Introduction
Complication | Definition |
---|---|
Device Embolization | The entire device travels from the ductus arteriosus to another intravascular location. Device embolization is more common to the pulmonary artery than the aorta and can frequently be retrieved with a vascular snare |
Device Migration | The device moves from the original implant location within the ductus and partially protrudes outside of the ductus, while the rest of the device remains within the duct. Migration might occur due to ductal vasoconstriction and shortening causing the device to be pushed partially out of the duct |
Device Protrusion | A portion of the device following release projects into either the aorta or the LPA. The degree of protrusion can range from clinically insignificant to causing severe aortic obstruction or LPA obstruction. Device protrusion usually occurs as a result of non-optimal device position, over-sizing, or migration |
Tricuspid Valve Regurgitation | Incompetence of the tricuspid valve resulting in leakage of blood from the right ventricle into the right atrium during right ventricular contraction. Tricuspid valve regurgitation may occur as a result of injury to the valve leaflets or chordae during passage of guidewires and catheters across the valve |
Cardiovascular Injury | Injury to the vasculature or heart that may range anywhere from partial thickness vessel wall injury to a full thickness vessel wall injury or perforation with bleeding into the vessel wall (dissection) or into a free space outside the vessel or heart resulting in a hematoma, pericardial effusion or a cardiac tamponade |
Residual Shunt | Incomplete closure of the PDA that results in persistent flow across the PDA that may occur around or through the device |
Hemolysis | The destruction of red blood cells most commonly due to high shear stress commonly caused by high flow through a narrow residual shunt channel |
Contrast Induced Nephropathy | Impairment of renal function that occurs within 24 to 72 h of intravenous contrast administration |
Device Embolization
Incidence, Mechanism, and Clinical Presentation
Author & Year | Weight at Implant (g) | Implant Success (%) | Embolization (%) | Aortic Obstruction (%) | LPA Obstruction (%) | Tricuspid Regurgitation (%) | Cardiovascular Injury (%) | Procedure-related mortality (%) |
---|---|---|---|---|---|---|---|---|
Baspinar 2015 (N = 12) [13] | 1538 ± 239 (1180–2000) | 10/12 (83%) | 1 (8.3%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (8.3%) | 1 (8.3%) |
Rodriguez 2017 (N = 27) [14] | 1325 ± 281 (1000–1980) | 27/27 (100%) | 2 (7.4%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
Moreville 2017 (N = 25) [15] | 1133 ± 302 (680–1700) | 24/25 (96%) | 0 (0.0%) | 0 (0.0%) | 1 (4.0%) | 0 (0.0%) | 1 (4.0%) | 1 (4%) |
Pamukcu 2018 (N = 26) [16] | 1396 ± 433 (750–2000) | 22/26 (85%) | 2 (7.7%) | 1 (3.8%) | 0 (0.0%) | 0 (0.0%) | 1 (3.8%) | 0 (0.0%) |
Milani 2019 (N = 73) [17] | ≤ 2000 | 73/73 (100%) | 0 (0.0%) | 0 (0.0%) | 3 (4.1%) | 3 (4.1%) | 0 (0.0%) | 0 (0.0%) |
Regan 2020 (N = 64) [18] | 1200 (1025–1700) | 63/64 (98%) | 2 (3.1%) | 1 (1.6%) | 0 (0.0%) | 2 (3.1%) | 0 (0.0%) | 0 (0.0%) |
Sathanandam 2020 (N = 100) [10] | 1248 ± 348 (700–2000) | 99/100 (99%) | 2 (2.0%) | 2 (2.0%) | 0 (0.0%) | 5 (5.0%) | 0 (0.0%) | 0 (0.0%) |
All | 1282 ± 353 (680–2000) | 318/327 (97%) | 9 (2.8%) | 4 (1.2%) | 4 (1.2%) | 10 (3.1%) | 3 (0.9%) | 2 (0.6%) |
Mechanisms for device embolization | |
---|---|
Inadequate Imaging | Underestimation of ductal dimension due to incomplete visualization of the ductus |
Device Size | Implanted device is too small for the encountered anatomy |
Ductal Spasm | Instrumentation of the ductus causes smooth muscle constriction leading to underestimation of ductal diameter |
Device Malposition | Intraductal disc placement in larger infants (> 2 kg) Incorrect device orientation or shape |
Delivery System | Anterior tension on the device by delivery wire. Delivery catheter preventing device to stay co-axial along the length of the duct |
Operator related | Pushing delivery wire or catheter forward after device release. Prolonged time interval between device placement and release. Inadvertent unscrewing of the device from the delivery wire. Unfamiliarity with device sizing and placement guidelines |
Patient related | Vigorous activity resulting in sudden increase in blood flow or intrathoracic pressure |
Duct Morphology | Implanted device shape does not match shape of ductus |
Prevention
-
Accurate assessment of the PDA morphology and dimensions is crucial and will help select a suitable device type and size. Whenever possible use both TTE and angiography to obtain PDA dimensions before and after instrumentation.
