Complications of Retrograde Percutaneous Arteriography

THE JOURNAL OF UROLOGY

Vol. 90, No. 5 ~o,·ember 1963 Copyright © IG63 by The Williams & Wilkins Co. Printed in U.S.A.

COMPLICATIONS OF RETROGRADE PERCUTANEOUS ARTERIOGRAPHY ERICH K. LANG* From the Department of Radiology, Methodist Hospital, Indianapolis, Incl.

The value of the information derived from any diagnostic procedure has to be balanced against the risk of the study. The recent literature shows an increasing rate of complications following retrograde percutaneous arteriography.1 - 11 In order to arrive at statistically valid data, a survey was carried out. Questionnaires were sent to 300 hospital radiologists, urologists, and vascular surgeons in the United States. Two hundred and four replies were received. However, only 142 contained adequate information to allow proper interpretation. In this series of 11,402 procedures, seven fatal complications were encountered. This represents a mortality rate of 0.06 per cent. In comparison with previous surveys of translumbar aortography, reporting a mortality rate of 0.28 per cent, Accepted for publication June 28, 1963. Read at annual meeting of American Urological Association, Inc., St. Louis, Mo., May 13-16, 1963. * Present address: Vanderbilt University Hospital, Nashville, Tenn. 1 Aagaard, P., Davidsen, H. G. and Andreassen, M.: Complications in percutaneous arteriography. Acta Chir. Scand., 119: 186-189, 1960. 2 Abrams, H. H.: Radiologic aspects of operable heart disease III. The hazards of retrograde thoracic aortography; a survey. Radiology, 68: 812-824, 1957.

3 Bowkiewicz, J., Zgliczynski, L. and Nielubowicz, J.: Abdominal aortography. Indications, technic, studies and prevention of complications. Pol. Przegl. Radio!., 23: 299-311, 1959. 4 Chieppa, S. and Marega, T.: Risks in peripheral arteriography. Arch. Ortop. (Milano), 72:

558-573, 1()59. 5 Herout, V. and V ortel, V.: On vascular changes in arteriography and its complications. Virchows. Arch. Path. Anat., 334: 367-378, 1961. 6 Lang, E. K.: Renal angiography in the evaluation of hypertension. Amer. J. Roentgenol., 85:

1120-1127, 1961. 7 Marley, A.: Methods of renal arteriography; their value and disadvantages. Minerva Med.,

50: 3201-3205, 1959. 8 Piza, F.: Failures, and hazards of angiography

by means of transfemoral sounding of the aorta. Klin. Med., 15: 454---459, 1960. 9 Seror, J. and Stoppa, R.: The complications of arteriography. Mem. Acad. Chir., 85: 659-665, 1959.

10 Sicard, A. and Na tali, J.: Apropos of complications of arteriography. Mem. Acad. Chir., 85:

or catheter aortography, reporting up to 1.7 per cent, this represents a very significant drop. 2 •12 The serious complications rate was calculated at 0.7 per cent (table 1). This value again compares well to complication rates reported in surveys of translumbar aortography. 12 The minor complication rate was relatively high (approximately 3 per cent), and appeared to be directly related to the experience of the operator and the immediate postoperative care. Minor complications are defined as complications resulting in a transient discomfort to the patient, but lacking late sequelae. Temporary arterial spasm, asymptomatic local hematomas, relatively asymptomatic intramural or subintimal dye injections, and relatively asymptomatic perforations of large vessels were the main minor complications reported in this survey. Multiple traumatic punctures, poor local anesthesia, trauma to the intima during advancement of the guide wire or catheter, or unduly long catheterization procedures appeared to be the most common causes of arterial spasm. The formation of local hematomas is most often related to inadequate manual compression of the puncture site or improper application of pressure dressings. Traumatic advancement of the guide wire or catheter has to be avoided at all costs, and particularly in patients with marked arteriosclerotic disease or diabetes, considerable prudence has to be used in determining whether a guide wire or catheter may be advanced under difficult conditions. Often the retrograde advancement of the catheter or guide wire may be contraindicated since subintimal advancement or dislodgment of plaques may result (fig. 1). Intimal irritation with resulting spasm due to the introduction of an unduly large catheter should be avoided. In the author's own experience, this is felt to account for a significant increased rate of complications in brachial artery catheterization. In the author's own experience, many of these complications can easily be eliminated in the hands of experienced operators, and by use of conservative prudence.

