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Complications of percutaneous procedures
American Journal of Emergency Medicine (2011) 29, 802–810
www.elsevier.com/locate/ajem
Review
Complications of percutaneous procedures Esther H. Chen MD a,⁎, Alexander Nemeth MD b a
San Francisco General Hospital, University of California, San Francisco, CA 94110, USA Hospital of the University of Pennsylvania, Philadelphia, PA, USA
b
Received 13 October 2009; revised 6 May 2010; accepted 15 May 2010
Abstract Minimally invasive percutaneous procedures are increasingly being performed by both interventional radiologists and noninterventionalists. Patients with postprocedural issues will likely present to the emergency department for evaluation and treatment. This review focuses on the evaluation and management of the complications of common percutaneous procedures. © 2011 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous interventions are often associated with lower morbidity and mortality, compared with traditional surgery, and provide an alternative for patients that may otherwise be poor surgical candidates. Because they are minimally invasive, these procedures are increasingly being performed by interventional radiologists and noninterventionalists. Consequently, patients with postprocedural complications are now routinely encountered in the emergency department (ED). Although some require specialist consultation, many postprocedural issues may be effectively evaluated and managed by emergency physicians.
2. General complications Complications common to most percutaneous interventions are related to the percutaneous access, contrast injection, and radiation exposure [1]. Puncture site-related issues typically occur during or immediately postprocedure. However, patients may return to the ED within the first 24 to 48 hours with puncture site hemorrhage, pain from arterial dissection, and swelling from a hematoma or pseudoaneurysm. Hemorrhage may be controlled with 20 minutes ⁎ Corresponding author. Tel.: +1 415 206 4354; fax: +1 415 206 5818. E-mail address: [email protected] (E.H. Chen). 0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2010.05.010
of direct manual compression over the vessel [2] and correction of underlying coagulopathy. A painful lump that forms within the first 1 to 2 days may be a hematoma or pseudoaneurysm and, if occurring after a week, an arteriovenous fistula or abscess. Ultrasonography is a helpful diagnostic adjunct to the physical examination to distinguish between these processes. Arterial manipulation may cause clots to embolize, causing distal limb ischemia. Furthermore, limb edema and pain may be caused by site thrombosis, an occlusive or nonocclusive deep venous thrombosis (DVT) that may develop after 1 to 2 weeks. Finally, it is important to recognize that both arterial emboli and DVTs may occur in the contralateral limb because a single puncture is often used to treat bilateral disease. Contrast material used during the procedures has several adverse effects. These include idiosyncratic (anaphylactoid) reactions, anaphylaxis, and contrast extravasation [1]. Patients may be given up to 4 mL/kg of intravenous contrast, about twice the quantity injected for an abdominal/pelvis computed tomography (CT) scan. Discharged patients may return 1 to 2 days later with contrast-induced nephropathy (CIN) [1]. Factors such as diabetes, chronic kidney disease, advanced age (N70 years), congestive heart failure, and use of high osmolar or high viscosity contrast may increase a patient's risk of developing CIN [3]. Although it is the third leading cause of hospital-acquired renal failure and associated with increases in short-term and long-term mortality, for most patients, CIN may be treated supportively by
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optimizing hydration status and assuring close physician monitoring until resolution of the renal impairment [4]. Finally, because most procedures are performed using fluoroscopy, patients are exposed to varying degrees of ionizing radiation, depending on the type and difficulty of the procedure [5]. For example, the average cumulative dose for an inferior vena cava (IVC) filter placement is 0.2 gray (Gy) (1 Gy is equivalent to a joule of energy absorbed per kilogram), but it ranges from 0.01 to 6.8 Gy, and that for uterine artery embolization (UAE) is 2.5 Gy (0.02-7.0 Gy). The highest exposure occurs to the skin at the entrance of the radiation beam. At a dose of 2 Gy, the injury to the skin is manifested by erythema, pain, and superficial skin breakdown, similar to a superficial or deep superficial burn. Treatment of skin injury is pain control and good wound care, with close monitoring for the rare progression to skin necrosis and chronic ulceration.
3. Procedure-specific complications 3.1. Vascular: venous procedures 3.1.1. Vena cava filters Vena cava filters are classified as permanent (ie, Greenfield) or retrievable [6] and typically implanted in the IVC, although other veins (eg, iliac, subclavian, superior vena cava) are also used [7]. Filter complications, either device-related or thrombotic events, may occur at any time after insertion but generally increase with dwell time [6,8]. Filter migration and filter strut fracture (Fig. 1) are devicerelated issues that were reported more frequently with older permanent filters compared with those placed in the past 6 years (5%-30% [migration] and 2% [strut fracture] vs
Fig. 1
0.3%-3% and 0%, respectively) [6,8,9]. Filter or strut migration may be entirely asymptomatic or cause pain in the vasculature resulting in end-organ damage. In contrast, IVC penetration by the filter has increased recently from 10% to 95% with the newer filters [6,8], an anchoring improvement that may partially explain the decrease in migration rate; through-and-through caval penetration is rare. Patients with filter migration or caval penetration may report tearing pain in their groin or flank followed by fever or signs of organ dysfunction (eg, small bowel obstruction, duodenal perforation, rectal bleeding). They require CT imaging for diagnosis and immediate interventional radiology (IR) consultation for filter removal. Very rarely, a filter may migrate to the heart causing myocardial perforation or life-threatening arrhythmias [8]. In addition, the filter itself may become infected, causing abscess formation and sepsis, which, though uncommon (1.2%), is potentially life threatening [9]. A more recently recognized device-related complication is entrapment of J-tipped guidewires used to place central venous catheters in the IVC filter. Because of the usual infrarenal position of the filter, femoral catheters have a higher risk for wire entrapment, although cases involving internal jugular wires have been reported [10,11]. In patients with a known IVC or superior vena cava filter, using the straight end of the wire is preferable to the J-tip. If any resistance is felt during wire withdrawal, tape the wire to the patient and immediately obtain a diagnostic abdominal radiograph. If the J-tipped end is ensnared in the filter, try to advance the wire to disengage the tip from the filter and then extend or straighten the curved J-tip by immobilizing the wire proximally with one hand while applying traction distally with the other hand [11]. If this maneuver fails, emergent IR consultation should be obtained for fluoroscopic removal.
Inferior vena cava filter strut fracture and migration.
