Dr. El Sayed is Associate Professor of Surgery at Eastern Virginia Medical School. He discusses various vascular complications encountered during cardiovascular procedures and offers early recognition and timely management of these complications.
Okay. On behalf of Sentara Heart Hospital and Eastern Virginia Medical School, I would like to welcome Dr Houssam El Saad. DR L. C. Odds talk today is entitled vascular complications. Dr Elsie Odd completed his medical degree at the University of Cairo than surgical residencies at the University of Cairo and Ohio State University. He then pursued his vascular fellowship here. Eastern Virginia Medical School. Doctor Al Saad has served as assistant professor of surgery at Baylor College of Medicine, whale Cornell School of Medicine. Used in methodist and the University of Cincinnati. He was an associate professor of surgery, vascular division at Ohio State. Before returning here to Tidewater assam, has authored innumerable articles and has been an ardent supporter of vascular fellow and surgical resident education and a mentor to many. It's almost kind enough to agree to discuss vascular complications of cardiac procedures with us this morning. Hassan, Welcome. We're looking forward to your presentation time to work. I'm really happy to be here today to be presenting on this subject. Um Hopefully it won't be too boring. Um Anyway, well that uh said, well we'll start um talking about vascular complications of cardiac procedures and I'm talking about vascular complications in general cardiac and peripheral vascular procedures. So points to cover today would be uh first talking about the national trends of vascular complications um factors associated with the vascular complications, some specifics related to different vascular access sites. And then we'll talk about management of some of the selected complications as we go. So the population is getting older and sicker. There is a significant steady increase in per cutaneous cardiovascular procedures. Both cardiac award tech and peripheral. There has been a tenfold increase in the Perky Tania's endovascular procedures since 1995. And endovascular procedures are becoming more complex, more demanding and there has been a significant increase in the endovascular procedures requiring large bore access. The incidence of vascular complications is about 1% in general for diagnostic procedures and about up to 10% in therapeutic interventions. However, The major complications that need intervention are in between 3-4 factors predisposing to those complications are either patient factors or procedure factor when it comes to patient factors. Um these are some of the factors that are associated with vascular complications. And it's very important to identify those factors early on because one of the most we can't stop vascular complications from happening, but we can manage them appropriately. And and we notice who are the ones who are at risk for developing these. We have better planning of what to do when this happens. Um one of the most important factors is obesity and also low body weight b. m. i. of less than 18 female patients are notoriously more prone to vascular complications in general, heavily diseased and calcified vessels, patients with end stage renal disease or chronic renal insufficiency for that matter. The worst their kidney function. The more liable they are to get vascular complications patients on anti coagulation and significant hypertension. All of these are patient factors that can be associated and kind of predictors of vascular complications down the road when it comes to procedure, factor is one of the most important factors in the procedure is a large bore axis. And when we talk about large bore, usually about seven french or eight french sheets, the bigger the access, the more the risk of having complications across the board, prolonged procedures definitely have more risk of complications and simultaneous arterial and venous punctures. Like electro physiologic procedures are more liable to have complications. Certain acts of sites are more prone to complications than others. Um We know that the communist access site that we use is the ephemeral approach, The common femoral artery um which doesn't really have a high risk of complications. But most of the complications are related to it because most of the procedures are done through it. But there are some exercise that are notoriously having a high complication rate, especially the break of artery. That's why we try to avoid using that artery as an access site for a procedure. So again, the proper management of vascular complications that we we we know we cannot avoid them completely, but we can reduce the risk. His first anticipation of the difficulty and that we alluded to. That is the patients will try to figure out who are the ones who are more liable to get a complication and plan ahead, choosing the appropriate procedure and the appropriate exercise is primary importance also. So if you have someone with heavily calcified, diseased femoral artery, you might resort to a different type of access so that we reduce the risk of complications, proper technical execution of the procedure goes without saying the better technical uh execution of the case, the less risk you're gonna have for complications above all, early recognition when a complication happens, it's very important to have a very high index of suspicion and know what are the warning signs and manifestations of the presence of a complication for early recognition because the earlier you recognize it, the better you're going to manage it in a timely fashion. And the less uh problems down the road and the better outcome you're gonna get. So what are the vascular complications we're talking about? We classify them into two different types. There are