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.     

Current Developments in Percutaneous Arterial Closure Devices

Annals of Vascular Surgery -     

Risk of Vascular Access Complications with Frequent Hemodialysis

Frequent hemodialysis requires using the vascular access more often than with conventional hemodialysis, but whether this increases the risk for access-related complications is unknown. In two separate trials, we randomly assigned 245 patients to receive in-center daily hemodialysis (6 days per week) or conventional hemodialysis (3 days per week) and 87 patients to receive home nocturnal hemodialysis (6 nights per week) or conventional hemodialysis, for 12 months. The primary vascular access outcome was time to first access event (repair, loss, or access-related hospitalization). Secondary outcomes were time to all repairs and time to all losses. In the Daily Trial, 77 (31%) of 245 patients had a primary outcome event: 33 repairs and 15 losses in the daily group and 17 repairs, 11 losses, and 1 hospitalization in the conventional group. Overall, the risk for a first access event was 76% higher with daily hemodialysis than with conventional hemodialysis (hazard ratio [HR], 1.76; 95% confidence interval [CI], 1.11–2.79; P=0.017); among the 198 patients with an arteriovenous (AV) access at randomization, the risk was 90% higher with daily hemodialysis (HR, 1.90; 95% CI, 1.11–3.25; P=0.02). Daily hemodialysis patients had significantly more total AV access repairs than conventional hemodialysis patients (P=0.011), with 55% of all repairs involving thrombectomy or surgical revision. Losses of AV access did not differ between groups (P=0.58). We observed similar trends in the Nocturnal Trial, although the results were not statistically significant. In conclusion, frequent hemodialysis increases the risk of vascular access complications. The nature of the AV access repairs suggests that this risk likely results from increased hemodialysis frequency rather than heightened surveillance.Establishing and maintaining a suitable vascular access for hemodialysis has long been considered the Achilles heel of hemodialysis. Any intervention that potentially increases risk to the vascular access must be carefully evaluated.Frequent hemodialysis provides multiple physiologic and quality-of-life benefits to patients with ESRD. The Frequent Hemodialysis Network (FNH) Daily Trial showed that, compared with conventional thrice-weekly hemodialysis, in-center hemodialysis performed 6 days per week improved self-reported health-related quality of life, left ventricular mass, and several other surrogate outcomes.¹ Similar improvement trends have been seen with nocturnal hemodialysis performed 6 nights per week.^2,3 Yet despite these demonstrated benefits, frequent hemodialysis may have potential risks. Compared with conventional hemodialysis, frequent hemodialysis requires using the vascular access up to twice as often. In addition to direct trauma caused by more frequent venipuncture of arteriovenous accesses, more frequent access use could theoretically result in increased endothelial trauma due to shear forces created by returning blood, more inflammation, and greater exposure to bacterial pathogens. These factors, in turn, could cause more access stenosis, thrombosis, and infection. In the FHN Daily Trial and Nocturnal Trial, we tested the hypothesis that both types of frequent hemodialysis would increase the risk of vascular access complications.     

Percutaneous Access Devices in Calves Receiving an Artificial Heart

Vegetative endocarditis and thromboembolism are the two leading pathologic findings and causes of death in calves receiving total artificial hearts (TAH). Percutaneous access devices (PAD) for the pneumatic drive lines often become infected and may serve as the nidus of infection of the vegetative lesions. Observations of 80 calves living with TAHs revealed that most infections began at the dorsal surface of the PAD. Chronic skin ulceration or acute, traumatic avulsion can result in PAD separation from the skin and bacterial implantation. Evaluation of 58 necropsy specimens from calves with TAHs demonstrated improper flange positioning in 76% of the PAD and gross infection in 57%. A new implantation technique and design of PAD have resulted in better flange position and less irritation at the skin/device interface. Necropsies of 11 animals with the new PAD have shown a reduction in superficial infections.     

