depending on the damage to the artery and the type of device used. Thus, the possibility of infection should be kept in mind when employing these devices. We report a case of groin infection associated with one such device, known as The Closer, which was successfully treated by drainage and removal of the suture material.     

Femoral artery occlusion with a percutaneous arterial closure device after a routine coronary angiogram: a case report and literature review

Groin vessels are most commonly used to obtain vascular access for angiography because of their size and accessibility. Haemostasis at the puncture site can be achieved with manual compression alone or by using a vascular closure device. We highlight the case of a 68-year-old woman who developed acute claudication in the right leg after a routine diagnostic coronary angiogram when an Angio-Seal(?) device had been employed to close a relatively low arterial puncture. On exploring the common femoral artery, fragments of the device were found occluding the bifurcation. A patch angioplasty was carried out and the patient's claudicant symptoms improved. The Angio-Seal(?) device has a polylactide and polyglycolide polymer anchor, a collagen plug and a suture contained within a carrier system. Haemostasis is achieved by compressing the arterial puncture site between the anchor and the collagen plug. The manufacturer's recommended criterion for using the device safely permits its use only for common femoral artery punctures with an internal vessel diameter of 4mm. Anatomical confirmation of the puncture site and evidence of any arterial disease or stenosis in the artery is detected on fluoroscopy during the procedure. Recent meta-analyses have cast doubt on the assumption that vascular closure devices are superior to mechanical compression alone and serious complications do occur occasionally but are under-reported. Clinicians should be aware of the potentially serious problems that may occur when deciding to employ vascular closure devices, especially with an anatomically low puncture site.     

Surgical complications from hemostatic puncture closure devices

BACKGROUND: For securing immediate hemostasis following percutaneous arterial catheterization, the Food and Drug Administration has approved three hemostatic puncture closure devices. We reviewed our institutional experience with one device (Angio-Seal). METHODS: A retrospective, single-center, nonrandomized observational study was made of all vascular complications following femoral cardiac catheterization. RESULTS: An immediate mechanical failure of the device was experienced in 34 (8%) patients. Surgical repair was required in 1.6% (7 of 425) of patients following Angio-Seal versus 0.3% (5 of 1662) following routine manual compression (P = 0.004). In 5 patients, the device caused either complete occlusion or stenosis of the femoral artery. The polymer anchor embolized in 1 patient and was retrieved with a balloon catheter at surgery. CONCLUSION: During the first year of utilization of a percutaneous hemostatic closure device following cardiac catheterization, we observed a marked increase in arterial occlusive complications requiring surgical repair. Surgeons must be familiar with the design of these devices to achieve precise repair of surgical complications.     

Changing patterns of access site complications with the use of percutaneous closure devices.

The authors report their experience with 15 cases of groin complications associated with the use of percutaneous closure devices following femoral arterial catheterization over a 2-year period. The complication rate was 1.7% for catheterizations in which a closure device was used. The 15 cases included 7 uncomplicated pseudoaneurysms (PSA), 3 infected pseudoaneurysms, 4 nonarterial groin infections (infected hematomas and/or abscesses), and 1 case of femoral artery occlusion. These complications presented at an average of 5 +/- 4 days postcatheterization. One patient with an infected PSA required a below-the-knee amputation. During the same time interval, there were no infectious complications in patients not receiving closure devices. We conclude that groin complications associated with such devices tend to present late and include a higher percentage of infections as opposed to complications occurring in patients not receiving closure devices. An aggressive surgical approach to these problems appears warranted.     