access site complications and non access site complications. Most of the complications are related to the access site and these include him thomas, to do aneurysms. Fischler's exercise, dissection, exercise, occlusion, neurologic complications, closures, device complications and retro, particularly a lot of complications. We're going to talk about some of those while we go through. There are also non exercise complications which are actually more ominous and uh things that we try to really avoid and that would be arterial ruptures, embolization, arterial dissection, distal ischemia of the limb, even spinal cord injury and pericardial tamponade. So these are the ones that are more dangerous uh and and more life threatening. However, thankfully they are much less common than the access complications which we will concentrate on today. Then we're going to talk about different exercise and some characteristics that are related to each of them will start with the common Communist one, which is the federal artery access. This is the Communist access. Used for endovascular procedure with a cardiac or peripheral. A large fraction of the access site complications are related to the femoral access. Not because it's a high risk for complications, but because it's most of the procedures are done through it. Um The key to avoid those complications is proper access technique and the most important step in that is the proper level. You want to access the common femoral artery just in front of the head of the femur. This is the primary most important step in avoiding complications of the groin. Single single wall access is better than trans fiction access through the double wall. Um That reduces definitely the complications of the growing ultrasound guidance was found to reduce the exercise issues and micro puncture access, although not uniformly accepted, but Um the micro puncture is a smaller needle. If you have a problem, it's a smaller problem. Uh you can always take the needle out, apply a little pressure and try again better than using the 18 gauge needle as an ax needle. When we talk about the the access level. Uh It's as we said, it has to be in front of the head of the femur. This is the area where you can compress the vessel really well. Uh If you're using uh compression for homeostasis, um this is above that area is a problem because if we get into the retro proscenium, whether it's a big space, you can get the retro hematoma, which is a life threatening problem below that level, you end up either sticking the S. F. A. Or the fonda with higher risk of occlusion of those vessels compared to the common femoral artery. And also a high risk of having hematomas. Because you can't compress those sites against bone as we see here. So the area is in the uh 23 centimeters below the inguinal ligament in the mid in going to point and it's always above the inguinal crease. And the early trainees will try to stick the femoral artery to the inguinal crease. And the inguinal creases, always always below the common femoral artery. So you have to be conscientious, especially in older people. The older patients. The lower the that grow increase becomes, and you know, if you stick in the grow increase, you most likely than not, you will have a low stick, The grow increases below the femoral bifurcation in 70% of cases. And as we said, both high and low stakes are associated with significant complications as we'll talk about later. The second exercise is the radial access, radial artery access and this emerged as the preferred approach for uh coronary interventions. Um It has many advantages, including reduced risk of vascular complications compared to the femoral artery with increased patient satisfaction. Actually reduced mortality in patients with them. Um It has its own interested challenges and it has a steep learning curve. It's complication profile is totally different from the femoral artery access, where the femoral artery, usually the complications are related to bleeding, but the radio artery are usually related to occlusion, Vascular complications requiring endovascular or open interventions are reported to be extremely low. Less than 1%. The complications of radial artery access are classified either intra procedure or false procedure. The inter procedure, communist complication is radial artery spasm and I'm not going to talk about that today. Um You will be much more educated and experienced about this than me and how it's managed. However, I'm going to talk today about perforation and hematoma, hardware entrapment, which is although a rare event, but it's very nerve wracking. And then both procedure complications are mostly related to radial artery inclusions. Um very rarely hematomas and compartment syndrome. And there are some other miscellaneous rarely occurring um complications that are usually not that dangerous. So today we're going to talk about the these four complications related to radial artery access. 