Temporal Risk Profile for Infectious and Noninfectious Complications of Hemodialysis Access

Vascular access complications are a major cause of morbidity in patients undergoing hemodialysis, and determining how the risks of different complications vary over the life of an access may benefit the design of prevention strategies. We used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) to assess the temporal profiles of risks for infectious and noninfectious complications of fistulas, grafts, and tunneled catheters in incident hemodialysis patients. We used longitudinal data to model time from access placement or successful treatment of a previous complication to subsequent complication and considered multiple accesses per patient and repeated access complications using baseline and time-varying covariates to obtain adjusted estimates. Of the 7769 incident patients identified, 7140 received at least one permanent access. During a median follow-up of 14 months (interquartile range, 7–22 months), 10,452 noninfectious and 1131 infectious events (including 551 hospitalizations for sepsis) occurred in 112,085 patient-months. The hazards for both complication types declined over time in all access types: They were 5–10 times greater in the first 3–6 months than in later periods after access placement or a remedial access-related procedure. The hazards declined more quickly with fistulas than with grafts and catheters (P<0.001; Weibull regression). These data indicate that risks for noninfectious and infectious complications of the hemodialysis access decline over time with all access types and suggest that prevention strategies should target the first 6 months after access placement or a remedial access-related procedure.Clinical practice guidelines recommend the arteriovenous fistula as the optimal vascular access for hemodialysis because mature fistulas have lower rates of thrombosis and infection compared with synthetic arteriovenous grafts or central venous catheters.^1–3 Given the mortality, morbidity, and costs associated with the use of grafts and catheters and low rates of fistula use in the United States in the mid-1990s,⁴ national initiatives were created to increase the placement of fistulas.⁵ These programs have had markedly increased fistula prevalence since their inception.⁵ However, 20%–60% of patients treated with hemodialysis worldwide use grafts or catheters,^6,7 at least in part because their vessels are unsuitable for fistula creation.^8,9 Increasing fistula attempts in all patients may therefore be insufficient to improve access and patient outcomes. Considering the limited benefits of available pharmacologic interventions,^9–11 novel strategies are needed to improve access outcomes. A better understanding of the timing and risk of complications of each type of access would help to develop new therapies or approaches.^12,13There are limited data on the temporal profiles of risk for infectious and noninfectious complications in different forms of vascular access. The risk for noninfectious complications (e.g., stenosis and thrombosis) declines over the life of the access in both fistulas and grafts. Data from centers where local policies favor fistula creation, early transition from catheters to arteriovenous accesses, and limited use of grafts indicate that the hazard for access failure due to noninfectious complication is initially higher with fistulas than grafts, declines more quickly with fistulas, and is lower with fistulas than grafts within 3–6 months of access creation.¹⁴ This pattern is consistent with the known higher rates of primary failure in fistulas and inferior long-term outcomes in grafts,¹⁵ although results from this study need to be confirmed in larger cohorts and different populations. No other risk patterns have been described, including the temporal profiles of risks for noninfectious complications with permanent catheters. Furthermore, the risk profile for infectious complications in any access type, including access infection and sepsis, remains uncharacterized. Knowledge about how these risks vary over time may be important for informing studies seeking to test the effectiveness of new interventions and for designing strategies that can improve access-related outcomes.We sought to describe and compare the profile of the risks over time for infectious and noninfectious complications of each permanent access type (fistula, graft, and tunneled catheter), accounting for patient characteristics and considering multiple accesses per patient. To maximize the generalizability of the results, we used data from the Dialysis Outcomes and Practice Patterns Study (DOPPS), an ongoing large, international, prospective cohort study of dialysis practices and patient outcomes.     

