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Access-related complications of percutaneous access for diagnostic or interventional procedures

Access-related complications of percutaneous access for diagnostic or interventional procedures
Literature review current through: Jan 2024.
This topic last updated: May 31, 2022.

INTRODUCTION — Complications after percutaneous access for peripheral procedures occur in up to 6 percent of patients [1-3]. The most common complication is hematoma (minor or major), although pseudoaneurysm, arteriovenous fistula, arterial thrombosis, and embolization may also occur.

Hemorrhage and hematoma typically occur within minutes to hours of sheath removal as evidenced by complaints of pain, focal mass, hypotension, or falling hematocrit, which lead to confirmatory noninvasive testing (ultrasound or computed tomography). By contrast, other complications such as pseudoaneurysm and arteriovenous fistula may not become apparent until days to weeks later.

Arterial access techniques for percutaneous diagnostic and interventional vascular procedures are reviewed separately. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures".)

GENERAL CONSIDERATIONS AND RISK FACTORS — Percutaneous access is used for various diagnostic and interventional vascular procedures including neurovascular, cardiac, mesenteric vascular, renovascular, and peripheral vascular disease. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Introduction'.)

Treated conditions and access sites — A variety of access sites are used to treat a multitude of conditions using instrumentation designed to regain lumen diameter (eg, angioplasty, stenting, atherectomy), remove thrombus (thrombolysis, mechanical thrombectomy), create vascular occlusion (angioembolization for bleeding, coil embolization of aneurysm), deliver intravascular devices or medications, or retrieve foreign bodies.

The access site is selected based on the location of the pathology being treated and the procedure planned. Thus, certain access sites and therefore access site complications are associated with some procedures more than others. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Site selection'.)

Common access sites include the:

Common femoral artery (see "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Common femoral artery')

Brachial artery (see "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Brachial artery')

Radial artery (see "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Radial artery')

Other less commonly used sites for lower extremity procedures include the:

Popliteal artery (see "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Popliteal artery')

Pedal arteries (see "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Pedal artery access')

Risk factors — Risk factors for vascular access complications at any access site include [1-14]:

Multiple access attempts

Failure to use ultrasound guidance during needle access

Periprocedural antithrombotic/fibrinolytic medications

Larger needle at initial arterial access (18- versus 21-gauge needle)

Larger sheath size

Longer sheath duration

Repeat procedures

Female sex

Risk factors specific to the common femoral access site include [15-21]:

Common femoral artery atherosclerotic disease

Use of intra-aortic balloon pump

Inadvertent access of the external iliac or superficial femoral artery

Closure device failure

Obesity

LOCAL ACCESS COMPLICATIONS

Access site bleeding — Postprocedure bleeding following arterial access can be overt or lead to hematoma or pseudoaneurysm formation depending upon the degree the bleeding is contained. These bleeding complications have been reported at all access locations.

Most hematomas can be managed conservatively with additional manual pressure and most resolve over a period of days, and surgical repair of the needle puncture site is generally not required. However, bleeding associated with femoral artery access can be significant and difficult to detect if extension to the retroperitoneum occurs (see 'Retroperitoneal hematoma' below). Hematoma formation in the soft tissue of the upper thigh can also occur, and the patient should be informed that the development of a large area of ecchymosis is possible.

Nerve compression related to hematoma can occur. The need for and urgency of decompression depends upon the severity of symptoms and the access site location. Although most hematomas resolve over a period of days, femoral nerve compression can occur, which may take weeks to months to resolve. Brachial plexus or median nerve compression associated with axillary or brachial access can lead to severe limb dysfunction, and early recognition and treatment are necessary. (See 'Axillary/brachial sheath hematoma' below.)

Anticoagulation using unfractionated heparin is used during most cardiac and peripheral vascular interventions to reduce the risk of thrombosis, but ongoing anticoagulation may make it more difficult to achieve hemostasis at the arterial access site. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Hemostasis at the access site'.)