1st. We're going to talk into a procedure preparation hematoma Thankfully it is rare. Less than 1% of cases. Usually the etiology is because of the anatomical variant of the radio artery. There is about 10-15% chance you have a high bifurcation of the break of artery which can be up in the Exelon. And this predisposes to the risk of perforation hematoma. Another important an atomic variant is the presence of extreme tortuous city or radial artery loops which predisposed to it. Prevention is always better than cure and it's composed of gentle technique and try to use a J wire, advancing advancement rather than an angled wire where the angled wire will try to get into smaller branches and pushing it will perforate them and cause the hematoma. Um Any resistance that happens when passing a wire deserves to have a an angiogram and that's for early detection detector and also detecting the anatomy of the vessel. Um And and so that you will know exactly the road map where you're going uh with your devices. Treatment is usually just by if it happens during the procedure, usually by advancing the catheter or the sheath across the area of the injury and that usually is enough to seal the hole and by the end of the procedure taking the sheet out the the perforation will have sealed. So usually you don't need to stop the calculation. You don't need to stop the procedure and you just go ahead and continue. Uh But just crossing that area of the injury hardware entrapment as we said, is very infrequent. Um Again, the etiology is related to the an atomic variant where high bifurcation or excessive tortuous city or looping um arterial spasm plays a role in where the the devices gets caught within the vessel that is in spasm. Um And and you can actually have nothing of the device simply if you're not careful with working your catheters while pushing them, especially if you don't have a wire through the catheter. And with that if you have some spasm in the vessels or an atomic variant, then you will get nothing of that catheter. And trying to pull that catheter out is not going to be easy. Um You would suspect the the entrapment by when you try to pull the device out, patient would have significant pain. He should not have pain. And if you have any pain in the forearm while pulling the device, you have to uh suspect the presence of entrapment. Another thing is with you pulling on the device and you start to have skin dimpling in the forearm that tells you where the area of the device is stuck. Um And the worst thing to do uh is try to just pull harder because that's how you evolve your vessel and destroy uh that radio artery. The treatment is usually you need to be innovative trying to help dislodge that device from the vessel and get it out safely. You can do that first by inter arterial value violators. Which will help to relieve the spasm which can be contributing to the entrapment. Um local reactive vessel violation. So if this doesn't work with criteria visa violators, you can do user and you you inflated proximal to the area of entrapment for five minutes. And that will lead to reactive high premium and vessel dilation of the vessel releasing the spasm. Um And and you treat the patients with all of the maneuvers including excessive sedation, uh better pain control all of that to help reduce the spasm factor as a cause of the entrapment. Now if you have a knot or a twist within your device, you will try to untwist it and to do that. You have to fix the tip of the device while you're talking the back end of it to fix the tip. You can try again the signalman on meter to to insert, flit around the approximate area of approximate tip of the device. And and the hope that that will fix the proximal tip and try to rotate the uh different in a different direction. Um That's why we talked about, you have to be conscientious with talking and what direction of talking you're doing so that you will undo it uh in the to try to take it out. Um If this doesn't work another way of uh fixing the tip is to come in from a different access site, snare the tip and fix it in place. And that will allow you to again torque the device approximately and unwind it and be able to pull it out. If all of that fails. You can use the swallow uh technique using a bigger sheet to swallow that whole catheter which is twisted within the sheet the way to do that. Uh If you look here, you see in a this is a catheter that is twisted upon itself with having a kink. Um you cut that catheter and on the outside, full original sheets that's short and replace it with a longer sheet that is bigger in caliber and push it over that catheter all the way up to like if you look at e. This is the tip of where the sheet is the new she's tip and then that will be able to pull the catheter through the sheath and actually unwind it and pulling it out. Procedure hematoma and compartment syndrome again are rare to happen between one and 2.5% of cases usually is mild and self limited. Again, anatomical variants including high bifurcation, tortuous city and loops or the Communist reason for its occurrence. Usually it's treated conservatively by proximal compression using a stigma, manama, local compression on the hematoma and close observation Compartment syndrome on the other hand is an ominous uh complication, thankfully it is extremely rare. Less than 0.05% of cases. However, when you suspect that early recognition is very important to avoid the equality, which can include uh significant neurologic deficit and loss of the limb. And the treatment for those cases would be essentially facial to me to decompress the fashion planes and the nerves inside. Uh You can see how over a significant operation that shot to me is for the forearm. And usually those patients will suffer significant neurologic deficits Following these procedures, however, they still remain having an arm which is really important. Radio artery occlusion. This constitutes the most common post operative complication of radio artery, about 2-10% of cases. The high risk factors include again females, uh small radial artery less than two millimeters radial artery sheath To radio artery size more than one and prolonged procedure and multiple access attempts. All of these are factors that can uh lead to the radio artery occlusion. Usually it is without clinical equality. The only problem is if you have an occluded radial artery, you can't access it again for doing another procedure in the future. And if you intend to use that artery as a conduit, you lose it because it's already included. The prevention is using smaller sheets, the smallest possible sheets um and and patent homeostasis. That means when you take the sheath out, you try to