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3.1.2. Venous access catheters and ports Central venous catheters and ports are either tunneled (ie, part of the catheter is embedded in the subcutaneous tissue) or nontunneled and often placed in the internal jugular or subclavian veins. Early postprocedural complications (within 24-48 hours) include pneumothorax (0.2%-2%), hemothorax, brachial plexus injury (rare) causing radicular neck/arm pain, or phrenic nerve injury (rare) exhibited by an elevated hemidiaphragm [12]. Treatment is not required for small, stable pneumothoraces, nonexpanding hematomas without vessel or airway compromise, and any brachial plexus or phrenic nerve injury. Other procedure-related issues include infection (fever with or without erythema and pain at the catheter site), DVT, or catheter malfunction (inability to inject fluid or aspirate blood) [12]. Infections occur in fewer than 20% of all access devices [13], with clinical presentations ranging from a local cellulitis to port pocket abscess to line-related septicemia. Treatment of line infections varies by institution and often depends on the clinical scenario. Uncomplicated local infections in immunocompetent patients may be treated with oral antibiotics without catheter removal and close outpatient follow-up, whereas catheter removal is recommended for most patients with systemic infections and underlying venous thrombosis (eg, septic thrombophlebitis). Aside from causing infections, venous access devices may malfunction. Associated arm swelling may suggest venous thrombosis (occurring in 35%-65% of central vein catheters) or catheter thrombosis as the cause of the malfunction for which an ultrasound (US) is most helpful for diagnosis. Otherwise, a plain chest radiograph is the preferred initial imaging of choice to investigate other causes of malfunction such as catheter kinking (Fig. 2), displacement, migration, dislocation, or fracture [12]. One should follow the entire length of the catheter from the external exit site to the tip at the caval-atrial junction, radiographically located between 2 and 4 cm below the carina [14]. The
Fig. 2
Central venous port catheter kinking.
catheter tip may dislocate or migrate cephalad into the internal jugular or across into the contralateral brachiocephalic vein (Fig. 3). A displaced tip increases the risk of DVT and vessel perforation. Also detected by radiography is a catheter fragment that has fractured off (b1%) and migrated [15]. Migration of the tip or a fragment into the pericardial sac may cause pericardial tamponade, a rare complication that should be considered in any patient with a central access device that develops sudden severe chest pain or shortness of breath with hemodynamic instability [12]. Another radiographic finding is the “pinch-off” sign, a narrowing and kinking of a subclavian catheter because it is compressed between the clavicle and the first rib. Although this is a rare observation (1% of all subclavian vein catheters), compression may result in intermittent catheter dysfunction; longterm compression may lead to material fatigue and catheter fracture (Fig. 4). Finally, rotation or dislocation of a port reservoir may be observed radiographically, particularly in cancer patients that undergo rapid weight loss as a consequence of treatment. Persistent catheter malfunction and catheter migration, fracture, or dislocation necessitates fluoroscopic examination, catheter removal, and replacement. Catheter-associated DVT is treated with catheter removal and anticoagulation. Fibrin sheath formation around the catheter, reported to be as high as 75%, can also cause catheter malfunction, thrombus formation, or infection. Because the fibrin sheath creates a 1-way valve mechanism, it is diagnosed by ease of injecting fluid but inability to aspirate blood [16]. This may be successfully managed (87%-97%) by infusing 2 to 4 mg of tissue plasminogen activator suspended in 50 mL of normal saline for 1 to 3 hours [12,15]. 3.1.3. Transvenous hepatic and renal biopsy Transvenous biopsies are most commonly performed on the liver and kidneys. Most (92%-98.6%) of the transvenous liver biopsy complications are minor [17,18] (eg, capsular perforation [3.9%] [18], postbiopsy intraperitoneal bleeding [3.5%] [19], and intrahepatic hematoma [29%] [20]), require no intervention, and are detected before hospital discharge. After discharge, patients may return with abdominal pain radiating to the right shoulder, indicating the delayed formation of a perihepatic hematoma. Diagnostic confirmation can be made with a right upper quadrant US. Acute intervention is often not required unless there is associated hemodynamic instability or a significant drop in the hemoglobin level. Finally, transient pyrexia may be observed up to 24 hours postprocedure and does not necessarily indicate an infection [18]. Persistent pyrexia, often with abdominal pain, however, suggests the presence of an intraor perihepatic abscess. Similarly, complications after a transjugular renal biopsy are minor (eg, postprocedural bleeding, capsular perforation, calyceal bleeding, and perinephric hematoma) and occur during or immediately after the procedure [21]. Almost ubiquitous after a renal biopsy is gross hematuria
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Fig. 3
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Migration of the catheter tip into the contralateral brachiocephalic vein.
from a perinephric hematoma or calyceal bleeding (66%); both conditions typically resolve spontaneously [21,22]. Patients with persistent hematuria causing hemodynamic instability or symptomatic anemia may have developed an arteriovenous or arteriocalyceal fistula, which require emergent embolization [23]. To prevent clot retention and subsequent urethral obstruction, one must manually irrigate the bladder through a large-bore (20F catheter or larger) Foley catheter. Continuous bladder irrigation is often reserved for patients without clot formation because the clots can obstruct the smaller lumen of the catheter and cause bladder perforation. For organized bladder hematomas recalcitrant to manual irrigation, instillation of 120 to 150 mL of 0.15% to 0.3% hydrogen peroxide solution for 2 to 3 minutes followed by manual bladder irrigation may be attempted before surgical evacuation [24]. Finally, acutely
Fig. 4
Subclavian catheter fracture.
ill patients without obvious hematuria but a drop in hemoglobin may have a retroperitoneal hemorrhage [25], detectable by CT. Interventional radiology consultation for vessel embolization should be obtained for patients with intractable bleeding or those with a retroperitoneal bleed. Persistent hemorrhage necessitating nephrectomy (0.06%) is rarely encountered [21]. 3.1.4. Transjugular intrahepatic portosystemic shunts Transjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat patients with complications of liver failure by diverting blood from the abnormally highpressure portal system to the low-pressure caval system [26]. Its overall complication rate is 10% [27] and may be attributed to the technique, the shunt, or the stent [28]. During the procedure, the hepatic capsule (5%-30%), gallbladder (5%-10%), and right kidney (b2%) may be punctured inadvertently [27]. Although most of these injuries are identified early, discharged patients may develop acute abdominal pain with a hemoglobin drop, acute cholangitis, or flank pain with hematuria, respectively. In addition, shunt failure caused by stent thrombosis (3%-10%), occlusion (2%-15%), or migration (1%-3%) [27] may result in symptoms of untreated portal hypertension [29]. Older, uncovered stents have a higher rate of thrombosis and stenosis than the newer, covered stents, presumably from leakage of bile through the fenestrations. Ironically, a well-functioning shunt may worsen hepatic encephalopathy after 2 to 4 weeks, necessitating treatment with lactulose [30] or, for severe cases, downsizing the shunt [27]. Finally, the stent itself may become infected (1%-10%), leading to sepsis [27], or cause hemolytic anemia (7%) [31]. Most stent-associated hemolysis is mild and self-limited, although severe cases resulting in highoutput heart failure have been reported. Acute ED management of TIPS-related issues requires stabilizing the patient, initiating treatment of the active issues (eg, lactulose for encephalopathy, antibiotics for infection,
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blood transfusion for gastrointestinal bleeding), and obtaining CT imaging to identify perihepatic abscesses, stent stenosis, and cirrhotic complications.