-
Ensure that the Piccolo occluder is the best device choice for the PDA dimensions and morphology. There are ductal morphologies such as a type A or conical PDA for which the Piccolo occluder may not be the preferred choice.
-
A hand injection angiogram performed with a pullback technique where contrast is injected beginning in the aortic isthmus and while pulling back the catheter used for injecting contrast from the aortic isthmus to the pulmonary artery may help delineate more fully the PDA morphology and allow for accurate measurement of the PDA dimensions across the entire length of the ductus
-
If there is inconsistency between angiography and TTE regarding the PDA size, then consider selecting the device size based on the modality that provides the larger PDA size. As the use of a larger device size may result in protrusion into the aorta or the left pulmonary artery (LPA), it is important to ensure that the most reliable imaging modality is utilized for guiding device size selection. Inconsistencies between imaging modalities may be due to multiple factors, such as variation in imaging angulation and windows, amount of contrast injected, and/or ductal vascular tone.
-
Device positioning depends on infant weight. In small infants (≤ 2 kg), the Piccolo occluder length is chosen to achieve intraductal placement, whereas in larger infants (> 2 kg), the occluder length is chosen to achieve an extraductal disc placement. The extraductal positioning in larger infants who have higher blood flow provides improved positional stability and minimizes the potential for device embolization.
-
Use of a longer device (4 mm rather than the 2 mm waist) in small infants (≤ 2 kg) when the duct is longer than 12 mm may potentially provide a more secure position of the device within the duct and possibly allow for a smaller diameter device which may limit compression on surrounding anatomical structures (i.e., a 4 mm × 4 mm device may be a better choice than a 5 mm × 2 mm device in infants ≤ 2 kg with a large diameter ductus with length). However, for infants < 1 kg, using the shorter, 2 mm length device is preferrable whenever possible (i.e., for the same PDA as above, use the 4 mm × 2 mm device if patient is < 1 kg).
-
During device preparation make sure to unlock the occluder from the delivery wire by turning the occluder counterclockwise 1/8 of a turn to make disconnection easier, while ensuring that the occluder remains threaded onto the delivery wire.
-
Following device deployment pull back the delivery catheter away from the device so that the floppy section of the delivery wire is exposed to permit imaging assessment of device position and orientation without the delivery system applying superior tension onto the device. This same maneuver should also be performed prior to device release.
-
Do not release the occluder from the delivery wire if the position of the occluder is not stable, or if the occluder shape and orientation are not correct.
-
A residual shunt may be observed by color Doppler through the center of the device. However, if a residual shunt on the TTE is visualized to go around the device, then either the device has a diameter that is too small for the encountered PDA diameter or there is a malposition of the device. Effort should be made to reposition the device and re-assess for residual shunting. If the residual shunt around the device is still present despite proper orientation of the device, then one should consider using a device that is one size larger.