compress the artist is the way to obtain homeostasis is compressing the artery, but compressing it just enough to stop the bleeding, but not to include the artery itself. Another maneuver that helps to improve the flow through the artery While performing compression is to compress the ulnar artery to on the same uh hand. And with that you will improve the flow through the radial artery because now it's the only artery that's supplying the hand and that will help to reduce the risk of occlusion of that artery. Of course, if it's diagnosed, patients are placed on anti coagulation, we don't have to do surgery on. Those people accept that they're symptomatic and this is extremely rare. A lot of those patients down the road will have recapitalization of their vessel again And Ischemia thankfully is extremely rare. Less than 0.1% of cases with occlusion of the radio artery. The high risk factors are smokers, especially patients with Reynolds phenomena and renal disease, which are essentially contraindicated to use radial access, hyper collectible states, significant peripheral theo collusive disease. Uh patients in shock and as oppressors for following the procedure are more liable to have hand ischemia. The management is surgical intervention always. However, the prognosis when it happens, even though it's a rare event. But when it happens it has a bad prognosis and patients will definitely have or most of the time will have some type of tissue loss. Hopefully with a procedure we will try to limit that amount of tissue loss. Whether that's open, throw back to me repairing the vessel the patch and plus the interposition grafting. Um And sometimes we use intra operative from dialysis to open up the vaster bed distantly. Which can uh completely include in those cases. That's why they develop the hand ischemia which is rare event. The next access site is the breaking of artery. And again it is not a preferred site for access complication. Risk is significantly higher than the femoral artery, which is about 10%, compared 3-4% um in the femoral artery, the an atomic predisposing factors to brachial artery access site complications is that the brachial artery is considered an end artery. There isn't much collateral ization around the elbow. Um So if the radial artery gets occluded, there is significant ischemia of the arms. Also another significant uh an atomic um risk factor is the medial break. Your fashion compartment. This is a facial sleeve that is around the neurovascular bundle of the upper arm surrounds the brachial artery vein and the nerves including the median and the owners and any bleeding that happens from the access sites will collect into that tight fashion sheets which will perform what looks like a localized compartment syndrome. And that will need to significant nerve damage even with a smaller sized hematoma. So that's why the risk of having a hematoma related to the exercise of the brachial artery is extremely high compared to having a liter of blood in the thigh. And still the patient will will do fine. Um Also there is difficulty compressing the brachial artery. There isn't really a good pony landmark that you can used to compress it appropriately. And there's a lot of mobility of the brachial artery in the upper and the upper arm, which will make hey more stasis using compression very difficult to avoid anything above six french ships access needs to be surgical cut down. We use the brachial artery a lot when we're accessing the vessel vessels. We were doing uh demonstrated bars, administrated graphs and branched into graphs. And we usually use a seven french sheets. And for all of these cases we do a cut down. We do not just do a cutaneous access because we know there is a high risk over 10% 10 15% risk of collusion. Um both hematoma and arterial collusions are constitute 5050 of the complications of the radial artery and both are bad. Uh it's a hematoma. Um As we said, small hematoma can cause significant nerve damage and that can be permanent. And uh occlusion will significant. Uh S kenya of the forearm. Uh digitally closure devices can be used in closing uh per continuously the access site and the regular artery. But I don't recommend it. It's outside the i a few and it has a significant risk of uh thrombosis and it doesn't reduce the risk of him at all. This is the an atomic uh huh basis for the complication where you can see here the brachial artery. In addition to the omni and median nerves. They are all invested in a tough layer of fashion. This is where you have a small hematoma. It will be like a sausage like him. We might not even feel it on the outside, but it has significance equality on that. The next exercise is the auxiliary artery and the axillary access site. Actually is the second exercise. We can use large caliber that allows the use of large access sheaths for complex cardiac procedures and awarded to graft repair. Um We use it routinely in vascular performing branch and the graphs. Um In in cardiac surgery, it can be used for taverns and mechanical circulatory support. Most of the access in the past, when we started using auxiliary access was using open approach with the subclavian uh incision. Um However, recently more approach to the axillary artery has been used pre closed technique exactly like what we do in the groin, where we use to proglide devices once we obtain the access um and uh without tying them down, use our large sheets. And then at the end after removing the sheets, we will close uh the access site. And now the axillary artery access has a steep learning curve. The first few cases you have to be very cautious. Use smaller sheets. Um um And and the more you will use that as a site, the more facility you'll be with it in in the less complication rate you're going to have accessing the axillary artery needs to be in the