The use of the Angioseal device for femoral artery closure

BACKGROUND: As vascular surgeons perform increasing numbers of percutaneous catheter-based procedures, they will need to become familiar with varying methods of femoral artery closure. Few studies on closure devices have included significant numbers of patients with peripheral arterial disease. It is the purpose of this study to determine whether the Angioseal device (St. Jude Medical) is a satisfactory method of achieving femoral artery puncture site hemostasis in these patients. METHODS: The records of all patients undergoing Angioseal closure of femoral artery puncture by a single vascular surgeon were reviewed. Indication, type of intervention, and size of the vascular sheath employed were recorded. Times to mobilization and discharge were determined. Patients were seen before discharge and 1, 4, and 12 weeks after the procedure, and at 3- month intervals thereafter. Complications including hemorrhage, pseudoaneurysm, infection, and vessel occlusion were noted. RESULTS: Between February 1, 2002, and August 31, 2003, 220 Angioseal collagen plugs were deployed in 188 patients. Attempts were made to deploy Angioseal devices in 92% of patients undergoing percutaneous procedures during this time period. One hundred forty-four procedures were diagnostic and 74 procedures included 76 therapeutic interventions. One hundred forty-four 5F sheaths, 47 6F sheaths, and 29 7F sheaths were employed during the procedures. Time to mobilization and discharge was 58 +/- 19 minutes and 102 +/- 31 minutes in patients undergoing diagnostic studies, 68 +/- 22 minutes and 146 +/- 42 minutes following interventions using 6F sheaths, and 127 +/- 18 minutes and 219 +/- 37 minutes when interventions were performed using 7F sheaths. No patient developed a major hematoma or infection following the use of an Angioseal. There were 2 complications related to device deployment. One patient developed a 1.4-cm false aneurysm at the femoral artery puncture site that resolved spontaneously. A second patient required operation for vessel occlusion when an Angioseal was deployed in a markedly diseased femoral artery. These adverse events occurred early in our experience. CONCLUSIONS: The Angioseal provides a secure method of achieving hemostasis following femoral artery puncture. It is easy to deploy, has a high level of patient satisfaction, and allows for early ambulation and hospital discharge. When simple guidelines are observed, the device can be safely used in the great majority of patients with peripheral vascular disease. It offers considerable advantages over the traditional method of manual compression.     

The management of peripheral vascular complications associated with the use of percutaneous suture-mediated closure devices

PURPOSE: The purpose of this study is to identify the peripheral vascular complications associated with the use of percutaneous suture-mediated closure (PSMC) devices and compare them with postcatheterization femoral artery complications not associated with PSMC devices. METHODS: This is a retrospective review of all patients admitted to the vascular surgery service at the Chattanooga Unit of the University of Tennessee Department of Surgery with a peripheral vascular complication after percutaneous femoral arteriotomy between July 1, 1998, and December 1, 1999. The complications followed the use of PSMC devices (group I, n = 11) and traditional compression therapy (group II, n = 14) to achieve arterial hemostasis. Group II was subdivided into patients who required operative intervention (group IIA, n = 8), and those who were treated without operation (group IIB, n = 6). RESULTS: No significant difference was found between groups I and II with regard to age (P =.227), time to vascular surgery consultation (P =.987), or diagnostic versus therapeutic catheterization (P =.897). A significant difference was found with regard to mean pseudoaneurysm size (group I = 5.9 cm, group II 2.9 cm; P =.003). Ultrasound compression was successfully performed in 66.6% of group II patients, but no (0.0%) patient in group I responded to this therapy (P =.016). Groups I and IIA had a significant difference for mean estimated blood loss (group I = 377.2 mL, group II = 121.8 mL; P =.017) and requirement for transfusion (P =.013). More patients in group I required extensive surgical treatment (P =.007), with six of these patients requiring vein patch angioplasty during their treatment. More patients in group I also had infectious complications (n = 3) compared with group IIA (n = 1). CONCLUSION: In comparison with complications that follow percutaneous arteriotomy when PSMC devices are not used for hemostasis: (1) pseudoaneurysms after the use of PSMC devices are larger and do not respond to ultrasound compression, (2) complications associated with PSMC devices result in more blood loss and increased need for transfusion and are more likely to require extensive operative procedures, and (3) arterial infections after the use of PSMC devices are more common and require aggressive surgical management.     