-
Gently release the device and minimize interaction with the delivery catheter. Once the occluder is released do not push the delivery wire or catheter forward since it may hit the device and cause embolization.
-
Following the release of the device continue to monitor the infant for several minutes prior to removing the vascular access sheath to ensure the device remains in stable position. If there are concerns, continue to monitor the infant post procedure and perform TTE or fluoroscopy to make sure the occluder is in the correct position before the patient is transferred out of the catheterization laboratory.
Percutaneous Retrieval of an Embolized PDA Occluder from the Pulmonary Circulation
Retrieval Sheaths | 4F Cook Flexor Ansel Guiding Sheath with Check-Flo Hemostasis Valve (45 cm; ANL0; 0.018 or 0.035; G48186)* 5F Cook Flexor Ansel Guiding Sheath with Check-Flo Hemostasis Valve (45 cm; ANL0; 0.018 or 0.035; G44153)* |
Diagnostic Catheters for accessing LPA | 4F Terumo Glidecath (100 cm; Multi-Purpose; 0.038; CG418) 3.3F Pedivascular Mongoose Pediatric (60 cm; JB1; 0.030; A-3JB1-60/0008) 3.3F Pedivascular Mongoose Pediatric (60 cm; JR2; 0.030; A-3JR2-60/0046) |
Diagnostic Catheters for accessing RPA | 4F Merit Performa Pediatric Judkins Right 2.0 (70 cm; JR 2.0; 0.038, 7701-B0) 4F Merit Performa Pediatric Judkins Right 2.5 (70 cm; JR 2.5; 0.038, 7701-C0) 4F Merit Impress Berenstein Hydrophilic Catheter (65 cm; 0.038; 46538BER-H) 4F Terumo Glidecath (65 cm; Angle; 0.038; CG415) 4F Terumo Glidecath (65 cm; C2; 0.038; CG409) 4F Terumo Glidecath (100 cm; JB1; 0.038; CG405) |
Guidewires | 0.035 Wholey Wire 0.035 Angled or Straight Glide Wire 0.014 Wire of choice (All-Star, Balanced Middle Weight, or others) |
Snares | 5 mm, 7 mm, and 10 mm Amplatz Gooseneck snare 3.2F Merit Ensnare (compatible with the 3.3F Mongoose catheters) 5 mm PFM Multi-snare (125 cm; 0.035; 147305V2) |
-
Administer heparin to ensure an ACT > 200 s if there is no contraindication for anticoagulation. If not already done, send a type and cross in the event a blood transfusion is needed secondary to blood loss from multiple catheter exchanges.
-
Select a suitable retrieval sheath that is large enough to retrieve the embolized device (Table 4). A 4F or 5F Cook Flexor Ansel guiding sheath may be used to retrieve all sizes of the Piccolo occluder based on bench testing. In contrast, bench testing demonstrates that the 4F TorqVue LP catheter cannot be used to fully recapture the Piccolo occluder consistently.
-
For devices in the pulmonary circulation position a retrieval sheath into the MPA and minimize the number of times the tricuspid valve is crossed (Fig. 2). If the sheath cannot be safely advanced or causes hemodynamic compromise (hypotension, bradycardia or desaturation), retract the sheath into the right ventricle or into the right atrium while maintaining guidewire position in the descending aorta via the PDA. If needed, maintain a buddy guidewire down the descending aorta via the PDA to stabilize the sheath position within the MPA.
-
Depending on the location of the device, select a 4F diagnostic catheter (as an alternative to the traditional snare catheter) to be used for snaring with a curve and characteristics suitable for reaching the vessel containing the device (such as JR2 for right pulmonary artery). Advance the catheter toward the device and grab the device with the snare.
-
When snaring the device, it is not necessary to grab the pin/screw and it is acceptable to snare the device wherever it can be grabbed because it is soft and can easily be pulled into the retrieval sheath. Advance the snare beyond the device and spin to entangle the device. It sometimes may be necessary to try different snare types to be able to snare the device successfully. A typical location for snaring is in region between the retention disc and the central waist.