third part of the auxiliary artery and just uh an atomic provisions here, the axillary artery starts and the outer border of the first trip as a continuation of the subclavian artery and ends at the lower border of the theorist major muscle. In the, Divided into three parts by the petrol minor muscle. And when we access the break the axillary artery, we try to do it in the third part. The reason for that is it's away from the thoracic outlet. It's easier to control if we need to do open surgery on it. But we have to be cautious because this is part of the artery to where the break of plexus starts to surround itself around the auxiliary artery compared to the proximal axillary artery where the break of plexus is completely behind it. So it's less risk of regular plexus injury. Now this is the the an atomic landmarks the clavicle and the where the radial artery. Sorry, auxiliary artery and vein are ultrasound is definitely used to identify the axillary artery and vein. Then um. Using the using usually micro puncture here in this picture, it shows the 18 gauge. I use always a micro puncture again, smaller needle, uh smaller uh mistake if it happens, then Replaced the two proglide devices first. And after that we can use this big sheet to hear. They're using 12 French sheath with Telescoping seven French to select the corresponding vessel vessel that we use in a branched device and then at the end. Um While taking the sheets out uh maintaining wire access. We close the the exercise uh Using the proglide placed during early in the case. But before losing the wire, we have to make sure that the access site is completely closed. And that requires a different site of access. Secondary size of access, which is usually the femoral artery. Uh You come from the femoral artery access into the axillary artery and perform an angiogram prior to removing the wire to make sure that the artery is patent. Uh Then there is no dissection and there is no bleeding. Um One of the techniques used here is to use a balloon through that secondary excess site and that balloon is a little kind of a millimeter or so smaller than the size of the artery itself. And what you would do with that is you inflate it while you're snitching down the uh proglide devices. And what that would do is uh gonna help to allow the field to completely be dry while you're doing the closure instead of bleeding until the closure is completed. Because there is difficulty using compression um for those proglide while performing the closure compared to the femoral artery where we can use compression. But in the auxiliary artery it's going to be difficult. And this is the end result of how it would look like Large cheese can be used with the axillary artery access. Which is an advantage up to 20 French has been reported, the puncture site has to be tested again proper prior to losing the wire and that's usually as we said, through the femoral approach. However, uh different other approaches can be used like the brachial artery or the radial artery. Problem with. That is it's usually only of diagnostic nature because if you try to do an intervention for a bleeding or uh dissection or stenosis, you will need usually a larger device that you don't want to put through the radial artery and the radial artery. We just talked about how bad of an access it should be. Now you might not after you become facile with with doing the axillary artery access, you might not need the secondary access. You can uh push a micro puncture sheath over the wire, lose the wire and use that sheath to test the area and make sure that the the the area is famous static and there is no significant dissection or stenosis or occlusion of the vessel. And in which case you replace back the wire completely snitch down the pro glides and take the wire out. But this I would not recommend doing that early on in the experience manager of the complications are likely to be performed using into vascular means that's why we have to have a if it happens, we need to have a secondary access site. Open surgery can be used and facilitated by a wire and sheath through the vessel where you can do balloon control and third party access, third part of the artery access uh is important again because this will make the access site easier uh to find and do proximal and distal preoperative planning with a. C. T. A. For the axillary access is mandatory to evaluate the anatomy of the auxiliary artery and the subclavian artery. Make sure that there isn't much tortuous city, there isn't much calcification which can be actually proved to be disastrous If it's the case, Hematoma is the commonest complication up to 6% of cases. Uh it gets lower with more experience and rarely needs an intervention by section. And stenosis can usually be managed inter operatively using endovascular means by using another remote exercise as we talked about. And this limits leukemia is rare um Compared to the trans femoral approach because there is a robust lateralization around the shoulder, something that's not present in the common femoral artery. So um the the you can have total occlusion of the axillary artery after removal of your sheet. And then and even with that you can have actually a palpable radio pulse. Of course the blood pressure will not be the same like the other arm. But uh definitely it's very rare to have uh huh ischemic upper extremity from axillary artery occlusion. And if it happens treatment is the same. Either endovascular means by standing across the area or open exploration. And uh whether that's patch angioplasty endarterectomy. And so this is how the collateral ization around the shoulder is. And you can see here this is this green ligature. You can actually litigate the artery there. And again, you can have a possible policy. We're then going to talk about selected bachelor