719-720, 1959. 11 Vas, G. and Papp, S.: On the disadvantages of percutaneous arteriography. Zbl. Chir., 85:

12 McAfee, J. G.: A survey of complications of abdominal aortography. Radiology, 68: 825-838,

465-470, 1960.

1957. 604

RETROGRADE PERCUTANEOUS ARTERIOGRAPHY TABLE

1. * Complications in 11,402 Seldinger procedures

Fatal complications ................ . Serious complications. Arterial thrombosis . (with secondary loss of limb). Tip of guide wire or catheter broken ............. . Arterial embolism . Perforation of major vessels with serious complications ....... . Renal complications .. Bowel ileus and necrosis ........ . Minor complications .. Perforation of a major vessel without sequelat ....... . Intramural or subintimal dye injection without sequelat .. Local hematomast ..... .

* Reproduced from Radiology, Aug.

t Temporary

7 81 47 6 5 9 13

2 5

325 22 136 167 1963.

arterial spasm and loss of pulse were also observed in practically all minor complications. Serious complications have been relatively uncommon, particularly as compared to preceding surveys of translumbar aortography. However, one of the reasons for this relative safety is a significant improvement in the safety of contrast media used. A limited survey was run for comparison purposes, and a complication rate of less than 0.3 per cent was encountered in translumbar aortography in this present survey (table 2). This reflects the significant improvement in recent times, which is largely due to the use of safer contrast media. The dreaded complication of renal shutdown and transverse myelitis is now extremely rare. 3 • 5 •9 •12 - 16 The single most common serious complication was arterial thrombosis (table 3). Poor vascular fitness, low output failure, severe arteriosclerotic changes, mitral disease, and previous arterial thrombosis appeared to predispose· to this complication. Improper technique 13 Baltz, D. A.: An unusual complication following aortogram. Delaware Med. J., 32: 165-166,

1960.

14 Choelzel, P.: The symptoms and prevention of intramural injection in aortography. Fortschr. Roen tgenstr., 92: 694-696, 1960. 15 Ferrand, J. and Elbaz, C.: Complications of aortography and arteriography. Minerva Cardioangiol. Europ., 7: 224-234, 1959. 16 Wolfman, E. F., Jr. and Boblitt, D. E.: Intramural aortic dissection as a complication of translumbar aortography. A.M.A. Arch. Surg.,

78:629-638, 1959.

605

alone did not appear to cause arterial thrombosis, although in combination with other predisposi11g. factors, it would tend to increase the chances for arterial thrombosis. The early institution of anticoagulant therapy appeared to be the single most successful method to combat arterial thrombosis (table 4). In many cases, thromboendarterectomy had to be carried out and the success of this procedure appeared to be related to the promptness of surgery in the cases deserving such treatment. If anticoagulant therapy was instituted within a short time after the diagnosis of arterial thrombosis, the majority of the patients could be rehabilitated, either by medical therapy alone or by medical therapy in combination with thromboendarterectomy. However, a delay of 2 hours or more resulted in a mortality rate of 33 per cent and severe morbidity-up to 66 per cent (table 4). This emphasizes the need for prompt recognition of this condition and immediate institution of anticoagulant therapy and/or thromboendarterectomy. In the majority of all patients seen with arterial thrombosis, the onset of symptoms was quite prompt. Eighty per cent showed clinical symptoms within 4 hours after the procedure. Although permanent dampness of the pulse may often result, even after successful thromboendarterectomy and prolonged anticoagulant therapy, this did not appear to result in a severe clinical disability to the patient. Although embolic phenomena might be expected with greater frequency, only 9 cases of arterial embolism were recorded. Two types of embolic phenomena are distinctly differentiated. The early embolic phenomena are due to dislodgment of arteriosclerotic plaques and atheromatous material by the catheter or guide wire. Immediate surgical intervention and removal of the atheromatous material will prevent further complications. The delayed embolic phenomena are usually the result of damage to the inti.ma, with formation of thrombi along the torn intima and resulting embolization from these areas. Anticoagulant therapy is the treatment of choice in these patients (table 1). In the author's own series, one patient showed the classical manifestations of shower emboli to the mesenteric bed, 2 weeks after catheterization. However, after prolonged anticoagulant therapy, the patient recovered quickly and showed no residual changes. Hematoma formation is a fairly common minor complication. In form of a serious complication, characterized by shock and formation of huge