-
Once the device is grasped with the snare, recapture the device into the retrieval sheath and pull the device through the sheath under fluoroscopic guidance and externalize.
-
If the infant does not tolerate having the retrieval sheath across the heart in the pulmonary artery and becomes unstable there are two options:
-
Bring back the retrieval sheath into the right atrium while keeping the diagnostic catheter in the MPA to permit snaring. Once snaring is accomplished, the retrieval sheath may be brought forward over the diagnostic catheter to the MPA to permit recapture of the device into the retrieval sheath.
-
If the retrieval sheath cannot be advanced easily into the pulmonary artery, a snared device in the pulmonary circulation can gently be brought into the right ventricle and recaptured into the retrieval sheath in the RV or if necessary, brought back further into the RA before recapturing into the sheath in the RA or IVC. Extreme caution must be taken to avoid disruption of the pulmonic or tricuspid valves.
-
In the event the retrieval procedure is prolonged, the procedure is not well tolerated, and the device does not appear to be causing any immediate danger to the infant (e.g., angiography shows good flow around the device without causing pulmonary branch obstruction), it may be reasonable to consider abandoning any further attempts to retrieve the device and postpone to a later time or consult with a surgeon for surgical retrieval of the device.
-
In cases where the device is retrieved without difficulty, consideration may be given to implantation of a different device. Sometimes a larger device may not be suitable and referral for surgical ligation may be reasonable. Following instrumentation of the ductus, spontaneous closure may sometimes occur, in which case, no further intervention is required.
Percutaneous Retrieval of an Embolized PDA Occluder from the Systemic Circulation
-
For a device embolization in the systemic circulation assess the feasibility of transcatheter retrieval via the ductus or carotid artery; or consult with a surgeon for retrieval via a surgical approach.
-
For a device that embolizes post-procedure two options exist for transcatheter retrieval depending on whether the ductus is patent. If the ductus is patent, then a long sheath may be introduced via the femoral vein, across the ductus to snare and retrieve the device. If the ductus has closed, then a carotid approach can be less harmful than a femoral arterial approach for infants < 2 kg. A long sheath is not necessary from the carotid artery, as long as the tip of the sheath is beyond the takeoff of the carotid from the aortic arch.
-
For a device that embolizes post-procedure and is not detected until after weeks to months post implant it may not be feasible to retrieve the device with a transcatheter approach due to tissue ingrowth and device endothelialization. If the patient is asymptomatic, then observation alone is all that may be needed until such time that the patient is large enough for a safe surgical retrieval if necessary.
-
If there are challenges maintaining a retrieval sheath across the ductus during attempts to recapture the device in the descending aorta, the sheath may be retracted into the MPA, RV, or RA. However, once the device is snared it should not be retrieved across the ductus unguarded and the retrieval sheath must be re-advanced across the ductus into the descending aorta prior to device retrieval.
Device Protrusion and Aortic and Pulmonary Artery Obstruction
Incidence, Mechanism, and Clinical Presentation
Device Size | Implanted device is too large for the encountered anatomy |
Delivery System | Anterior tension on the device by delivery wire. Delivery catheter preventing device to stay co-axial along the length of the duct |
Inadequate Imaging | Inability to adequately visualize location of aortic disc relative to aorta. Relying exclusively on temperature probe to identify aortic end of the ductus |
Ductal Vasoconstriction | Post-procedure ductal vasoconstriction on pulmonic end causes device to be pushed out of aortic end; or vasoconstriction causing device lengthening |
Device Malposition | Device positioned in small infant (≤ 2 kg) with one or both discs in an extraductal position. Difficulty in device positioning due to ductal distortion by delivery catheter |
Operator related | Device pulled inadvertently into left pulmonary artery during or after deployment. Prolonged time interval between device placement and release |
Migration | Device migrates following device release |
Duct Orientation | Acute angulation of the ductus relative to the descending aorta resulting in more exposure of the superior edge of the aortic disc into the aortic lumen |
Prevention
-
In small infants (≤ 2 kg) the length of the occluder is chosen to be shorter than the length of the PDA to achieve intraductal positioning with a preference to use the 2 mm length device in infants ≤ 1 kg. If a decision is made to use a 4 mm length device, it is important to ensure that the PDA length is at least 12 mm and that the entire device is implanted intra-ductal. If the entire device can be implanted intra-ductal, there may be a scenario where a smaller diameter device with more length (3 mm × 4 mm) may fit the anatomy better compared to a larger diameter device with a shorter length (4 mm × 2 mm).