Blood flow velocity in the femoral artery 1–3 years after catheterization. A prospective study in neonates and children

During the period 1987–1989 femoral artery cannulations were performed in 95 patients of whom 74 were neonates. Catheter sizes were 24 G (n= 28), 22 G (n= 54) and 20 G (n= 13). Median indwelling time was 3 days (range: 1–13 days). Catheter removal was due to perfusion related symptoms in 12 cases, malfunction in 16 cases and because they were no longer needed in 67 cases. One to three years after the catheterization event the systolic peak flow velocity in the femoral artery was analysed with a Doppler sonography system in 28 neonates and in 6 older children. Measurements were performed where the external iliac artery ascends from the pelvic fossa (proximal site) and in the common femoral artery which was considered to be the site for catheter introduction (puncture site). In the neonatal group (n= 28), there was a significant increase in the peak flow velocity at the puncture site in the catheterized leg (P < 0.05), as well as a signficant increase in the quota of the puncture and proximal site values in the catheterized leg (P < 0.05). In the catheterized leg, the peak flow velocity at the puncture site correlated positively with the length of the indwelling time (r= 0.467, P < 0.01). It is concluded that the use of the femoral artery for intra-arterial monitoring in neonates and children is clinically a safe method. The findings of peak systolic velocity may indicate damage to the vessel and/or adjacent vessel tissue present 1–3 years after the catheterization event.     

Ischemic complications of percutaneous femoral artery catheterization

Ischemic injuries following percutaneous femoral artery catheterization are uncommon but have been associated with vascular closure devices (VCDs). The purpose of this study was to retrospectively compare ischemic and hemorrhagic complications of femoral artery catheterization and to identify factors associated with ischemic injuries. The operative registries of the attending vascular surgeons at one academic and two community hospitals were retrospectively reviewed to identify all complications of femoral artery catheterization requiring operative intervention. Demographic, clinical, procedural, operative, and outcome data were compared between patients who sustained ischemic and hemorrhagic complications. From January 2001 to December 2006, 95 patients required operative management of complications related to femoral artery catheterization including 40 patients who experienced ischemic (group 1) and 55 patients who experienced hemorrhagic (group 2) complications. Compared to those sustaining hemorrhagic complications, ischemic complications were more frequently associated with younger age, smoking, VCD deployment, and, when controlling for VCD use, female gender. Time to presentation was also significantly longer in patients experiencing ischemic complications. Ischemic complications are increasingly recognized following femoral artery catheterization. Vascular surgeons should anticipate a new pattern of injury following femoral artery catheterization, one that often requires complex arterial reconstruction.     

掌上无线超声引导桡动脉穿刺置管的护理配合

目的 总结掌上无线超声引导桡动脉穿刺置管的护理配合要点。 方法 对51例患者采用掌上超声定位桡动脉穿刺置管,护理配合包括患者准备、仪器及耗材等准备,Allen试验评估,穿刺中配合医生摆放穿刺体位、进行桡动脉穿刺配合,穿刺后护理及常见并发症处理等。 结果 51例均完成置管,其中一次穿刺成功44例（86.28%）,1例5次穿刺成功患者出现穿刺处血肿,其余患者未发生感染、血管痉挛、动脉血栓、神经损伤等并发症。 结论 高效、规范的护理配合可提高掌上无线超声引导桡动脉穿刺置管成功率,减少并发症。     

医源性股动脉假性动脉瘤的超声诊断与治疗

目的评价彩色多普勒超声在医源性股动脉假性动脉瘤诊治中的价值。方法对13例股动脉插管术后穿刺部位触及搏动性肿物、闻及血管杂音的患者,采用Philipsiu22彩色超声诊断仪进行二维、彩色多普勒、频谱多普勒超声检查,观察其大小、形态、内部回声及血流形态、频谱特征,对明确诊断者,在超声引导下进行压迫。结果13例临床上高度怀疑假性动脉瘤形成的患者均通过彩色多普勒超声检查明确诊断,且在超声引导下进行压迫,成功闭合动脉破裂口。结论彩色多普勒超声是医源性股动脉假性动脉瘤的首选诊断、治疗方法。     

Iatrogenic femoral artery pseudoaneurysm: Studies relating to the current treatment strategies including observation,ultrasound-guided compression,and duplex-directed thrombin injection