3.2. Vascular: arterial procedures 3.2.1. Uterine artery embolization Uterine artery embolization has an overall complication rate of 34% to 39% [32,33], with a 5% to 15% [32-34] rate of major adverse events. Major complications include persistent abdominal/pelvic pain, fibroid extrusion, infection complicated by sepsis, venous thromboembolism, and massive vaginal bleeding requiring transfusion. Minor complications include menstrual disturbances, headaches, hot flashes, and vaginal discharge [34-36]. A constellation of minor symptoms that patients may develop (eg, vaginal discharge, spotting, bloating, fever, dysuria, hot flashes, mood swings, fibroid passage) is called postembolization syndrome and thought to be caused by fibroid infarction [34]. Postembolization syndrome is benign and resolves spontaneously after 3 to 4 days. The 2 most clinically significant reasons for ED visits and hospital readmission are severe, intractable abdominal pain and evaluation for possible infection [34]. Abdominal pain may be caused by postembolization syndrome, fibroid passage, fibroid necrosis, or infection. Clinically, the symptoms of postembolization syndrome can mimic those of serious pelvic infections (eg, endometritis, myometritis, infected necrotic leiomyoma, pelvic abscess). For example, 21% of UAE patients will routinely exhibit a leukocytosis within 24 hours postprocedure [36]. Furthermore, both conditions may be seen within the first postoperative week, although the actual infection rate is low (4%) [33,34]. The most reliable diagnostic study to distinguish a uterine infection or abscess from postembolization syndrome is magnetic resonance imaging with gadolinium [37] (Fig. 5). If this is not readily available, CT is preferred to US.
Fig. 5
3.2.2. Endovascular aortic aneurysm repair Endovascular aortic aneurysm repair (EVAR) has a higher rate of graft thrombosis and reintervention for graft infection and graft rupture compared with traditional surgical repair [38,39]. The most common reported complication is the formation of endoleaks, occurring in about 14.6% to 25% of all EVARs [40]. They are created by leakage of blood either around or through the graft into the aneurysm, causing endotension and increasing the risk of rupture. Unfortunately, endoleaks do not cause any symptoms until they rupture. Other postprocedural issues that may cause symptoms are graft rupture (1%-2%), graft kinking (2%), graft migration (1%-2%), and graft thrombosis (2%-4%) [40]. Finally, graft infection and aortoenteric fistulas, though even less common, may have catastrophic consequences if missed. Therefore, any post-EVAR patient that develops acute abdominal pain, back pain, or fever should be imaged with CT angiography to evaluate the stent. 3.2.3. Chemoembolization Chemoembolization is a selective arterial infusion of chemotherapeutic drugs and embolic agents for controlling nonresectable liver tumors. Target organ embolization can cause symptoms related to tumor necrosis, liver failure (20%-58%), or biliary tract injury because of the shared blood supply. Patients may also develop hepatic encephalopathy, ascites, hepatic and splenic abscesses, chemical cholecystitis, or ascending cholangitis [41,42]. Symptoms caused by tumor necrosis are collectively called postembolization syndrome (60%-80%) [42], but they are different from the symptoms caused by UAE. Patients will report abdominal pain, fever (typically b102°F), nausea, and malaise, and have elevated transaminase levels. Although these symptoms last only 3 to 4 days and are usually self-limited, they are difficult to distinguish from intra-abdominal infections and abscesses. Consequently, patients are often admitted for pain control and extensively imaged to exclude infection.
Magnetic resonance images of A, endometritis and B, uterine fibroid extrusion.
Percutaneous complications Other complications of chemoembolization result from inadvertent ischemic damage to nearby nontarget organs. For example, embolization of surrounding arteries may cause gastrointestinal hemorrhage from gastroduodenal ulceration [42] and acute pancreatitis (1.7%) [43]. Very rarely will nontarget embolization affect the pulmonary and cerebral arteries, causing pulmonary infarction and stroke, respectively [41]. Physicians evaluating symptomatic patients should have a high index of suspicion for vessel embolization causing organ ischemia and order the appropriate diagnostic angiography.
3.3. Nonvascular procedures 3.3.1. Percutaneous radiological gastrostomy Percutaneous gastrostomy, gastrojejunostomy, and jejunostomy tubes have a major complication rate of 2% to 6% [44-47]. They include peritonitis (1.3%) from pericatheter leakage of gastric contents into the peritoneum, gastric perforation or hemorrhage (1.7%), deep stomal infection or abscess (0.8%), aspiration pneumonia (0.6%), and inadvertent injury to adjacent organs [45,47]. A case series of 400 gastrostomy procedures reported 4 cases of peritonitis in patients with significant comorbidities; one patient developed a liver abscess after inadvertent liver puncture during the procedure [44]. These complications occur early, within a few days after the procedure, and patients may present with abdominal pain and fever or severe sepsis. They require diagnostic CT imaging to detect an intra-abdominal abscess or gastric perforation and IR or surgical consultation for tube removal and/or abscess drainage. Minor complications occur more frequently, up to 23% of all procedures, and can occur at any time postprocedure. They include cellulitis from pericatheter leakage, tube dislodgment, tube obstruction, and pain at the catheter site. Complete tube displacement is a very common reason for ED visits because patients can easily tug on the catheter with daily activity. A tube that has been in place for at least 2 weeks (up to 4 weeks for immunocompromised or chronically ill patients) will have a patent, stable tract that should be simple to recannulate with a replacement tube [44]. Tracts left open for more than 48 hours can constrict or close completely and should not be cannulated blindly (without fluoroscopy) or forcibly. Appropriate temporary tube substitutions are red rubber tubes that can be anchored to the skin with sutures and 16 to 18F Foley catheters. Foley catheters generally have a smaller internal diameter than an equivalent-sized gastrostomy catheter so patients should be cautious when infusing crushed medications. Once the tube is reinserted, placement may be confirmed by aspirating gastric contents, injecting fluid without causing abdominal pain or fluid leakage around the tube, or obtaining a plain abdominal radiograph with gastrograffin (Fig. 6) or air insufflation through the tube to detect air or contrast extravasation. Insufflation of 300 mL of air has been shown to be as effective for placement confirmation as dilute gastrograffin [48]. Radiographic
807 confirmation is required for tubes placed in an immature tract (b2 weeks for an immunocompetent patient or 4 weeks in a patient with delayed healing), those replaced after 48 hours, and those that were difficult to replace. Almost as common a complication is tube obstruction, frequently from crushed pill fragments. Obstruction may be relieved by flushing the catheter with warm water, saline, or any carbonated beverage or by injecting pancreatic enzymes diluted in a bicarbonate solution (5-mL suspension of pancreatic enzymes [lipase 2000 U, amylase 1500 U, protease 100 U] in water with 90 mg of sodium bicarbonate to maintain a pH 7.5) [49]. Persistently obstructed catheters may be replaced with a temporary catheter. 3.3.2. Percutaneous biliary drains There are 3 types of percutaneous biliary drains: external (sits above the obstruction and drains bile into an external drainage bag), internal (a metallic or plastic stent that drains into the bowel), and internal-external (external catheter enters a duct above the obstruction and crosses the obstruction into the duodenum) drainage catheters [50]. The rate of acute major complications after drain placement is reported to be about 2% [51]. Tube obstruction is the most common and can cause ascending cholangitis and intrahepatic abscesses, especially in patients with malignant biliary obstruction (47%) [52]. Computed tomography imaging may be useful in detecting these fluid collections. Moreover, in patients with an external or internal/external catheter where the external catheter is capped, prompt uncapping of the external portion sometimes can relieve the obstruction. Intraperitoneal bile leakage may be mild and not cause any symptoms or severe and lead to peritonitis and sepsis [51]. Significant hemorrhage (2.5%) from inadvertent liver laceration, pseudoaneurysm, or hepatic-portal vein fistula may manifest as hemobilia and require emergent embolization. Postprocedural bleeding that occurs after 1 to 2 weeks may be due to the erosion of the stent into a portal or hepatic vein or artery. Brisk arterial bleeding can also occur around the catheter, necessitating emergent embolization. Venous bleeding may be treated with repositioning of the drain or upsizing the drain to tamponade the vessel. Other complications include pleural lesions (ie, pneumothorax, empyema, hemothorax, or biliary-pleural fistulas) [51,53] and tumor spread along the transhepatic tract [54]. Minor complications have also been reported. Pain at the site of a newly placed catheter may be caused by irritation of the intercostal periosteum or neurovascular bundle. Patients may develop mild fever and chills from transient bacteremia. Pericatheter bile leakage from an obstructed drain may irritate the skin. Finally, inadvertent injury to the pancreas may cause transient hyperamylasemia and, rarely, acute pancreatitis [51]. 3.3.3. Percutaneous nephrostomy/ureteral stents Percutaneous nephrostomy with stent placement typically entails inserting a pigtail catheter to drain urine from the
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Fig. 6
Misplaced percutaneous gastrostomy with contrast extravasation.