606

LANG

Frn. l. Typical appearance of subintimal dye injection. Tube-like dye pattern outlines subintimal space of vessel. Note absence of dye filling within lumen of vessel. 2.* Survey of complications in translumbar aortograms (40 questionnaires sent~22 returned~ 19 tabulated with adequate information)

TABLE

Total number of cases analyzed. Fatal complications. Serious complications. Retroperitoneal hemorrhage and/ or dissecting aneurysm .... Bowel necrosis, mesenteric thrombosis, and ileus. Hemorrhagic pancreatitist, :j:. Renal shut-down t .... Thrombosis of the aorta . Pneumo-hemo-chylothorax.. Hypertensive crisist. Minor complications. . . . Extravasation and intramural injections. . . . Small retroperitoneal hematomas (seen on followup excretory urogram) Asthma, urticaria, and allergic reactionst. Transient hematuria t.

3,240 1 11 4 2

1 1 1 1 1 134

97

34 2 1

* Reproduced from Radiology, Aug. 1963. t These 6 cases may conceivably be classified as dye reactions; 20 to 90 cc of 50 to 75 per cent hypaque used in each case. :j: An accidental selective injection of pancreatico-duodenal artery with 30 cc of 75 per cent hypaque was carried out.

3. * Factors predisposing to arterial thrombosis following catheterization

TABLE

Total number of cases analyzed. Low output failure. Advanced age group with arteriosclerotic change . Subintimal dissection or subintimal dye injection. Broken off guide wire tip .. Mitral insufficiency .. Mitral stenosis and/or insufficiency ... Diabetes. History of previous thrombosis ..... .

28

17 26 7 2 2 4 4

7

* Reproduced from Radiology, Aug. 1963.

hematoma, only 7 cases were recorded. In 3 instances, large arteries had been perforated with the catheter, and massive retroperitoneal hemorrhage resulted. Surgical intervention was necessary to save the patient's life. Pseudoaneurysms of the puncture site of the femoral artery may occur and are probably secondary to a predisposing weakness of the wall of the femoral artery. One patient of the author's own series showed a tomato-sized pseudoaneurysm following an uneventful femoral artery puncture. The patient was able to time the formation of this pseudoaneurysm very accurately, which enlarged to a walnut-sized pulsatile mass within 20 minutes. At surgery, the appearance of the aneurysm was

607

RETROGRADE PERCUTANEOUS ARTERIOGRAPHY TABLE

4. * Results in treatment of arterial thrombosis at the puncture site. 'Total number of cases analyzed, 26 Total l'-.To. of

J\1edica1 Treatment

Surgical Trea tmcn t

Cases

Anticoagulant therapy during procedure

1 Rx continued. Dampness of pulse and intermittent claudication.

Anticoagulant therapy started 22 immediately following diagnosis of thrombosis

Treatment continued m all. (Re- Thromboendarterectorny, 14 covered 8.) (12 recovered) 1 loss of limb 1 amputated and died later

Anticoagulant therapy started within 2 hours

2 Treatment continued m all. (Re- Thromboendarterectomy, 1 covered 1.) (1 loss of limb)

Anticoagulant therapy started ·with 4 hour delay

1 Treatment continued.

Thromboendarterectomy, 1 (loss of limb and died later)

* Reproduced from Radiology, Aug. 1963.