-
Placement of an esophageal temperature probe pre-procedure may serve as a useful landmark of the aortic isthmus in small infants (≤ 2 kg). However, it is important to recognize that the exact position of the temperature probe relative to the anterior aortic wall at the level of the ductus should be interpreted with caution since it varies across patients and depends on image angulation. Use angiography to determine the position of the temperature probe relative to the ductal ampulla and if needed consider optimizing the imaging projection angulation to achieve better alignment of the temperature probe.
-
In infants with an upper extremity central line in the superior vena cava (SVC), the tip of the central line may mark the pulmonary artery end of the PDA and serve as a useful landmark for device positioning. However, similar to the temperature probe the exact position of the tip of the central line relative to the PDA should be interpreted with caution.
-
For small infants (≤ 2 kg), it may be necessary to deploy the aortic disc within the PDA to achieve an intraductal position. Deployment of the aortic disc in the descending aorta followed by retraction into the ductus may not always result in the entire disc entering the ductus. In particular, the superior edge of the aortic disc may protrude into the aorta whenever the ductus has an acute angle into the descending aorta and device positioning favors the aortic end of the ductus (Fig. 3) [27]. The device ideally should be deployed to achieve a central position along the ductus aiming to place the proximal disc within the pulmonary ampulla while ensuring there is no LPA protrusion.
-
For small infants (≤ 2 kg), it may be necessary to push the device forward while retracting the catheter to fully pack the device within the duct and achieve an intraductal position and avoid protrusion into the LPA.
-
A “football” shaped disc may be indicative of a device diameter that may be too large. This disc configuration could eventually flatten out and bring the disc to lie in an extraductal location. Therefore, if the disc does not flatten within the PDA, then changing to a one size smaller device may be necessary.
-
Following device deployment and prior to releasing the device from the delivery wire, it is important to rely on intra-procedural TTE and fluoroscopy/angiography to ensure the device is in a co-axial position and proper orientation (10 o’clock) without obstructing the aorta or LPA. If there is evidence of aortic or LPA protrusion, recapture the entire device and reposition to achieve an intraductal position. If the device cannot be repositioned successfully, the device may be too large, and consideration should be given to either using a smaller device or pursuing an alternative approach for treating the PDA. Recapturing only the proximal portion of the device and redeploying using a “packing-type” approach can be effective for LPA protrusion, but less likely to work for an aortic obstruction where complete device recapture is recommended.
-
TTE may be used to assess the Doppler velocity and waveform pattern to rule out an aortic or LPA protrusion. A Doppler velocity greater than 2.5 m/s in combination with an obstructive flow pattern and two-dimensional color Doppler imaging showing possible protrusion should not be ignored and warrants repositioning the device if can be done safely. Following PDA closure, the Doppler velocity in the descending aorta typically decreases, while the Doppler velocity in the LPA increases slightly, and in most cases the velocity remains below 2 m/s [29]. Intra-procedural Doppler velocity alone may not be a reliable indicator to declare an increased or decreased risk for subsequent obstruction and must be used in context with other imaging modalities noted herein.