renal pelvis into an external drainage bag or internal double J catheters that drain urine from the renal pelvis into the bladder. These catheters may be easily visualized on plain radiography, a simple initial imaging study used to confirm catheter position. Two major complications are bleeding and infection. Gross hematuria from puncture of the renal parenchyma is observed almost immediately after the procedure, but hemorrhage that requires transfusion is much less common (2%-3%) [55,56]. Venous bleeding is almost always selflimited; arterial bleeding from injury to the vascular bundle (1%) can cause persistent or massive hematuria, arteriove-
Fig. 7
Ureteral stent fenestrations obstructed by calcifications.
nous fistulas, pseudoaneurysms, and retroperitoneal hematomas [56]. Delayed, massive hemorrhage can also occur from erosion of the stent into adjacent vascular structures [57]. Significant hematuria requires bladder irrigation to prevent clot retention, blood transfusion, and immediate embolization of arterial bleeding. Patients without obvious hematuria but a decrease in hemoglobin should be evaluated by CT for a retroperitoneal hematoma. In addition, instrumentation of an obstructed urinary tract can lead to infection and sepsis early postprocedure, as can having a chronic indwelling nephrostomy or ureteral catheter. Obstruction of the catheter can occur early, from hematoma or
Fig. 8
Ureteral stent fracture.
Percutaneous complications debris, and cause acute pyelonephritis or perirenal abscesses. Late obstruction may be caused by encrustation by calcium deposits, especially in patients with nephrolithiasis (Fig. 7) [57]. The 30-day patency rate for ureteral stents is 54% if the initial obstruction is malignant [56]. Patients with an obstructed stent may present with fever, flank pain, or decreased urine output from the catheter and require urgent IR evaluation for patency. Other postprocedural issues include stent migration or malposition within the urinary tract, which may cause flank pain or perforate the renal pelvis and cause hemorrhage. Chronic, indwelling stents may also fracture at the fenestration sites and cause flank pain (Fig. 8) [57]. Inadvertent puncture of adjacent organs, particularly the retroperitoneal region of the colon, may be treated with ureteral diversion and removal of the nephrostomy drain to allow the injured colon to heal. Similarly, inadvertent lung injury may cause a pneumothorax (0.3%) or pleural effusion, which often spontaneously resolve [55].
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[8] [9] [10]
[11]
[12]
[13] [14]
[15]
[16]
4. Conclusions Patients with complications from percutaneous interventions will often present to the ED. Although some conditions require emergent specialist consultation, most of these complications may be effectively managed by emergency physicians.
Acknowledgment
[17]
[18] [19] [20]
[21] [22]
The authors thank Dr Anthony Dean and Dr Jeanmarie Perrone for their photo contribution and Arthur Chen for photo editing.
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810 [31] Sanyal AJ, Freedman AM, Purdum PP, et al. The hematologic consequences of transjugular intrahepatic portosystemic shunts. Hepatology (Baltimore, Md) 1996;23(1):32-9. [32] Edwards RD, Moss JG, Lumsden MA, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med 2007;356(4):360-70. [33] Worthington-Kirsch R, Spies JB, Myers ER, et al. The Fibroid Registry for outcomes data (FIBROID) for uterine embolization: shortterm outcomes. Obstet Gynecol 2005;106(1):52-9. [34] Pron G, Mocarski E, Bennett J, et al. Tolerance, hospital stay, and recovery after uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial. J Vasc Interv Radiol 2003;14(10): 1243-50. [35] Marshburn PB, Matthews ML, Hurst BS. Uterine artery embolization as a treatment option for uterine myomas. Obstet Gynecol Clin North Am 2006;33(1):125-44. [36] Ganguli S, Faintuch S, Salazar GM, et al. Postembolization syndrome: changes in white blood cell counts immediately after uterine artery embolization. J Vasc Interv Radiol 2008;19(3):443-5. [37] Kitamura Y, Ascher SM, Cooper C, et al. Imaging manifestations of complications associated with uterine artery embolization. Radiographics 2005;25(Suppl 1):S119-32. [38] Schermerhorn ML, O'Malley AJ, Jhaveri A, et al. Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 2008;358(5):464-74. [39] Lovegrove RE, Javid M, Magee TR, et al. A meta-analysis of 21,178 patients undergoing open or endovascular repair of abdominal aortic aneurysm. Br J Surg 2008;95(6):677-84. [40] Wilt TJ, Lederle FA, Macdonald R, et al. Comparison of endovascular and open surgical repairs for abdominal aortic aneurysm. Evid Rep Technol Assess 2006(144):1-113. [41] Gates J, Hartnell GG, Stuart KE, et al. Chemoembolization of hepatic neoplasms: safety, complications, and when to worry. Radiographics 1999;19(2):399-414. [42] Marelli L, Stigliano R, Triantos C, et al. Transarterial therapy for hepatocellular carcinoma: which technique is more effective? A systematic review of cohort and randomized studies. Cardiovasc Intervent Radiol 2007;30(1):6-25.