FIG. 2. Note tomato-sized pseudoaneurysm in right groin. The aneurysm retains dye after most of contrast medium has cleared out of femoral artery. In surgery, the appearance of aneurysm was reminiscent of inner tube herniating through tire. The defect was small and the neck of aneurysm could easily be closed by 2 mattress sutures. reminiscent of an inner-tube herniating through a defective tire. The neck of the aneurysm was rather narrow and the normal rims of the artery could easily be approximated with 2 mattress sutures (fig. 2). Renal complications, particularly anuria and oliguria, were observed in only 2 cases. One of these may be classified as a true dye reaction.

FIG. 3. Sound delineates normal appearing femoral artery.Note small slit-like defect in intima secondary to entrance puncture of Odman needle. Overlying, inadvertently punctured saphenous vein is completely thrombosed and served as source for ultimately fatal pulmonary emboli.

608

LANG TABLE

Case

No.

5.* Death caiisecl by or resulting from retrogracle perwtaneoils arteriograrns

P rearteriographic Diagnosis

Predisposing Factor

Autopsy Findings-Mode of Death

Treatment

-- ---------- -----------1---------1--------------

1

Bladder tumor; Jewett's clarnification C

Low output failure, arteriosclerosis

None

Pulmonary infarcts 2 weeks after catheterization (Thrombosis of an inadvertently punctured saphenous vein was demonstrated on autopsy. This was felt to be source of emboli.)

2

Hypertension

Low output failure

Thromboendarterectomy anticoagulant therapy and amputation

Pulmonary infarct, gangrene of lower extremities, ascending thrombosis of aorta.

3

CVA Impaired carotid flow

Arteriosclerosis, low output failure

None

Rupture of thoracic aorta following intramural injection of 50 cc 90 per cent hypaque.

4

CVA Impaired carotid flow

Arteriosclerosis, low output failure

? Medical

Thrombosis of aorta and renal arteries. Thromboendarterectomy of right femoral artery was attempted, but segment re-thrombosed.

5

Coarctation aorta

of

Coarctation

None

Sudden death following introduction and passage of catheter through coarcted segment. No dye injection was carried out. No autopsy was obtained.

6

Aneurysm of ascending aorta

? Aneurysm

None

Sudden death following injection of 50 cc 90 per cent hypaque. Autopsy was not obtained.

I I

7

CVA

Arteriosclerosis, low output failure

None

I

Convulsions, hemiplegia, death 2 hours later. Autopsy: old and fresh arterial thrombosis, probably caused by dislodged plaque and thrombus.

I

* Reproduced from Radiology, Aug. 1963. This is a remarkably low incidence rate of renal complications, particularly in comparison with l\fcAfee's Eeries.12 Small bowel ileus was observed in 5 patients. In one instance, the disease entity progressed to necrosis of a large segment of the ileum and a surgical resection of this segment had to be carried out. The other 4 patients recovered on anticoagulant therapy. In 5 instances, either a catheter tip or guide wire broke off during catheterization and the

foreign body had to be recovered surgically. In none of these cases were there any further sequelae. Practically all patients were examined under local anesthesia. Premedication and the use of local anesthesia do not significantly influence the rate of complications. The amounts of dye injected varied greatly. Up to 2½ cc. per kg. body weight was injected in series of multiple injections. There appeared to be no significant increase in the complications with