While access site bleeding is often related to administration of antithrombotic therapies, it is also related to the size of the sheath and duration of cannulation. Other risk factors for bleeding requiring transfusion have included female sex, which is explained in part, but not completely by smaller vessel size [22], and older age (9 percent in a series of patients undergoing coronary intervention [23]).

Retroperitoneal hematoma — Retroperitoneal bleeding represents a particularly serious type of preventable vascular complication. If the arterial puncture occurs proximal to the inguinal ligament, a hematoma may extend into the retroperitoneal space, causing hypotension and ipsilateral flank pain. This can be prevented in most cases by using ultrasound guidance during needle access and with careful attention to anatomic landmarks and fluoroscopy of the femoral head prior to needle puncture. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Common femoral artery'.)

Retroperitoneal hemorrhage can also occur with puncture sites below the inguinal ligament, as blood can track along the vascular fascial sheath into the retroperitoneum or rectus sheath. Even with appropriate access position, back wall punctures that exit above the inguinal ligament may result in retroperitoneal bleeding and may not be sealed by manual compression or closure devices. Injudicious advancement of the guidewire or sheath by an inexperienced operator can also traumatize the iliac artery, lateral circumflex femoral artery, or inferior epigastric artery (figure 1) and result in bleeding into the retroperitoneal space. A noncontrast computed tomography (CT) scan or abdominal ultrasonography can help to establish the diagnosis. Treatment is usually conservative if no active bleeding is noted (eg, bleeding through the wound, extravasation on CT scan), consisting of bed rest and blood transfusion rather than surgical correction. Reversal of systemic anticoagulation may be indicated if bleeding persists or is associated with hemodynamic compromise.

If bleeding is active, percutaneous methods including balloon inflation or placement of a covered stent to tamponade or seal the bleeding segment may be useful for emergency treatment. Surgical management (vascular repair) is recommended for retroperitoneal bleeding with hemodynamic instability or ongoing transfusion requirements (>2 units), which allows identification and control of bleeding point and evacuation of the hematoma. Some patients with severe ongoing pain may also benefit from exploration. Techniques for exploration are similar to those used to manage spontaneous retroperitoneal hematoma and are reviewed separately. (See "Spontaneous retroperitoneal hematoma and rectus sheath hematoma", section on 'Surgical intervention'.)

Axillary/brachial sheath hematoma — Relative to other access sites, the complication rate for axillary or brachial access is high [24,25]. In one review of 109 patients, the overall complication rate was 21 percent [24]. Major complications occurred in 8.3 (1 of 12) for surgical cutdown via the brachial artery, 13.7 percent (7 of 51) for percutaneous puncture of the brachial artery, and 4.3 percent (2 of 46) for surgical cutdown of the axillary artery. Because of the association with neurologic complications, cutdown for access is commonly used.

Hematoma or pseudoaneurysm after axillary or brachial access frequently leads to nerve compression given the limited space beneath the tight surrounding fascia. Due to the higher rates of compression of the brachial plexus, percutaneous axillary access has largely been abandoned. The location of brachial access affects the rates of complications. Distal brachial artery access is associated with lower rates of hematoma and subsequent nerve compression compared with more proximal access. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Brachial artery'.)

Proximal brachial access has rates of hematoma and nerve compression similar to axillary access [26]. Axillary and proximal brachial access hematomas with compression can take up to two weeks to present. Hematomas can spread along the brachial sheath and make detection more difficult. Also, brachial sheath hematoma at the antecubital fossa may not be visualized with ultrasound. Significant hand symptoms (pain, paresthesias) should prompt consideration of surgical exploration to prevent permanent neurological injury. Patients may present with numbness, pain, or weakness in median nerve distribution. However, they may have concomitant radial or ulnar neuropathies, or mononeuropathy in the ulnar or radial distribution [27]. Therefore, it is imperative that interventionalists can prevent, diagnose, and rapidly treat brachial sheath hematomas to prevent permanent disability. (See "Traumatic peripheral neuropathies".)