E.H. Chen, A. Nemeth [43] Lopez-Benitez R, Radeleff BA, Barragan-Campos HM, et al. Acute pancreatitis after embolization of liver tumors: frequency and associated risk factors. Pancreatology 2007;7(1):53-62. [44] Ho SG, Marchinkow LO, Legiehn GM, et al. Radiological percutaneous gastrostomy. Clin Radiol 2001;56(11):902-10. [45] Given MF, Hanson JJ, Lee MJ. Interventional radiology techniques for provision of enteral feeding. Cardiovasc Intervent Radiol 2005;28(6): 692-703. [46] Silas AM, Pearce LF, Lestina LS, et al. Percutaneous radiologic gastrostomy versus percutaneous endoscopic gastrostomy: a comparison of indications, complications and outcomes in 370 patients. Eur J Radiol 2005;56(1):84-90. [47] Wollman B, D'Agostino HB, Walus-Wigle JR, et al. Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology 1995;197(3):699-704. [48] Burke DT, El Shami A, Heinle E, et al. Comparison of gastrostomy tube replacement verification using air insufflation versus gastrograffin. Arch Phys Med Rehabil 2006;87(11):1530-3. [49] Sriram K, Jayanthi V, Lakshmi RG, et al. Prophylactic locking of enteral feeding tubes with pancreatic enzymes. JPEN J Parenter Enteral Nutr 1997;21(6):353-6. [50] Covey AM, Brown KT. Palliative percutaneous drainage in malignant biliary obstruction. Part 2: Mechanisms and postprocedure management. J Support Oncol 2006;4(7):329-35. [51] Winick AB, Waybill PN, Venbrux AC. Complications of percutaneous transhepatic biliary interventions. Tech Vasc Interv Radiol 2001;4(3):200-6. [52] Wu SM, Marchant LK, Haskal ZJ. Percutaneous interventions in the biliary tree. Semin Roentgenol 1997;32(3):228-45. [53] Yee AC, Ho CS. Percutaneous transhepatic biliary drainage: a review. Crit Rev Diagn Imaging 1990;30(3):247-79. [54] Gendler R, Shapiro RS, Mitty HA, et al. CT findings after percutaneous biliary procedures. Radiology 1993;187(2):373-6. [55] Zagoria RJ, Dyer RB. Do's and don't's of percutaneous nephrostomy. Acad Radiol 1999;6(6):370-7. [56] Kirkham AP, Ho SG. Radiological interventions in gastrointestinal and urological oncology. Semin Roentgenol 2007;42(3):191-204. [57] Dyer RB, Chen MY, Zagoria RJ, et al. Complications of ureteral stent placement. Radiographics 2002;22(5):1005-22.
www.elsevier.com/locate/ajem
Review
Complications of percutaneous procedures Esther H. Chen MD a,⁎, Alexander Nemeth MD b a
San Francisco General Hospital, University of California, San Francisco, CA 94110, USA Hospital of the University of Pennsylvania, Philadelphia, PA, USA
b
Received 13 October 2009; revised 6 May 2010; accepted 15 May 2010
Abstract Minimally invasive percutaneous procedures are increasingly being performed by both interventional radiologists and noninterventionalists. Patients with postprocedural issues will likely present to the emergency department for evaluation and treatment. This review focuses on the evaluation and management of the complications of common percutaneous procedures. © 2011 Elsevier Inc. All rights reserved.
1. Introduction Percutaneous interventions are often associated with lower morbidity and mortality, compared with traditional surgery, and provide an alternative for patients that may otherwise be poor surgical candidates. Because they are minimally invasive, these procedures are increasingly being performed by interventional radiologists and noninterventionalists. Consequently, patients with postprocedural complications are now routinely encountered in the emergency department (ED). Although some require specialist consultation, many postprocedural issues may be effectively evaluated and managed by emergency physicians.
2. General complications Complications common to most percutaneous interventions are related to the percutaneous access, contrast injection, and radiation exposure [1]. Puncture site-related issues typically occur during or immediately postprocedure. However, patients may return to the ED within the first 24 to 48 hours with puncture site hemorrhage, pain from arterial dissection, and swelling from a hematoma or pseudoaneurysm. Hemorrhage may be controlled with 20 minutes ⁎ Corresponding author. Tel.: +1 415 206 4354; fax: +1 415 206 5818. E-mail address: [email protected] (E.H. Chen). 0735-6757/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2010.05.010
of direct manual compression over the vessel [2] and correction of underlying coagulopathy. A painful lump that forms within the first 1 to 2 days may be a hematoma or pseudoaneurysm and, if occurring after a week, an arteriovenous fistula or abscess. Ultrasonography is a helpful diagnostic adjunct to the physical examination to distinguish between these processes. Arterial manipulation may cause clots to embolize, causing distal limb ischemia. Furthermore, limb edema and pain may be caused by site thrombosis, an occlusive or nonocclusive deep venous thrombosis (DVT) that may develop after 1 to 2 weeks. Finally, it is important to recognize that both arterial emboli and DVTs may occur in the contralateral limb because a single puncture is often used to treat bilateral disease. Contrast material used during the procedures has several adverse effects. These include idiosyncratic (anaphylactoid) reactions, anaphylaxis, and contrast extravasation [1]. Patients may be given up to 4 mL/kg of intravenous contrast, about twice the quantity injected for an abdominal/pelvis computed tomography (CT) scan. Discharged patients may return 1 to 2 days later with contrast-induced nephropathy (CIN) [1]. Factors such as diabetes, chronic kidney disease, advanced age (N70 years), congestive heart failure, and use of high osmolar or high viscosity contrast may increase a patient's risk of developing CIN [3]. Although it is the third leading cause of hospital-acquired renal failure and associated with increases in short-term and long-term mortality, for most patients, CIN may be treated supportively by
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optimizing hydration status and assuring close physician monitoring until resolution of the renal impairment [4]. Finally, because most procedures are performed using fluoroscopy, patients are exposed to varying degrees of ionizing radiation, depending on the type and difficulty of the procedure [5]. For example, the average cumulative dose for an inferior vena cava (IVC) filter placement is 0.2 gray (Gy) (1 Gy is equivalent to a joule of energy absorbed per kilogram), but it ranges from 0.01 to 6.8 Gy, and that for uterine artery embolization (UAE) is 2.5 Gy (0.02-7.0 Gy). The highest exposure occurs to the skin at the entrance of the radiation beam. At a dose of 2 Gy, the injury to the skin is manifested by erythema, pain, and superficial skin breakdown, similar to a superficial or deep superficial burn. Treatment of skin injury is pain control and good wound care, with close monitoring for the rare progression to skin necrosis and chronic ulceration.
