General description of procedure, equipment, technique

Options for patients with complex congenital heart disease

Vascular access is obtained using the standard Seldinger technique. This is often difficult for adults with a history of complex congenital heart disease due to multiple previous vascular procedures. Also, vascular adverse events is one of the most common complications for catheterization procedures in this patient population.

General description of vascular access procedure

Vascular access is attempted in the femoral vein and artery; but in the presence of bilateral femoral occlusion, other access locations are considered. For bilateral femoral arterial occlusion, other access considerations include radial, brachial, or axillary artery locations. For bilateral femoral venous occlusion, the internal jugular, subclavian, or transhepatic route is considered.

Compared with the standard femoral approach; the upper body venous access route has a slightly higher risk for pneumothorax or phrenic nerve injury and the hepatic route has a slightly higher risk for bleeding or blood loss into the hepatic capsule or the abdominal cavity.

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Transhepatic access is contraindicated if the patient has significant liver disease, is taking blood thinners, or has other medical conditions that increase the risk of bleeding.

Outcomes (applies only to therapeutic procedures)

Potential severe adverse events related to vascular access include a retroperitoneal bleed, arteriovenous fistulae, and pseudoaneurysm. Each of these require a different management approach.

Complications and their management

Adverse events related to the vascular access site are common and can pose a management challenge due to the often late presentation following interventional cardiac catheterization procedures.

Retroperitoneal bleed is a complication related to vascular access technique and vascular access entry location. Careful understanding of the entry location for femoral access should make this a very rare adverse event.

  • Management of this complication is initiated upon recognizing the adverse event during postprocedure recovery. Patients’ clinical appearance, vital signs, and laboratory data can all tip the provider that there is a retroperitoneal bleed.
  • Ultrasound or computed (CT) imaging can confirm the diagnosis.
  • Bleeding is stopped with surgical vascular intervention.

Arteriovenous fistula management varies depending on size and if clinical symptoms:

  • Small and clinically asymptomatic fistula can be followed for the first year given the possibility of spontaneous closure.
  • Large or clinically symptomatic fistula can should be managed with ultrasound guided compression, or surgical repair of the fistula. Additionally, there are several case reports of covered stent angioplasty to exclude the fistula and recreate separate channels for the arterial and venous flow.

A pseudoaneurysm forms when the arterial puncture fails to close, thus allowing arterial blood to jet into the surrounding tissues and form a pulsatile hematoma. These lesions lack a fibrous wall and are contained by a surrounding shell of hematoma and the overlying soft tissue.

  • The suggested management is either manual compression or ultrasound-guided thrombin injection, typically using radiology. This is a relatively quick procedure that requires a period of several hours of bedrest and can be done as an outpatient.

What’s the evidence?

vol. Volume 6. September/October 2012.

Additional references and studies include:

Kelm, M. “Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas implications for risk stratification and treatment”. J Am Coll Cardiol. vol. 40. 2002. pp. 291-7. (This is a nice review for cardiac catheterization access methods.)

Tao, Z. “Treatment of post catheterization femoral arteriovenous fistulas with simple prolonged bandaging”. Chinese Med J. vol. 120. 2007. pp. 952-5. (This is a nice review of femoral arteriovenous fistula management.)

Eisenberg, L, Paulson, EK, Kliewer, MA, Hudson, MP, DeLong, DM, Carroll, BA. “Sonographically guided compression repair of pseudoaneurysm: further experience from a single institution”. AJR Am J Roentgenol. vol. 173. 1999. pp. 1567-73. (This article reviews iliac-femoral pseudoaneurysm management.)

Lenartova, M. “Iatrogenic pseudoaneurysm of femoral artery: Case report and literature review”. Clin Med Res. vol. 1. 2003. pp. 243-7. (This is a nice literature review for femoral pseudoaneurysm management.)