Complications and great escapes: equipment and techniques

Abstract

All endovascular procedures have the potential for complications. The primary aims should always be avoidance of preventable complications and to minimize the impact of any complication. The core principles of an effective preventive strategy are: involving the interventional and clinical teams in a clear outline of the procedure and its potential adverse outcomes; ensuring an adequate inventory of required and backup equipment; the use of "time-out" to minimize wrong patient/wrong side adverse events; and an active audit program to identify areas of improvement. In the event of an adverse outcome there are many strategies that can be employed to rectify the situation or minimize the iatrogenic injury. This article provides a case-based discussion highlighting some of these techniques and how they can be used in a clinical setting.

Keywords: complications; distal embolization; iatrogenic arteriovenous fistula; iliac arterial rupture; interventional radiology; thrombolysis; vascular snare.

Figure 1

Embolism of the contralateral limb following stent placement. (A, B) Following stenting of the right CIA, there are large emboli in the left EIA (arrow), CFA (solid arrow), and profunda femoris (arrowhead) arteries. (C) Following restoration of flow in the left SFA, the left popliteal artery occlusion is confirmed (arrow). (D) Following overnight thrombolysis there is residual nonobstructive thrombus in the distal CFA and profunda femoris (arrow). CIA, common iliac artery; CFA, common femoral artery; EIA, external iliac artery; SFA, superficial femoral artery.

Figure 2

Accidental stent malposition. (A) The balloon mounted CP stent herniated off the balloon (arrow), and the cephalic end partially expanded. (B) The delivery sheath is impacted in the inner lumen of the CP stent (open arrow), and the caudal end of the stent is now partially deployed (closed arrow). (C) A snare retrieval device (arrow) has been placed from the left upper limb around the partially opened cephalic end of the stent, and the cephalic end of the stent closed by the snare. (D) The stent and sheath have been pulled back into the abdominal aorta. A snare has been placed from the left common femoral artery (arrow) and is used to secure the stent in position for capture by a new balloon. CP, Cheatham platinum.

Figure 3

Rupture following angioplasty. (A) Preangioplasty angiography demonstrates a stenosis above the left CFA patch graft (arrow). (B) Angiography postangioplasty demonstrates contrast extravasation (arrow) consistent with CFA rupture. (C) Following deflation of the left EIA balloon, the contrast extravasation from the left CFA has ceased, but significant stenosis remains (arrow). (D) Completion angiography following deployment of an 8-mm covered stent (between arrows) demonstrates the resolution of the stenosis as well as the resolution of the contrast extravasation. CFA, common femoral artery; EIA, external iliac artery.

Figure 4

Iatrogenic arteriovenous fistula noted during recanalization procedure. (A) Postangioplasty angiogram demonstrating contrast extravasation (open black arrow), extra-arterial position of the distal catheter tip (solid black arrow); and persistent occlusion of the SFA (open white arrow), (B) poststenting angiogram demonstrates contrast-filling multiple venous structures of the leg (open black arrows) as well as visualization of the distal stent in a vein (solid white arrow). (C) Angiogram following coiling (arrows) of the stent to close the arteriovenous fistula.