Pseudoaneurysm — Pseudoaneurysm following percutaneous access represents a false aneurysm due to an incomplete hemostatic plug at the injury site. Localized extravasation of blood outside the arterial wall is confined and controlled by the pseudocapsule that develops. The main risk factor for pseudoaneurysm formation is an inadequate period of manual compression. This was illustrated in a series of 581 angiographic procedures involving femoral artery catheterization [28]. A pseudoaneurysm occurred in 14 percent of the first 300 procedures in which standard manual compression was performed, compared with 1.1 percent of the next 281 procedures when manual compression was continued for at least five minutes after local bleeding had stopped.

Other risk factors include large-bore sheaths, postprocedural anticoagulation, antiplatelet therapy during the intervention, age >65 years, obesity, hypertension, peripheral artery disease, hemodialysis, cannulation of the superficial rather than common femoral artery, and complex interventions [28-30].

A pseudoaneurysm is easily recognized by the presence of a pulsatile mass at the access site. Most pseudoaneurysms are evident within the first few days following percutaneous procedure [29]. The clinical diagnosis is confirmed by ultrasonography, which demonstrates a typical yin-yang sign (image 1).

Small pseudoaneurysms (<3 cm for common femoral site) can be observed, and ultrasound-guided thrombin injection is used in those that persist or are symptomatic (algorithm 1). This general principle can be applied at other access sites, although size criteria are not well defined. Due to low success rates and discomfort associated with ultrasound-guided manual compression, thrombin injection remains the treatment of choice.

Pseudoaneurysm can occur at any access site, but the common femoral artery is the most common site for iatrogenic pseudoaneurysm. In a review of femoral artery pseudoaneurysms, 86 percent of pseudoaneurysms less than 3 centimeters in diameter resolved spontaneously. Femoral artery pseudoaneurysm is reviewed in detail separately [31]. (See "Femoral artery pseudoaneurysm following percutaneous intervention".)

The success rate of ultrasound-guided injection of bovine thrombin was illustrated in a series of 240 patients with simple or complex pseudoaneurysms [29]. The primary success rate was 96 percent with simple pseudoaneurysms and 89 percent with complex pseudoaneurysms. The secondary success rate was 99.6 percent (all but one patient). The authors also reviewed 34 studies with 1388 patients; the overall success rate was 97.2 percent [31].

Surgical management should be performed when a pseudoaneurysm becomes very large and threatens or causes skin necrosis or causes other symptoms, is expanding rapidly, or after failure of minimally invasive attempts to close the fistula [30]. Expanding hematomas have a propensity toward eventual rupture, especially if the patient is maintained on anticoagulation [1,3,32,33].

Arteriovenous fistula — Arteriovenous fistula formation can occur at any access site. The clinical features are reviewed separately. Treatment is tailored to the extremity of the access site. (See "Acquired arteriovenous fistula of the lower extremity".)

Ongoing bleeding from the arterial puncture site may decompress into an adjacent venous puncture, leading to the formation of an arteriovenous fistula. This complication may be recognized by the presence of a thrill or continuous bruit at the site of catheter insertion.

Surgical repair is often necessary at the femoral access site since fistulae tend to enlarge over time. The most common finding at surgery is a puncture site below the common femoral artery, which underscores the importance of careful technique in avoiding this complication [32]. These can also be repaired with placement of a covered stent to occlude the anomalous connection. Fistula formation at other access sites is individualized depending on the access site but can often be managed with observation. Repair should be considered if it is causing hemodynamic consequences (eg, increased cardiac output).