3. Procedure-specific complications 3.1. Vascular: venous procedures 3.1.1. Vena cava filters Vena cava filters are classified as permanent (ie, Greenfield) or retrievable [6] and typically implanted in the IVC, although other veins (eg, iliac, subclavian, superior vena cava) are also used [7]. Filter complications, either device-related or thrombotic events, may occur at any time after insertion but generally increase with dwell time [6,8]. Filter migration and filter strut fracture (Fig. 1) are devicerelated issues that were reported more frequently with older permanent filters compared with those placed in the past 6 years (5%-30% [migration] and 2% [strut fracture] vs
Fig. 1
0.3%-3% and 0%, respectively) [6,8,9]. Filter or strut migration may be entirely asymptomatic or cause pain in the vasculature resulting in end-organ damage. In contrast, IVC penetration by the filter has increased recently from 10% to 95% with the newer filters [6,8], an anchoring improvement that may partially explain the decrease in migration rate; through-and-through caval penetration is rare. Patients with filter migration or caval penetration may report tearing pain in their groin or flank followed by fever or signs of organ dysfunction (eg, small bowel obstruction, duodenal perforation, rectal bleeding). They require CT imaging for diagnosis and immediate interventional radiology (IR) consultation for filter removal. Very rarely, a filter may migrate to the heart causing myocardial perforation or life-threatening arrhythmias [8]. In addition, the filter itself may become infected, causing abscess formation and sepsis, which, though uncommon (1.2%), is potentially life threatening [9]. A more recently recognized device-related complication is entrapment of J-tipped guidewires used to place central venous catheters in the IVC filter. Because of the usual infrarenal position of the filter, femoral catheters have a higher risk for wire entrapment, although cases involving internal jugular wires have been reported [10,11]. In patients with a known IVC or superior vena cava filter, using the straight end of the wire is preferable to the J-tip. If any resistance is felt during wire withdrawal, tape the wire to the patient and immediately obtain a diagnostic abdominal radiograph. If the J-tipped end is ensnared in the filter, try to advance the wire to disengage the tip from the filter and then extend or straighten the curved J-tip by immobilizing the wire proximally with one hand while applying traction distally with the other hand [11]. If this maneuver fails, emergent IR consultation should be obtained for fluoroscopic removal.
Inferior vena cava filter strut fracture and migration.
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3.1.2. Venous access catheters and ports Central venous catheters and ports are either tunneled (ie, part of the catheter is embedded in the subcutaneous tissue) or nontunneled and often placed in the internal jugular or subclavian veins. Early postprocedural complications (within 24-48 hours) include pneumothorax (0.2%-2%), hemothorax, brachial plexus injury (rare) causing radicular neck/arm pain, or phrenic nerve injury (rare) exhibited by an elevated hemidiaphragm [12]. Treatment is not required for small, stable pneumothoraces, nonexpanding hematomas without vessel or airway compromise, and any brachial plexus or phrenic nerve injury. Other procedure-related issues include infection (fever with or without erythema and pain at the catheter site), DVT, or catheter malfunction (inability to inject fluid or aspirate blood) [12]. Infections occur in fewer than 20% of all access devices [13], with clinical presentations ranging from a local cellulitis to port pocket abscess to line-related septicemia. Treatment of line infections varies by institution and often depends on the clinical scenario. Uncomplicated local infections in immunocompetent patients may be treated with oral antibiotics without catheter removal and close outpatient follow-up, whereas catheter removal is recommended for most patients with systemic infections and underlying venous thrombosis (eg, septic thrombophlebitis). Aside from causing infections, venous access devices may malfunction. Associated arm swelling may suggest venous thrombosis (occurring in 35%-65% of central vein catheters) or catheter thrombosis as the cause of the malfunction for which an ultrasound (US) is most helpful for diagnosis. Otherwise, a plain chest radiograph is the preferred initial imaging of choice to investigate other causes of malfunction such as catheter kinking (Fig. 2), displacement, migration, dislocation, or fracture [12]. One should follow the entire length of the catheter from the external exit site to the tip at the caval-atrial junction, radiographically located between 2 and 4 cm below the carina [14]. The
Fig. 2
Central venous port catheter kinking.
catheter tip may dislocate or migrate cephalad into the internal jugular or across into the contralateral brachiocephalic vein (Fig. 3). A displaced tip increases the risk of DVT and vessel perforation. Also detected by radiography is a catheter fragment that has fractured off (b1%) and migrated [15]. Migration of the tip or a fragment into the pericardial sac may cause pericardial tamponade, a rare complication that should be considered in any patient with a central access device that develops sudden severe chest pain or shortness of breath with hemodynamic instability [12]. Another radiographic finding is the “pinch-off” sign, a narrowing and kinking of a subclavian catheter because it is compressed between the clavicle and the first rib. Although this is a rare observation (1% of all subclavian vein catheters), compression may result in intermittent catheter dysfunction; longterm compression may lead to material fatigue and catheter fracture (Fig. 4). Finally, rotation or dislocation of a port reservoir may be observed radiographically, particularly in cancer patients that undergo rapid weight loss as a consequence of treatment. Persistent catheter malfunction and catheter migration, fracture, or dislocation necessitates fluoroscopic examination, catheter removal, and replacement. Catheter-associated DVT is treated with catheter removal and anticoagulation. Fibrin sheath formation around the catheter, reported to be as high as 75%, can also cause catheter malfunction, thrombus formation, or infection. Because the fibrin sheath creates a 1-way valve mechanism, it is diagnosed by ease of injecting fluid but inability to aspirate blood [16]. This may be successfully managed (87%-97%) by infusing 2 to 4 mg of tissue plasminogen activator suspended in 50 mL of normal saline for 1 to 3 hours [12,15]. 3.1.3. Transvenous hepatic and renal biopsy Transvenous biopsies are most commonly performed on the liver and kidneys. Most (92%-98.6%) of the transvenous liver biopsy complications are minor [17,18] (eg, capsular perforation [3.9%] [18], postbiopsy intraperitoneal bleeding [3.5%] [19], and intrahepatic hematoma [29%] [20]), require no intervention, and are detected before hospital discharge. After discharge, patients may return with abdominal pain radiating to the right shoulder, indicating the delayed formation of a perihepatic hematoma. Diagnostic confirmation can be made with a right upper quadrant US. Acute intervention is often not required unless there is associated hemodynamic instability or a significant drop in the hemoglobin level. Finally, transient pyrexia may be observed up to 24 hours postprocedure and does not necessarily indicate an infection [18]. Persistent pyrexia, often with abdominal pain, however, suggests the presence of an intraor perihepatic abscess. Similarly, complications after a transjugular renal biopsy are minor (eg, postprocedural bleeding, capsular perforation, calyceal bleeding, and perinephric hematoma) and occur during or immediately after the procedure [21]. Almost ubiquitous after a renal biopsy is gross hematuria
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Fig. 3
805
Migration of the catheter tip into the contralateral brachiocephalic vein.
from a perinephric hematoma or calyceal bleeding (66%); both conditions typically resolve spontaneously [21,22]. Patients with persistent hematuria causing hemodynamic instability or symptomatic anemia may have developed an arteriovenous or arteriocalyceal fistula, which require emergent embolization [23]. To prevent clot retention and subsequent urethral obstruction, one must manually irrigate the bladder through a large-bore (20F catheter or larger) Foley catheter. Continuous bladder irrigation is often reserved for patients without clot formation because the clots can obstruct the smaller lumen of the catheter and cause bladder perforation. For organized bladder hematomas recalcitrant to manual irrigation, instillation of 120 to 150 mL of 0.15% to 0.3% hydrogen peroxide solution for 2 to 3 minutes followed by manual bladder irrigation may be attempted before surgical evacuation [24]. Finally, acutely
Fig. 4
Subclavian catheter fracture.
