Access-site complications in ultrasound-guided endovascular thrombectomy: a single-institution retrospective cohort study

Abstract

OBJECTIVE Mechanical endovascular thrombectomy (EVT) is an increasingly relied-on treatment for clot retrieval in the context of ischemic strokes, which otherwise are associated with significant morbidity and mortality. Despite several known risks associated with this procedure, there is a high degree of technical heterogeneity across both centers and operators. The most common procedural complications occur at the point of transfemoral access (the common femoral artery), and include access-site hematomas, dissections, and pseudoaneurysms. Other interventional fields have previously popularized the use of ultrasound to enhance the anatomical localization of structures relevant to vascular access and thereby reducing access-site complications. In this study, the authors aimed to describe the ultrasound-guided EVT technique performed at a large, quaternary neurovascular referral center, and to characterize the effects of ultrasound guidance on access-site complications. METHODS A retrospective chart review of all patients treated with EVT at a single center between January 2013 and August 2020 was performed. Patients in this cohort were treated using a universal, unique, ultrasound-guided, single-wall puncture technique, which bears several theoretical advantages over the standard technique of arterial puncture via palpation. RESULTS There were 479 patients treated with EVT within the study period. Twenty patients in the cohort were identified as having experienced some form of access-site complication. Eight (1.67%) of these patients experienced minor access-site complications, all of which were groin hematomas and none of which were clinically significant, as defined by requiring surgical or interventional management or transfusion. The remaining 12 patients experienced arterial dissection (n = 5), arterial pseudoaneurysm (n = 4), retroperitoneal hematoma (n = 2), or arterial occlusion (n = 1), with only 1.04% (5/479) requiring surgical or interventional management or transfusion. CONCLUSIONS The authors found an overall reduction in total access-site complications as well as minor access-site complications in the study cohort compared with previously published randomized controlled trials and observational studies in the recent literature. The findings suggested that there may be a role for routine use of ultrasound-guided puncture techniques in EVT to decrease rates of complications.

Factors for failure of ultrasound-guided compression repair for femoral pseudoaneurysms after neuroendovascular therapy

“…Pseudoaneurysms at the femoral artery puncture site have a low incidence of 0%-2%. 2,3,[8][9][10][11] At the time of onset, acute persistent pain at the puncture site, an expanding hematoma, a pulsating mass, palpable thrill, decreased hemoglobin level, hypotension, distal ischemia, tachycardia, chronic persistent pain due to compression neuropathy, clinical evidence of local site infection, and incidental findings can occur. [2][3][4]12 As factors that cause pseudoaneurysm, anticoagulant/antiplatelet drugs, emergency catheterization, large sheath, obesity, women, hemodialysis, hypertension, inadequate post-sheath removal compression, superficial femoral artery puncture, atherosclerotic common femoral artery, and simultaneous venous and arterial catheterization have been reported.…”

Management of Acute Complications during Endovascular Procedures in Peripheral Arterial Disease: A Review

“…1 The assistance of fluoroscopy and ultrasound (US) during arterial access reduces the incidence of access site complications. 2 hypertension. [3][4][5][6][7] The recommended site for the common femoral artery (CFA) access is over the lower third of the femoral head below the inguinal ligament.…”

“…1 The assistance of fluoroscopy and ultrasound (US) during arterial access reduces the incidence of access site complications. 2…”

Mechanical Thrombectomy for Ischemic Stroke Secondary to Large Vessel Occlusions in Patients on Extracorporeal Membrane Oxygenation

“…Arterial access to perform MT for these cases must take into account the presence of ECMO cannulas, central access lines, arterial lines, or the presence of IABP. The use of ultrasound to obtain arterial access during MT is associated with lower access site complications and is recommended in ECMO patients as they are often on anticoagulation or have hematologic abnormalities including thrombocytopenia [16]. Moreover, ultrasound is especially important in cardiogenic shock patients since the continuous blood flow from MCS devices may reduce the pulse pressure, resulting in a significantly diminished or absent pulse [17].…”