RETROGRADE PERCUTANEOUS ARTERIOGRAPHY

609

F'rn. 4. Petechial rash developed in supply area of left subclavian artery following massive dye injection of this structure (60 cc of 50 per cent hypaque). the use of multiple injections. This is in strict contrast to previously recorded data, where a statistically significant increase of complications was observed with multiple injections. 2 •12 In this series there were no cases of cerebral damage or central nervous system damage following dye injection. Any serious complication may potentially cost the life of a patient. Thrombosis of the aorta and/ or renal arteries and thrombosis of the carotid arteries accounted for three of the fatal complications (table 5). One patient died suddenly following the passage of a catheter through a coarcted segment. This is a well-known complication during catheterizations of coarcted segments. One death may qualify as a true dye reaction. Intramural injection and rupture of the aorta accounted for the death of one other patient. In one instance, the death of a patient may be attributed to the catheterization that was performed some 2 weeks prior to the onset of massive pulmonary emboli. The pulmonary infarcts were caused by thrombi originating from a thrombosed saphenous vein which had been inadvertently punctured during a catheterization procedure. A fatal complication could prob-

ably have been averted by early and proper use of anticoagulant therapy (fig. 3). No significant allergic manifestations or severe cutaneous necrosis were observed in this series.17 One patient of the author's own series showed petechial rash following injection of 60 cc of 50 per cent contrast medium into the subclavian artery. The petechiae were demonstrated over the entire supply area of the subclavian artery, but subsided within 2 weeks without further sequela (fig. 4). PREVENTION OF COMPLICATIONS

The most common complication of arterial spasm is most readily averted by a meticulous and atraumatic puncture of the artery under good local anesthesia. The formation of local hematomas is easiest prevented by proper postoperative compression of the arterial puncture site. Small thin-walled needles and small, preferably siliconated, polyethylene catheters will substantially decreaRe the likelihood of irritation to the intima and possible late thromboemboliza17 Csillag, A.: Cutaneous necrosis resulting from arteriography. Orv. Hetil., 101: 201-202,

1960.

610

LANG

tion. Atraumatic advancement of the guide wire and catheter under strict fluoroscopic control will prevent the dreaded complication of subintimal dye injection and/or perforation of large vessels. Careful selection of patients and immediate use of anticoagulant therapy in case of suspected arterial thrombosis will safeguard against a serious complication. The use of external compression devices for compression of the puncture site should be curtailed because of the possibility of arterial thrombosis. SUMMARY

Seven deaths and 81 serious complications were encountered in a survey of 11,402 retrograde percutaneous arteriograms. Three hundred and twenty-five minor complications were recorded. J\Iost of the minor complications were felt to be secondary to improper technique. Arterial thrombosis at the puncture site is the most dreaded serious complication. Low output failure, poor vascular fitness and arteriosclerotic conditions are the determining predisposing factors. Early institution of anticoa?;ulant therapy and surgical endarterectomy will decrease the morbidity.

REFERENCES BumvIISTROV, M. I., JYIISHURA, V. I., PrsAREV, I. F. AND RuKHIMOVICH, G. S.: Complications in cardiac catheterization and angiocardiography. Vestn. Khir Grekov., 83: 25-30, 1959. DOTTER, C. T. AND STRAUBE, K. R.: Vertebral angiography. Percutaneous transfemoral technic suitable for outpatient application.Northwest. Med., 60: 697-700, 1961. EDHOLM, P. AND SELDINGER, S. I.: Percutaneous catheterization of renal artery. Acta radiol., 45: 15-20, 1956. LANG, E. K.: The use of arteriography in the demonstration and staging of bladder tumors. Radiology, 80: 62-68, 1963. LANG, E. K.: X-ray diagnosis of neurovascular compression syndromes. Radiology, 79: 5863, 1962. LANG, E. K. AND SABISTON, D. C., JR.: Coronary arteriography in the selection of patients for surgery. Radiology, 76: 32-38, 1961. LANG, E. K., WISHARD, w. N., JR., NOURSE, M. AND MERTZ, J. H. 0.: Retrograde arteriography in the diagnosis of bladder tumors. J. Urol., 89: 422-426, 1963. TILLE, D.: On the angiographic technic of the percutaneous catheter method in the presence of markedlv kinked arteries. Fortschr. Roentgenstr., 94: 782-784, 1961. VAs, G. AND PAPP, S.: Hazards in arteriography. Ovv. Hetil., 101: 1112-1114, 1960.