Complication case of vascular access: Trials and Tribulations

Tóm tắt

Background

68 years old Male. Admitted in a district hospital for NSTEMI in failure 1 month ago.Referred for further cardiac management. He has a background history of ESRF on regular dialysis, Hypertension,  Diabetes Mellitus, Dyslipidemia and Obesity with BMI of 32

On examination, Afebrile, BP recorded was 135 / 70 mmHG with heart rate of 72 bpm. Systemic examination was unremarkable. No signs of failure noted

Investigations 

Investigation

Full blood count

WCC 9.5 / Hb 11.4 / PLt 302

Renal Profile

Urea 15 / Na 139 / K 5.6 / Creat 677

Liver function test

Bili 7 / ALT 60 / ALP 166

Troponin

754

NT ProBNP

14 680

CRP

6.9

INR

1.1

ECG

Sinus rhythm, LVH, LAD , TWI in anterior leads

2D Echocardiography

LVEF 35% ,Grade 3 diastolic dysfunction, TAPSE 1.8cm,LA dilated, no LV clot, no pericardial effusion

Methods

Coronary angiogram was performed via the Right femoral approach under fluoroscopy and USG guidance. 6F sheath was inserted with JL 4.0 and JR 3.5 diagnostic catheter used.
Findings showed :
LMS       : mild distal disease
LAD        : severe proximal disease
LCX         : mild moderate ostial and proximal disease
RCA        : severe stenosis at proximal segment

Results

Quantitative flow ration (QFR) of Left anterior descending artery was 0.74 (significant).

Decided for Percutaneous Coronary Intervention (PCI) to LAD. Engaged LM with EBU 3.5,6F.Wired across with SION BLUE.Predilated with SC 2.5 x 15mm , Scoring 2.75 x 15mm.STENTED with DES 2.75 x 26mm at nominal pressure. Postdilated with NC 2.75 x 15mm at high pressure. QFR of LAD post PCI  improved to 0.92

Proceeded with PCI to RCA. JR 3.5 guiding engaged the RCA. Wired across the lesion with SION BLUE. Attempted to predilate with SC 2.5x15mm unable to cross the tight lesion. Used SC 2.0x15mm to predilate first. Further predilatation with Scoring 3.0 x15mm at high pressure. STENTED with DES 3.5 x18mm at nominal. Post dilated with NC 3.5 x15mm at high pressure. Final shot showed good results with TIMI III flow established. Femoral shot taken again. Manual compression done

Patient developed hypotension 30 minutes later in recovery bay.Urgent restudy done via Left Femoral Artery (LFA).Noted RCA stent patent. IVUS showed no stent edge dissection. Rechecked LCA. Noted LAD stent patent with TIMI III flow. Fluid resuscitation and inotropes ongoing to stabilize patient. Patient was restless due to hypotension, femoral sheath. Decided to check femoral shot with contralateral shot. Noted contrast leakage from previous RFA puncture site indicating perforation. Aorto-Iliac view taken with JR 3.5 , 5 Fr.Wired into contra lateral CFA into SFA using Terumo wire. Balloon tamponade done with Admiral Extreme 7.0mm x 20mm x 130cm. Contrast leak still present. Balloon tamponade done with Admiral Extreme 8.0mm x 40mm for longer duration. Still unsuccessful to seal the perforation. 2nd pint Packed cell on going at this point. Patient tachypnoeic despite on FHM. Electively intubated for respiratory distress by Anaest team. Deployed Covered STENT  7.0 mm x 38mm x 120 mm at the site of leak. Postdilated with ADMIRAL Extreme 8.0mm x 40mm x 80cm and ADMIRAL Extreme 9.0mm x 40mm x 80cm. Finally secured the perforation successfully. Patient was extubated the next day and discharged well Day 4 post procedure. Review in 3 months in clinic , patient is well with FC NYHA 1

Conclusion

Access Site Perforation can be life threatening which require time-sensitive emergency management.In our case, despite femoral puncture done under fluoroscopy and Ultrasound guidance, complication occurred. Extra caution needed in patient with predictors of femoral artery complications such as Elderly female, obese patients, calcified vessels, ESRF, Peripheral artery disease , use of anti coagulation and anti thrombotic agents and femoral puncture which are either too high or low.