ill patients without obvious hematuria but a drop in hemoglobin may have a retroperitoneal hemorrhage [25], detectable by CT. Interventional radiology consultation for vessel embolization should be obtained for patients with intractable bleeding or those with a retroperitoneal bleed. Persistent hemorrhage necessitating nephrectomy (0.06%) is rarely encountered [21]. 3.1.4. Transjugular intrahepatic portosystemic shunts Transjugular intrahepatic portosystemic shunt (TIPS) placement is used to treat patients with complications of liver failure by diverting blood from the abnormally highpressure portal system to the low-pressure caval system [26]. Its overall complication rate is 10% [27] and may be attributed to the technique, the shunt, or the stent [28]. During the procedure, the hepatic capsule (5%-30%), gallbladder (5%-10%), and right kidney (b2%) may be punctured inadvertently [27]. Although most of these injuries are identified early, discharged patients may develop acute abdominal pain with a hemoglobin drop, acute cholangitis, or flank pain with hematuria, respectively. In addition, shunt failure caused by stent thrombosis (3%-10%), occlusion (2%-15%), or migration (1%-3%) [27] may result in symptoms of untreated portal hypertension [29]. Older, uncovered stents have a higher rate of thrombosis and stenosis than the newer, covered stents, presumably from leakage of bile through the fenestrations. Ironically, a well-functioning shunt may worsen hepatic encephalopathy after 2 to 4 weeks, necessitating treatment with lactulose [30] or, for severe cases, downsizing the shunt [27]. Finally, the stent itself may become infected (1%-10%), leading to sepsis [27], or cause hemolytic anemia (7%) [31]. Most stent-associated hemolysis is mild and self-limited, although severe cases resulting in highoutput heart failure have been reported. Acute ED management of TIPS-related issues requires stabilizing the patient, initiating treatment of the active issues (eg, lactulose for encephalopathy, antibiotics for infection,
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blood transfusion for gastrointestinal bleeding), and obtaining CT imaging to identify perihepatic abscesses, stent stenosis, and cirrhotic complications.
3.2. Vascular: arterial procedures 3.2.1. Uterine artery embolization Uterine artery embolization has an overall complication rate of 34% to 39% [32,33], with a 5% to 15% [32-34] rate of major adverse events. Major complications include persistent abdominal/pelvic pain, fibroid extrusion, infection complicated by sepsis, venous thromboembolism, and massive vaginal bleeding requiring transfusion. Minor complications include menstrual disturbances, headaches, hot flashes, and vaginal discharge [34-36]. A constellation of minor symptoms that patients may develop (eg, vaginal discharge, spotting, bloating, fever, dysuria, hot flashes, mood swings, fibroid passage) is called postembolization syndrome and thought to be caused by fibroid infarction [34]. Postembolization syndrome is benign and resolves spontaneously after 3 to 4 days. The 2 most clinically significant reasons for ED visits and hospital readmission are severe, intractable abdominal pain and evaluation for possible infection [34]. Abdominal pain may be caused by postembolization syndrome, fibroid passage, fibroid necrosis, or infection. Clinically, the symptoms of postembolization syndrome can mimic those of serious pelvic infections (eg, endometritis, myometritis, infected necrotic leiomyoma, pelvic abscess). For example, 21% of UAE patients will routinely exhibit a leukocytosis within 24 hours postprocedure [36]. Furthermore, both conditions may be seen within the first postoperative week, although the actual infection rate is low (4%) [33,34]. The most reliable diagnostic study to distinguish a uterine infection or abscess from postembolization syndrome is magnetic resonance imaging with gadolinium [37] (Fig. 5). If this is not readily available, CT is preferred to US.
Fig. 5
3.2.2. Endovascular aortic aneurysm repair Endovascular aortic aneurysm repair (EVAR) has a higher rate of graft thrombosis and reintervention for graft infection and graft rupture compared with traditional surgical repair [38,39]. The most common reported complication is the formation of endoleaks, occurring in about 14.6% to 25% of all EVARs [40]. They are created by leakage of blood either around or through the graft into the aneurysm, causing endotension and increasing the risk of rupture. Unfortunately, endoleaks do not cause any symptoms until they rupture. Other postprocedural issues that may cause symptoms are graft rupture (1%-2%), graft kinking (2%), graft migration (1%-2%), and graft thrombosis (2%-4%) [40]. Finally, graft infection and aortoenteric fistulas, though even less common, may have catastrophic consequences if missed. Therefore, any post-EVAR patient that develops acute abdominal pain, back pain, or fever should be imaged with CT angiography to evaluate the stent. 3.2.3. Chemoembolization Chemoembolization is a selective arterial infusion of chemotherapeutic drugs and embolic agents for controlling nonresectable liver tumors. Target organ embolization can cause symptoms related to tumor necrosis, liver failure (20%-58%), or biliary tract injury because of the shared blood supply. Patients may also develop hepatic encephalopathy, ascites, hepatic and splenic abscesses, chemical cholecystitis, or ascending cholangitis [41,42]. Symptoms caused by tumor necrosis are collectively called postembolization syndrome (60%-80%) [42], but they are different from the symptoms caused by UAE. Patients will report abdominal pain, fever (typically b102°F), nausea, and malaise, and have elevated transaminase levels. Although these symptoms last only 3 to 4 days and are usually self-limited, they are difficult to distinguish from intra-abdominal infections and abscesses. Consequently, patients are often admitted for pain control and extensively imaged to exclude infection.
Magnetic resonance images of A, endometritis and B, uterine fibroid extrusion.
Percutaneous complications Other complications of chemoembolization result from inadvertent ischemic damage to nearby nontarget organs. For example, embolization of surrounding arteries may cause gastrointestinal hemorrhage from gastroduodenal ulceration [42] and acute pancreatitis (1.7%) [43]. Very rarely will nontarget embolization affect the pulmonary and cerebral arteries, causing pulmonary infarction and stroke, respectively [41]. Physicians evaluating symptomatic patients should have a high index of suspicion for vessel embolization causing organ ischemia and order the appropriate diagnostic angiography.