-
Once the device has been deployed and prior to release, a delicate balance exists between using too much time performing a TTE to assess device positioning and absence of aortic obstruction prior to release from the delivery wire versus causing proximal device migration while attached to the delivery wire. Prolonged duration may cause the device getting pulled anterior by the tension of the delivery system and the device may no longer be properly positioned by the time the device is released.
-
Assess femoral pulses and lower extremity pulse oximetry tracing before and after device deployment to rule out aortic obstruction. Comparison of blood pressure cuff readings between the upper and lower extremities can also be helpful to rule out aortic obstruction.
-
Angiograms performed with the device attached to the delivery wire through the sidearm of the delivery catheter can rule out LPA obstruction with the aortic end visualized on levophase. Useful projections include 90° lateral and 30° LAO with 10°-15° cranial angulation.
-
Following device release from the delivery wire there is a potential for the device to shift in position and result in aortic or LPA protrusion. Therefore, it is important prior to leaving the cardiac catheterization laboratory to perform a thorough imaging assessment to ensure there is no device protrusion.
-
If there is device-related LPA or aortic arch obstruction noted before transport of the child from the catheterization laboratory, considerations to re-intervention should be given.
Management
-
Infants with evidence of aortic or LPA protrusion should be closely monitored for potential signs of vascular obstruction and treated promptly whenever there are signs of clinical compromise. Limb or intestinal ischemia, worsening respiratory status, hypoxia, decreasing urine output, or acidosis secondary to vascular obstruction caused by the device requires urgent intervention.
-
When contemplating transcatheter retrieval of the device, femoral arterial access should not be utilized in small infants ≤ 2 kg to retrieve the device secondary to the risk of causing vascular injury with limb ischemia.
-
Infants ≤ 1 kg with a significant aortic obstruction are at an increased risk for a fatality if not treated promptly. Larger infants with evidence on TTE of a significant aortic obstruction (Doppler velocity >2.5 m/s), but without symptoms and without a significant blood pressure differential between the upper and lower extremities (≥ 20 mmHg) may be expectantly managed with close follow-up.
-
LPA obstruction (Fig. 5) without associated symptoms often may be managed conservatively without intervention. However, when lung perfusion scan demonstrates less than 30% flow to the left lung, intervention may be considered. There have been instances where LPA obstruction completely resolved by simply waiting for the infant to grow.
-
Following retrieval of the device it may be reasonable to use another device to occlude the ductus whenever the ductus remains patent and the infant is clinically stable.
-
It may be prudent to implant a stent from a carotid artery approach to treat aortic arch obstruction in infants < 1kg rather than trying to retrieve the device. Device retrieval in such small infants, especially 24-48 hours post procedure can result in significant hemodynamic compromise. Therefore, stent implantation to treat aortic obstruction may be a more prudent treatment option to stabilize these very small infants, with future reinterventions required when the child is older.
Tricuspid Valve Regurgitation
Incidence, Mechanism, and Clinical Presentation
-
Initial passage of the catheter between the chordae rather than between the valve leaflets themselves.
-
Mismatch between a guidewire and the internal lumen of a catheter resulting in chordae entrapment [17].
-
A lengthy and challenging implant procedure, particularly involving device embolization with multiple crossings of the tricuspid valve with various catheters and sheaths.
-
Retrieval of an embolized device unguarded (i.e., not within a retrieval sheath) through the tricuspid valve.
Prevention
-
Never advance a catheter over a guidewire across the tricuspid valve without imaging guidance if resistance is encountered, or if there is significant mismatch between the catheter lumen and the guidewire diameter.