These articles demonstrate 3 “conservative” management strategies for postcatheterization femoral artery pseudoaneurysms. The continuum of watchful waiting in selected patients to ultrasound-guided compression, to ultrasound-guided thrombin injection mirrors many of the changes in the surgical treatment of myriad disease states. Operative repair of these lesions, such as open cholecystectomy, is not going to be of historical importance because many of these lesions will still require open repair. However, with the ever-increasing use of catheter-based therapies, minimally invasive techniques that demonstrate similar efficacy and safety are needed.The most frequent complication of femoral artery catheterization is the development of a femoral artery pseudoaneurysm. Approximately 500,000 interventional cardiologic procedures are performed in the United States every year. This does not take into account the interventional radiologic and other (femoral arterial line placement) procedures used to gain access to the central arterial system via the femoral artery. The reported incidence of complications after femoral artery catheterization ranges from 0.2%–9%. Pseudoaneurysm formation has been reported as a complication in 0.05%–5% of all femoral artery catheterizations.Obviously, with the large number of procedures being performed each year, femoral artery pseudoaneurysm formation is not an uncommon lesion referred to general and vascular surgeons.The first article reviewed explores the conservative management of femoral artery pseudoaneurysms. This article is important in that it documents the benign natural history of a large number of these lesions. Although the conservatively managed patients were a relatively select group, they were not so select that the findings of the study become uninterpretable. This study demonstrates that many of these lesions can in fact be observed with frequent spontaneous resolution.The second article discusses another “conservative” management strategy for the treatment of femoral artery pseudoaneurysms, involving ultrasound-guided compression of the lesion. Ultrasound-guided compression has been adopted in many centers and has shown very good results. Success rates of 70%–100% have been reported. Unfortunately, a recurrence rate of 20% is still seen, especially in patients undergoing anticoagulant therapy. Also, a large number of patients fail this therapeutic method secondary to intolerance of the pain associated with compression. Still, it is clear that ultrasound-guided compression is a highly effective choice in many patients.The third article addresses duplex-directed thrombin injection, a novel technique that is being employed in certain centers. This technique appears to be quite effective and safe. Although this study included only 11 patients, this paper is one of a series of papers that have documented the efficacy and safety of the technique. Duplex-directed thrombin injection is also very expeditious with thrombosis, occurring in only 30 seconds in most patients.Surgical repair of femoral artery pseudoaneurysms will always be necessary for a number of these lesions. However, many can be observed with spontaneous thrombosis. Other techniques have been and are being designed to treat this common condition. With the economic pressure for decreased in-patient treatment, the conservative strategies that have been reviewed will continue to occupy a central role in the management of these lesions.     

Comparative characteristics of the variants of vascular approach during performing hemosorption in patients with acute poisoning

In performance of hemosorption in 108 patients with acute intoxications, 210 manipulations of Seldinger's central venous puncture and catheterization, Skribner's arteriovenous shunting, section of the basal brachial vein were accomplished. In 23 (10.1%) patients, the complications developed: hematoma at the site of puncture--in 10, puncture of the subclavian artery--in 3, puncture of the femoral artery--in 6, shunt thrombosis--in 2, catheter thrombosis--in 2. In patients with acute intoxications, the use of veno-venous method of hemosorption with Seldinger's catheterization of the subclavian and femoral veins is preferrable.     

Acute claudication caused by Angio-Seal closure devices: a report of four cases

Femoral artery closure devices are increasingly used after percutaneous arterial interventions to obtain hemostasis at the puncture site. Their efficacy and advantages in patient comfort are established. Nevertheless they can cause their own specific complications. In a five month's period we had to treat four patients with sudden onset invalidating claudication after the use of an Angio-Seal closure device. Malpositioning of the device led to the ischemic complications. We describe and illustrate the pre- and peroperative findings and the treatment. Interventionalists should monitor and register ischemic complications following the use of puncture site closure devices in order to try and minimize these. The occurrence of few serious complications can outweigh the relative small benefits these devices offer.     

Acute Claudication caused by Angio-Seal Closure Devices: a Report of Four Cases

Femoral artery closure devices are increasingly used after percutaneous arterial interventions to obtain hemo-stasis at the puncture site. Their efficacy and advantages in patient comfort are established. Nevertheless they can cause their own specific complications. In a five month’s period we had to treat four patients with sudden onset invalidating claudication after the use of an Angio-Seal closure device. Malpositioning of the device led to the ischemic complications. We describe and illustrate the pre-and peroperative findings and the treatment. Interventionalists should monitor and register ischemic complications following the use of puncture site closure devices in order to try and minimize these. The occurrence of few serious complications can outweigh the relative small benefits these devices offer.