3.3. Nonvascular procedures 3.3.1. Percutaneous radiological gastrostomy Percutaneous gastrostomy, gastrojejunostomy, and jejunostomy tubes have a major complication rate of 2% to 6% [44-47]. They include peritonitis (1.3%) from pericatheter leakage of gastric contents into the peritoneum, gastric perforation or hemorrhage (1.7%), deep stomal infection or abscess (0.8%), aspiration pneumonia (0.6%), and inadvertent injury to adjacent organs [45,47]. A case series of 400 gastrostomy procedures reported 4 cases of peritonitis in patients with significant comorbidities; one patient developed a liver abscess after inadvertent liver puncture during the procedure [44]. These complications occur early, within a few days after the procedure, and patients may present with abdominal pain and fever or severe sepsis. They require diagnostic CT imaging to detect an intra-abdominal abscess or gastric perforation and IR or surgical consultation for tube removal and/or abscess drainage. Minor complications occur more frequently, up to 23% of all procedures, and can occur at any time postprocedure. They include cellulitis from pericatheter leakage, tube dislodgment, tube obstruction, and pain at the catheter site. Complete tube displacement is a very common reason for ED visits because patients can easily tug on the catheter with daily activity. A tube that has been in place for at least 2 weeks (up to 4 weeks for immunocompromised or chronically ill patients) will have a patent, stable tract that should be simple to recannulate with a replacement tube [44]. Tracts left open for more than 48 hours can constrict or close completely and should not be cannulated blindly (without fluoroscopy) or forcibly. Appropriate temporary tube substitutions are red rubber tubes that can be anchored to the skin with sutures and 16 to 18F Foley catheters. Foley catheters generally have a smaller internal diameter than an equivalent-sized gastrostomy catheter so patients should be cautious when infusing crushed medications. Once the tube is reinserted, placement may be confirmed by aspirating gastric contents, injecting fluid without causing abdominal pain or fluid leakage around the tube, or obtaining a plain abdominal radiograph with gastrograffin (Fig. 6) or air insufflation through the tube to detect air or contrast extravasation. Insufflation of 300 mL of air has been shown to be as effective for placement confirmation as dilute gastrograffin [48]. Radiographic
807 confirmation is required for tubes placed in an immature tract (b2 weeks for an immunocompetent patient or 4 weeks in a patient with delayed healing), those replaced after 48 hours, and those that were difficult to replace. Almost as common a complication is tube obstruction, frequently from crushed pill fragments. Obstruction may be relieved by flushing the catheter with warm water, saline, or any carbonated beverage or by injecting pancreatic enzymes diluted in a bicarbonate solution (5-mL suspension of pancreatic enzymes [lipase 2000 U, amylase 1500 U, protease 100 U] in water with 90 mg of sodium bicarbonate to maintain a pH 7.5) [49]. Persistently obstructed catheters may be replaced with a temporary catheter. 3.3.2. Percutaneous biliary drains There are 3 types of percutaneous biliary drains: external (sits above the obstruction and drains bile into an external drainage bag), internal (a metallic or plastic stent that drains into the bowel), and internal-external (external catheter enters a duct above the obstruction and crosses the obstruction into the duodenum) drainage catheters [50]. The rate of acute major complications after drain placement is reported to be about 2% [51]. Tube obstruction is the most common and can cause ascending cholangitis and intrahepatic abscesses, especially in patients with malignant biliary obstruction (47%) [52]. Computed tomography imaging may be useful in detecting these fluid collections. Moreover, in patients with an external or internal/external catheter where the external catheter is capped, prompt uncapping of the external portion sometimes can relieve the obstruction. Intraperitoneal bile leakage may be mild and not cause any symptoms or severe and lead to peritonitis and sepsis [51]. Significant hemorrhage (2.5%) from inadvertent liver laceration, pseudoaneurysm, or hepatic-portal vein fistula may manifest as hemobilia and require emergent embolization. Postprocedural bleeding that occurs after 1 to 2 weeks may be due to the erosion of the stent into a portal or hepatic vein or artery. Brisk arterial bleeding can also occur around the catheter, necessitating emergent embolization. Venous bleeding may be treated with repositioning of the drain or upsizing the drain to tamponade the vessel. Other complications include pleural lesions (ie, pneumothorax, empyema, hemothorax, or biliary-pleural fistulas) [51,53] and tumor spread along the transhepatic tract [54]. Minor complications have also been reported. Pain at the site of a newly placed catheter may be caused by irritation of the intercostal periosteum or neurovascular bundle. Patients may develop mild fever and chills from transient bacteremia. Pericatheter bile leakage from an obstructed drain may irritate the skin. Finally, inadvertent injury to the pancreas may cause transient hyperamylasemia and, rarely, acute pancreatitis [51]. 3.3.3. Percutaneous nephrostomy/ureteral stents Percutaneous nephrostomy with stent placement typically entails inserting a pigtail catheter to drain urine from the
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Fig. 6
Misplaced percutaneous gastrostomy with contrast extravasation.
renal pelvis into an external drainage bag or internal double J catheters that drain urine from the renal pelvis into the bladder. These catheters may be easily visualized on plain radiography, a simple initial imaging study used to confirm catheter position. Two major complications are bleeding and infection. Gross hematuria from puncture of the renal parenchyma is observed almost immediately after the procedure, but hemorrhage that requires transfusion is much less common (2%-3%) [55,56]. Venous bleeding is almost always selflimited; arterial bleeding from injury to the vascular bundle (1%) can cause persistent or massive hematuria, arteriove-
Fig. 7
Ureteral stent fenestrations obstructed by calcifications.
nous fistulas, pseudoaneurysms, and retroperitoneal hematomas [56]. Delayed, massive hemorrhage can also occur from erosion of the stent into adjacent vascular structures [57]. Significant hematuria requires bladder irrigation to prevent clot retention, blood transfusion, and immediate embolization of arterial bleeding. Patients without obvious hematuria but a decrease in hemoglobin should be evaluated by CT for a retroperitoneal hematoma. In addition, instrumentation of an obstructed urinary tract can lead to infection and sepsis early postprocedure, as can having a chronic indwelling nephrostomy or ureteral catheter. Obstruction of the catheter can occur early, from hematoma or
Fig. 8
Ureteral stent fracture.
Percutaneous complications debris, and cause acute pyelonephritis or perirenal abscesses. Late obstruction may be caused by encrustation by calcium deposits, especially in patients with nephrolithiasis (Fig. 7) [57]. The 30-day patency rate for ureteral stents is 54% if the initial obstruction is malignant [56]. Patients with an obstructed stent may present with fever, flank pain, or decreased urine output from the catheter and require urgent IR evaluation for patency. Other postprocedural issues include stent migration or malposition within the urinary tract, which may cause flank pain or perforate the renal pelvis and cause hemorrhage. Chronic, indwelling stents may also fracture at the fenestration sites and cause flank pain (Fig. 8) [57]. Inadvertent puncture of adjacent organs, particularly the retroperitoneal region of the colon, may be treated with ureteral diversion and removal of the nephrostomy drain to allow the injured colon to heal. Similarly, inadvertent lung injury may cause a pneumothorax (0.3%) or pleural effusion, which often spontaneously resolve [55].
809
[8] [9] [10]
[11]
[12]
[13] [14]
[15]
[16]
4. Conclusions Patients with complications from percutaneous interventions will often present to the ED. Although some conditions require emergent specialist consultation, most of these complications may be effectively managed by emergency physicians.
Acknowledgment
[17]
[18] [19] [20]
[21] [22]
The authors thank Dr Anthony Dean and Dr Jeanmarie Perrone for their photo contribution and Arthur Chen for photo editing.
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