-
Two approaches have been used for crossing the tricuspid valve:
-
The first approach uses a 4 French angled glide catheter (Radifocus™ Glidecath™ Non-Taper ANGLE RF * ZV9410GA - 4Fr x 65cm x .038", CG415, Terumo, Japan) that is advanced over a floppy atraumatic tip 0.035-inch wire. Once in the right atrium, the catheter is pointed toward the tricuspid valve and the wire advanced into the RV. The wire and the guide catheter are gradually advanced through the heart while taking advantage of the angled catheter tip to guide the wire into the RV initially followed by the pulmonary outflow tract. The guidewire can then be advanced across the PDA down the descending aorta. Subsequently, the delivery catheter can be passed directly over this 0.035” wire with insignificant wire-catheter mismatch (Amplatzer TorqVue LP Catheter, 4Fr x 80cm x 0.046”, Abbott, Plymouth, MN, USA).
-
The second approach uses a 4 French balloon end-hole catheter advanced to the mid-right atrium and directed and passed across the tricuspid valve with the assistance of a curved stiff end of an 0.018-inch guidewire that must remain within the catheter lumen. A 0.014-inch floppy tipped coronary guidewire is then advanced out the pulmonary artery across the PDA into the descending aorta. With this approach there is significant mismatch between the 0.014” guidewire and the delivery catheter lumen and it is strongly recommended that this be addressed by placing a 0.21” microcatheter coaxially within the delivery catheter before passing it over the guidewire.
-
Retrieval of an embolized device from the pulmonary artery should be performed through a long sheath to minimize the potential for injuring the tricuspid valve. If a long sheath cannot be utilized during retrieval, an unguarded device may be gently pulled through the right heart under imaging guidance. Use of TTE during this process may permit retrieval through the valve while limiting the formation of TR. If resistance is encountered, further attempts to retrieve the device should be abandoned and an alternative interventional technique or a surgical approach for device retrieval may be needed.
Management
Cardiovascular Injury
Incidence, Mechanism, and Clinical Presentation
Prevention
-
Do not deliver the device in small infants (≤ 2 kg) using the retrograde approach as small infants are at an increased risk for arterial injury. In small infants, it is recommended to deliver the device using an anterograde transvenous approach only. Arterial access in this population should be reserved for emergencies only and may be best accomplished using a surgical cutdown.
-
Utilization of a vascular ultrasound to guide femoral vein access may further decrease the risk of inadvertently accessing the femoral artery [30‐32]. Once access is gained with a guidewire to the femoral vein, confirm guidewire position with fluoroscopic imaging prior to insertion of an introducer.
-
Whenever advancing guidewires and catheters through the vasculature rely on fluoroscopic guidance to prevent damage to the vessels and cardiac tissue. Do not advance a catheter over a guidewire without image guidance if resistance is encountered. Advancing the catheter under such circumstances has the potential to result in cardiovascular injury.
-
If there is suspicion for cardiac perforation, immediate TTE to identify a pericardial effusion and prompt treatment can be lifesaving.
Management
-
Vascular access site injury with formation of a hematoma may be managed conservatively as long as the hematoma is not expanding. Femoral artery thrombosis may be treated with either short-term intravenous anticoagulation (unfractionated heparin) or aspirin if there are no systemic contraindications.
-
Cardiac perforation with formation of a pericardial effusion requires emergency intervention to drain the pericardial effusion and repair the site of perforation. Pericardiocentesis under TTE guidance and/or cardiac surgery may be needed to prevent a fatality particularly in the setting of cardiac tamponade. Pericardiocentesis may be accomplished using a 4 French micro-introducer kit (Galt Medical, REF#KIT-002–34) to access the pericardial space followed by drain placement (Cook Pediatric Pericardiocentesis Set, 5 Fr; 30 cm; 0.028; REF#G05251).
-
Utilization of a clear, plastic drape will allow visualization of the infant under the drape at all times. This may potentially help identify hemoperitoneum from accidental perforation sooner allowing for prompt intervention.
-
In case of a large perforation, or vascular injury with massive hemorrhage, consider auto-transfusion by drawing up the bleeding from the pericardium, pleura or peritoneum until the bleeding site can be identified and effectively controlled or surgically repaired.
-
Call for surgical backup immediately in case of cardiac or vascular perforation.