complications irrespective of the site. Most of them are related to the femoral access site. The first being a hematoma and the access site hematoma is the communist vascular complication across the board. The incidents and significance varies by the access site. Um transfer moral approach carries between two and 12% uh hematoma uh incidents. And uh usually most of them are self limited and conservatively treated Hematomas requiring blood transfusion and invasive procedure. Or less than 1% of cases. And there are some independent predictors of hematoma requiring transfusion. That includes older age. Again, females chronic renal failure, large sheet size patients in emergency situations and using GP two B 3 inhibitors and from politics, surgical exploration may be indicated. Um And usually that's in case of severe pain and you're a crack CIA or compromise of the overlying skin essentially. It's a d compressive uh This is a hematoma here in the thigh. Again, it's a low uh low stick. This is how you develop a hematoma that can be significant and pretty uh big I have had patients who had a couple of liters of blood in the thigh. And usually in those cases you can see up here, there is a skin blister um up there where the skin is starting to buy out and this is an indication for ah decompression of that hematoma. Pseudo aneurysm is another very common complication related to especially ephemeral exercise incidences between half to 6%. It's more common following interventional procedures compared to diagnostic procedures. Obesity, S. F. A. And profound punctures. Sites are common predisposing factors. Uh Most of them will resolve spontaneously within three weeks. So we don't really treat all of pseudo aneurysms. Only indications for treatment are either large pseudo aneurysm that's causing symptoms in the patient or pseudo aneurysm larger than two cm or any size when the patient is continued on anti calculation, the diagnosis is usually clinical again high index of suspicion with swelling in the groin hematoma or some pain. Ultrasound is always diagnostic. Find the pseudo aneurysm identify its neck, identify the anatomy if it's multiple. Ocular single low key. Oh um um C. T. A. Performed. And then we have a lot of patients who got C. T. A. For other reasons and accidentally discovered of a small pseudo aneurysm. Most of these cases don't need treatment. As we said, this is how it will look on ultrasound and there is the pseudo aneurysm will look like a lot Oculus with a yin and yang appearance flow because it's too and and down here in the D. You can see the pseudo aneurysm has three locals. And if we're going to treat that pseudo aneurysm just treating the first lock you'll next to the artery will be enough taking care of the rest. The the treatment is either external compression which is most of the time is effective. Um If that doesn't we can use duplex directed external compression by the vascular lab. However this is time consuming not appropriate. Use of the resources and pretty uncomfortable for the patients using the dr probe to compress the neck of the pseudo. Uh more likely what we use nowadays is duplex directed from the injection. And uh you can see here this is the ultrasound, this is the flow pattern and this is here injecting this the thrombin within the pseudo aneurysm and you can see immediately you see the snow flaking effect and complete resolution of the pseudo. Now the amount of thrombin we inject is actually 0.1 millimeter. It's extremely small dose. We don't fill it with thrombin. We actually just put a really really tiny amount. That's why when we talk about the embolization and risk of thrombosis of the femoral artery. It's not that common to happen. Um uh In those cases um Open repair is usually reserved for patients with failed D. D. D. I. But more reason for open repair is someone who comes in with a pseudo aneurysm that is old. Someone or other procedure let's say two months ago and is coming back and there is a pseudo aneurysm related to the procedure it's very unlikely too that the thrombin injection will help actually from an injection came from both the pseudo early on but it will wreck analyze because usually that pseudo aneurysm is now industrialist in the psyllium is the enemy. For from avery fisher Is another complication related to the growing incidence is less than one more frequency. In cases where both the artery and vein are access, it's usually asymptomatic usually does not require treatment and a lot of them will heal spontaneously. It can be associated with the aneurysm in which case the treatment, preferably is not using uh thrombin injection because of fear of embolization up to the lung, ultrasound ct or angiogram are all diagnostic which will show the early filling of the vein with arterial ized flow within the vein. Treatment is usually conservative. As we said accepted. The patient is symptomatic symptoms will be either significant pain and it's usually related to a big pseudo aneurysm compressing the nerves next to it, significant leg swelling. Uh And that's usually from venus hypertension or exacerbation of heart failure, which is a high cardiac output failure. These are rare events in which situation the treatment active treatment is needed. Again, this is an ultrasound picture showing the common femoral artery and vein with arterial Ized flow within the vein and the treatment is usually endovascular uh usually through an arterial exercise, usually from the contra lateral common femoral artery. Again, duplex directed from an injection is usually avoided. We can use coils or plugs flood the communication between the artery and the vein and uh sometimes we can't really identify that uh communication or the complication is pretty complex in which case a covered stent is used. If the usually a navy official is related to