The Impact of Transvenous Cardiac Devices on Vascular Access Patency in Hemodialysis Patients

Creating a vascular access in the presence of a cardiovascular implantable electronic device (CIED) in a patient with or approaching end‐stage renal disease can be challenging. In this study, we aimed to evaluate the impact of a CIED on the outcomes of vascular access creation in hemodialysis patients and determine their effects on vascular access patency. This is a single‐center retrospective review of hemodialysis patients who underwent vascular access creation after CIED placement. Outcomes of vascular access creation and need for endovascular interventions were compared between patients with vascular access created ipsilateral and contralateral to the site of CIED. Comparing patients with arteriovenous (AV) access created ipsilateral to CIED placement (n = 19) versus the contralateral side (n = 17), the primary failure rate was 78.9% versus 35.3% (p = 0.02). For AV accesses that were matured, the median primary patency durations for AV accesses created ipsilateral to the CIED was 11.2 months compared to 7.8 months for AV accesses created contralateral to the CIED (p = 1.00). AV accesses created ipsilateral to a CIED have a higher primary failure rate compared with the contralateral arm and should be avoided as much as possible.     

Early Vascular Complications after Endovascular Repair of Aortoiliac Aneurysms

The purpose of this study was to estimate the frequency of and review the treatment options for intraoperative endograft access-related vascular complications and early postoperative vascular complications of endovascular repair for aortoiliac aneuryms (EVAR). Between February 1998 and April 2000, 53 patients (46 males, 7 females) with aneurysms of the abdominal aorta (AAA) and iliac arteries were treated with endovascular grafts (48 AAA, and 5 iliac aneurysms). All procedures were performed using open exposure of the femoral arteries. One patient with an AAA was converted to open repair (primary technical success, 98.1%). We recorded the need for adjunctive vascular procedures or intervention to the access arteries (iliofemoral) or the endograft because of thrombosis or distal embolization. Events were classified as either intraoperative, early postoperative (< 30 postoperative days), or late postoperative. Their etiology and treatment were recorded. The results were compared to those from other series reported in the literature and to published registry data. From our results we concluded that the need for adjunctive vascular procedures to the iliofemoral arteries at the time of EVAR is significant. These procedures are necessary to either repair damage to the access arteries from the delivery system or provide a conduit for graft delivery in cases where the access arteries are inadequate. Early postoperative vascular complications are due to technical factors resulting in residual graft limb stenoses. Both intraoperative and early postoperative vascular complications after EVAR are more common in female patients. These complications can be effectively treated with a variety of open surgical and transfemoral endovascular techniques.     

冠状动脉介入诊疗术后血管闭合装置与压迫止血效果比较

目的比较经皮冠状动脉介入性诊疗术后使用血管闭合装置与传统人工压迫止血方式对外周血管并发症的影响。方法选择冠状动脉介入性诊疗术后使用血管闭合装置的62例为观察对象（血管闭合装置组）,选择与之匹配的以人工压迫方式止血的68例患者作为对照（人工压迫组）,比较两组术后卧床时间及穿刺血管并发症发生率。结果血管闭合装置组患者术后卧床时间显著短于人工压迫组（P〈0.01）;两组穿刺血管并发症发生率比较,差异无显著性意义（均P〉0.05）。结论冠状动脉介入性诊疗术后使用外周血管闭合装置可缩短患者卧床时间,但是否能降低外周血管并发症的发生率尚需进一步研究。     

冠状动脉介入诊疗术后血管闭合装置与压迫止血效果比较

目的 比较经皮冠状动脉介入性诊疗术后使用血管闭合装置与传统人工压迫止血方式对外周血管并发症的影响.方法 选择冠状动脉介入性诊疗术后使用血管闭合装置的62例为观察对象(血管闭合装置组),选择与之匹配的以人工压迫方式止血的68例患者作为对照(人工压迫组),比较两组术后卧床时间及穿刺血管并发症发生率.结果 血管闭合装置组患者术后卧床时间显著短于人工压迫组(P＜0.01);两组穿刺血管并发症发生率比较,差异无显著性意义(均P＞0.05).结论 冠状动脉介入性诊疗术后使用外周血管闭合装置可缩短患者卧床时间,但是否能降低外周血管并发症的发生率尚需进一步研究.