CATHETER/SHEATH/WIRE COMPLICATIONS

Arterial thrombosis — Arterial thrombosis is rare at lower extremity access sites and occurs slightly more often when the brachial approach is used [34,35]. Predisposing factors to femoral artery thrombosis include small vessel lumen, peripheral artery disease, diabetes mellitus, female sex, placement of a large diameter catheter or sheath (eg, intra-aortic balloon pump, aortic stent grafting, etc), or a long catheter dwell time [1,3,33-38]. Patients with lower extremity pain or paresthesia, plus reduced or absent distal pulses not responding to catheter removal, should be evaluated for possible flow obstructing thrombus or dissection. Urgent open or mechanical thrombectomy may be required for preservation of the limb. Thrombosis of the access site would typically require exploration, thromboendarterectomy, and patch closure. However, endovascular treatment using thrombectomy and stenting can be considered selectively in high-risk patients.

Radial artery access is associated with a 5 to 19 percent risk of radial artery occlusion [4,39]. Systemic anticoagulation and use of smaller sheaths may reduce the risk. This complication is usually not clinically important in most patients because the hand is perfused by both the radial and ulnar arteries with extensive collateral flow between the two. However, some patients have incomplete palmar arches, which may diminish collateral perfusion, possibly leading to hand ischemia in the presence of radial artery occlusion (figure 2). (See "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Radial artery'.)

Embolism — As a result of arterial access (any site), embolization can occur and may be related to atheromatous debris/thrombus or device components. The clinical features associated with embolism of various vascular beds are reviewed separately.

(See "Endovascular repair of the thoracic aorta", section on 'Cerebrovascular ischemia' and "Overview of carotid artery stenting", section on 'Stroke' and "Stroke after cardiac catheterization".)

(See "Embolism to the upper extremities".)

(See "Acute mesenteric arterial occlusion".)

(See "Embolism from atherosclerotic plaque: Atheroembolism (cholesterol crystal embolism)".)

(See "Embolism to the lower extremities".)

Atheroembolism — Stiff wires and large-bore guiding catheters can traumatize the aortic lumen, causing atheromatous debris to shear from the aortic wall. The reported incidence in cardiac catheterization series of atheroembolic events has ranged from 0.6 to 0.9 percent in retrospective studies to 1.4 to 1.9 percent in prospective series [40,41]. The risk of atheroembolism can be reduced by avoiding the practice of readvancing a guidewire through the infrarenal aorta rather than exchanging it through a catheter.

Distal microembolization can result in tissue loss and may be very difficult to treat. The clinical features of atheroembolism after diagnostic cardiac catheterization were examined in a prospective evaluation of 1786 patients ≥40 years of age [40]. The following observations were made:

Twenty-five patients (1.4 percent) were diagnosed with atheroembolism; 12 had cutaneous signs (eg, "blue toes" syndrome, livedo reticularis) (picture 1A-B), and 16 had acute renal failure that was considered to be atheroembolic in origin because it persisted for at least two weeks (while contrast nephropathy typically reverses within the first week).  

Eosinophil counts were significantly higher in patients suffering from atheroembolism both before and after catheterization.

Four patients with atheroembolism died in the hospital (16 percent); all had progressive renal dysfunction. The mortality rate was much lower (0.5 percent) in the patients without atheroembolism.

With lower extremity revascularizations, it is important to assess the patency of the runoff vessels before the procedure not only by reviewing preprocedural vascular imaging but also by injecting contrast after crossing occlusions to determine if any embolization has occurred during crossing. Filter protection can be considered when treating more distal lesions at high risk of embolization or during procedures known to be associated with higher risk of embolization, such as atherectomy procedures.

Treatment of atheroembolism is largely supportive. Therapies that have been evaluated are discussed separately. (See "Embolism from atherosclerotic plaque: Atheroembolism (cholesterol crystal embolism)", section on 'Instrumentation'.)