profound access or S. F. A. It's rare to happen from common femoral access. But if it is usually surgical approach is needed because we don't want to put a covered stent in the common sense. Now, if we have to do open surgery for those cases, they are extremely difficult. They are not simple. They are not simple to find. Usually the artery and vein are so much uh stuck to each other. And there is a significant chance that you're going to injure the vein while you're doing the dissection has significant blood loss. Exercise of illusion, is more common in the radio and Rakell artery access. Uh Radio artery is usually without sequel, but in the regular access, it's it's a bit of a problem. It's less common in the femoral access. And maybe due to prolonged cases with insight of thrombosis localized by section or as a complication of vascular closure device. Preoperative vascular exam is primary importance. So the patient. Before you do any procedure, you have to know what's the baseline clinical exam of that patient because you compare post operatively his clinical exam and vascular exam to what it was pre operative. Any difference should raise the suspicion that there is a problem and this is how you identify those cases because early on they might not have symptoms can be difficult to evaluate in emergency situations, especially if the patient is crashing or intubated. High index of suspicion is the key for early detection. As we talked about immediate vascular consultation. Usually hybrid repair is needed where the patient is taken to the O. R. Will do open exploration, opening up the vessel, cleaning it up and sometimes endarterectomy with the patch. But at the same time we have to go a retrograde fashion and perform an angiogram. Make sure that there is no dissection upstream that will need treatment exercise arterial dissection usually the the the the. Yeah the the incidence is underestimated because all most of them are usually asymptomatic and accidentally discovered. Risk factors include either high or a low stick heavily pacific vessels, tortuous, iliac and large sheets Used diagnosis can be intra procedure or post procedure which is usual case scenario where the patient had a C. T. A. Or a duplex ultrasound for a different reason and found the dissection. The dissection is asymptomatic. It doesn't need anything done. I mean we treat those patients conservatively and a lot of them will recover and the dissection will heal because usually the dissection is retrograde fashion. So with the flow it actually tax the flash and and and things get better over time. However in symptomatic patients with flow limiting dissection. um we will need to treat that most of the time can be treated by balloon angioplasty alone or with standing if it's in the iliac vessels. But if a dissection that's flow limiting is affecting the femoral artery. The best thing to do is open exploration with endarterectomy and patch angioplasty which is actually a simple procedure can be done expeditiously. Retro personnel hematoma Is the most dreaded life threatening complications thankfully it's rare less than 1% of cases. However if it happens there is about 6% mortality rate which is extremely high. Risk factors as we said includes a high stick where the stick is above the inguinal ligament. Female patients. Again anti coagulation and GP two B. Three A. Inhibitor diagnosis depends on high index of suspicion. Early on you have to look at the subtle manifestations that this patient might have a retro hematoma, presence of a high stick dominant and back pain, lower quadrant tenderness even without the swelling, unexplained hypertension. All of these are red marks That will tell you there is a possibility of retro hematoma. If you suspected the C. T. A. Is very important because it will show you if there's a martoma or not what's the size of the hematoma whereas the site of the injury and above all if there is active extra visitation or not because if there is no active extra visitation most of those patients will recover with conservative therapy if there is active extra position that will tell you we need active management whether that's in the vascular or open the I have seen a lot of non contrast city. I mean non contrast ct doesn't tell us much because usually if you're doing a ct scan, you're suspecting a hematoma. You know it's there. You just want to know its character. If you do a ct without contrast, it doesn't tell you much. Just there is a hematoma if there is active bleeding or not, where is the injury? Where do I need to treat? You have no clue. So, you know, doing a ct without contrast is really self serving. It doesn't really add to the to the to the diagnosis C. T. A. Again, the management is usually conservative with correction of co ags blood transfusion. The research station in him. A dynamic and unstable patient where there is extra visitation, emergency intervention is needed. Whether that's by covered stent placement or open repair which usually is just a simple stitch in the distal external iliac artery which would be enough. We can't finish the talk without closure device complications and closure devices. They were found to reduce the time to homeostasis and reduce the time to ambulance nation and improve patient comfort. However, closure devices have not demonstrated reduced leading complication. Salvation is whether they use close your devices or not, they will get the bleeding complications. You just have to treat them the same way complications related to closure devices are either failure of the device with bleeding or malfunction of the device leading occlusion or both. We have a lot of patients who come in with a closure device failure where the vessel is totally occluded, but still it's leading to. And we have a lot of that with the manta device when we're doing taverns. You know, a lot of the failure modes is not just bleeding, it's bleeding and inclusion. So these are some of the available or most of the devices used nowadays. And there are two types of those devices, one of them, they call them here intravascular. They are active devices. What they do? We are essentially going after the hole in the vessel and treating it. Whether that's by plugging it and putting an anchor on the inside that's for the angio seal and the manta device. Or using a stitch like the proglide or using a National Star, which kind of snitches on the vessel. These are active ways of closing the hall. The extra vascular ways, they're essentially not dealing with the whole but dealing with the track in front of the vessel and you usually just plug that track, allowing reduced time of compression to secure him. And all of these devices are good. There is no one device better than the other, definitely the manta and the frog glides. They are important for large sized access. Um And and you know, you you use whatever you feel uh comfortable with using another important subject is mechanical circulatory support. We have a lot of patients who have ventricular assist devices. ECMO uh impeller. All of these, those patients are constituting the perfect store patients are usually vascular path. They have large bore access in a small disease. Perfusion is always love. Anyway. They are already on massive pressures. The patient is usually out of it and you can't have a clinical exam on them and the flow is a lot of times it's not even pulse, it'll so it's really difficult in those patients to say if their leg is scheming or not, you have to have very high index of suspicion for lega scheming of those patients. A lot of patients lose their legs from this because you put in your device, you're saving their lives. But the leg is hyper fused. And many centers have used routine list of perfusion sheets used per cutaneous lee. Get into the S. F. A. Or into the brachial artery. And that will allow anti great flow using the side arm of the sheets from the big device. And uh you can use it selectively. But you know where I came from when I was in Houston. It was a mandatory anyone who has circulatory mechanical circulatory support device needs to have an anti great sheet when we take this sheet out including the big device and we need to do that under open surgery because a lot of times there is clot that start to develop around those devices and we have to clean the vessel, not just taking them out and leaving the cloth. We can't finish the talk without vascular complications related to tackle devices. You know, major vascular complications associated with tavern has improved significantly over the years. Currently. It's between the range between six and 8%. I remember early on and they experienced back in the 2010, we had a lot of complications related to it. Nowadays. It's much better. This is due to better patient selection, improvement technique, learning more about the procedure and improvement of the devices. The devices are smaller. They're more flexible Vascular complications are associated with increased higher uh significantly higher 30 day mortality in patients with taverns. And again, risk factors include older vessels, vascular paths, multiple com abilities and large board access. There are ways to try to avoid and reduce the risk of having a significant vascular complications. One of them is very important to have preoperative ct A. That will show you exactly the anatomy. What's the pathology on the iliac vessels? The axis vessels? How much virtuosity we have, decides which side you use the right side or the left side improvement in the access procedure. As we talked before, laparoscopy, ultrasound, micro puncture, etcetera, avoid rough manipulations, pushing harder is not better. You know, because a lot of times when you do that, you're going to destroy the vessel. And sometimes it's not just pushing harder if you push harder and get the vessel in the device and a lot of times getting the device out will lead to the complication. With structure of the vessels, retain evaluation of the There are there have been recent technique of shockwave life. So plastic. I'm not sure you've used that here already, but we we are actually using it uh in multiple vascular beds including the karate. We do transkaryotic stents now with with shockwave light of plastic. Oh wow. Routine evaluation of the ephemeral region is important via secondary access. And some of the centers I think here they do the same. They always check the iliac uh side of the axis side by contra lateral access through the other common femoral artery. Some centers actually have even a safety wire that at the beginning of the procedure they pass an 018 wire from the contra lateral side to maintain access throughout the procedure. And if there is a problem with the access, they can have already already made access across it. Improved vascular closure devices is actually important in reducing the risk. Although every now and then we get a consult with you know, for a failed Manta which happens to about 10% of cases an early vascular consultation when something wrong happens is very important because that will again, we know that we can't really completely avoid having a vascular complications. But it is important if we have one to treat it appropriately. So the take home messages from today is vascular complications, are here to stay, anticipate the difficulty and always have a proper setup on plan ahead. Each exercise has its own characteristics and complication profile, high index of suspicion, every recognition and timely management is the key to have a good outcome. Management is usually endovascular. However, open surgery is not considered a defeat in the management of this case. Thank you very much.