Thromboembolism — Thromboembolization related to the access site can occur with any type of endovascular intervention, and recognition of high-risk lesions is important to prevent this complication. Embolization due to manipulation of catheters in the iliac vessels can be related to soft iliac plaques or those containing fresh or organizing clots, which are more likely in subacute occlusions. For patients at high risk for embolization, femoral cutdown and clamping of the femoral artery before the intervention can be considered before proceeding with the recanalization (balloon angioplasty and stenting) (image 2).

Once embolization has occurred, initial management includes ensuring adequate systemic anticoagulation. Embolization can be managed either using pharmacomechanical thrombolysis or by surgical thrombectomy, which may be more appropriate for patents with embolization of large thrombus to the common femoral artery. Removal can be attempted using a variety of thrombectomy catheters (suction, mechanical). Adjunctive thrombolysis will likely be necessary, and these devices may themselves cause additional embolization to more distal vessels, even with the use of protective distal filters during thrombectomy. Surgical embolectomy may be needed if embolic material cannot be adequately retrieved (image 3). (See "Embolism to the lower extremities".)

Arterial dissection — Dissection of the treated artery may occur during access to a severely diseased artery, unrecognized subintimal access, wire manipulation, or as part of crossing occlusions in a subintimal fashion, at the site of reentry, or after balloon angioplasty. When the anatomy is not clear, intravascular ultrasound can be helpful to identify the extent of the dissection. Stent placement may also be needed to tack down dissections that are flow limiting.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute extremity ischemia".)

SUMMARY AND RECOMMENDATIONS

Percutaneous access – Percutaneous access site complications for diagnostic or interventional procedures are uncommon overall, occurring in about 6 percent of patients. Such procedures include neurovascular, cardiac, mesenteric, renal, and peripheral vascular procedures. Percutaneous access sites include the common femoral artery, brachial artery, radial artery, pedal arteries, and less commonly the axillary artery. (See 'General considerations and risk factors' above.)

Categories – Complications of percutaneous access fall into two broad categories, including those related to the puncture site, which includes bleeding, hematoma, arteriovenous fistula, pseudoaneurysm, arterial dissection, and thrombosis, and those more typically related to access with wires and sheaths, including atheroembolism, thromboembolism, and vessel perforation. These complications can occur at any access site. Some are more common at a specific access site compared with others. (See 'Local access complications' above and 'Catheter/sheath/wire complications' above.)

Risk factors – General risk factors for vascular access complications include periprocedural antithrombotic/fibrinolytic medications (prolonged, excessive), repeat procedure, larger sheath size, and prolonged sheath duration. In addition to these, risk factors specific to common femoral access, which is the most accessed site, include atherosclerotic plaque at the puncture site, obesity, use of intra-aortic balloon pump, and inadvertent access of the external iliac or superficial femoral artery. (See 'Risk factors' above.)

Access site bleeding – Bleeding (eg, hemorrhage, hematoma) is the most common complication at any access site. Bleeding typically occurs within minutes to hours of sheath removal, whereas other complications related to bleeding from the access site (eg, pseudoaneurysm, neurologic dysfunction) may not become apparent until days or weeks later. Most bleeding can be controlled with additional manual pressure, and surgical intervention to repair the puncture sites is not usually necessary. (See 'Access site bleeding' above.)

Common access sites

Common femoral artery access – Bleeding and hematoma are the most common complications associated with femoral artery access. Bleeding extending into the retroperitoneum or deep thigh causing large hematomas can be difficult to detect. (See 'Retroperitoneal hematoma' above.)

Radial artery access – Thrombosis is the most common complication related to radial artery access. Most often thrombosis does not lead to significant symptoms. However, if the palmar arch is not intact, hand ischemia may result that needs to be addressed. (See 'Arterial thrombosis' above.)

Brachial artery access – As with common femoral access, bleeding complications are the most common; however, at this site, the adjacent median nerve is at risk for compression, which can lead to neuropathy, which in some cases can be permanent if hematoma is not recognized and treated in a timely manner. (See 'Axillary/brachial sheath hematoma' above.)

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References

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