Takajo D, Newkirk B, Shahanavaz S. Catheter Cardiovasc Interv. 2024 Mar;103(4):580-586. doi: 10.1002/ccd.30966. Epub 2024 Feb 14.PMID: 38353500
Take-Home Points:
- Screening for pseudoaneurysms after procedures using carotid or axillary artery access aids in early detection and treatment.
- Longer sheath dwell times (in-to-out time) and higher activated clotting times (ACT) might be associated with pseudoaneurysm development.
Commentary from Dr. Subhrajit Lahiri, section editor of Congenital Heart Disease Interventions Journal Watch:
The authors accurately note that pseudoaneurysms following arterial access have been studied in adults. In these studies, interventional procedures, electrophysiology procedures, large sheath sizes, and left groin access were identified as risk factors. While Bauser-Heaton et al. reported pseudoaneurysms after carotid or axillary access in children, their lack of post-procedural complication screening limited the true incidence.
This paper describes the authors’ institutional practice of performing ultrasound screening 24 hours after every axillary or carotid access. They analyzed 29 young infants who underwent cardiac catheterization between 2013 and 2022. The median patient age was 6 days, with most having single ventricles. Procedures included PDA stenting, aortic valvuloplasty, and thrombectomy. Both carotid and axillary access were used, with ultrasound guidance for access establishment. Hemostasis was achieved using compression, and heparin was administered to maintain target ACT levels. The median procedure duration was 82 minutes, and the median compression time was 20 minutes. ACT values were recorded for most patients, with a median closing ACT of 208 seconds. All 29 patients underwent Doppler ultrasound within this timeframe.
Four patients with carotid access and one with axillary access were diagnosed with access-related pseudoaneurysms. Bedside ultrasound compression in the ICU resolved the pseudoaneurysm in 3 patients. One patient underwent trans-arterial flow-diverting stent placement at 6 weeks, and another required embolization of the left common carotid artery. Comparing groups with and without pseudoaneurysms revealed significantly longer sheath dwell times (135 minutes vs. 75 minutes) and higher ACT (268 seconds vs. 200 seconds) in the pseudoaneurysm group.
The authors acknowledge the lack of treatment guidelines for carotid or axillary pseudoaneurysms in children, with treatment depending on factors like size, location, and physician preference. However, they emphasize the importance of early detection.
Limitations:
- Small sample size limits the statistical power of the conclusions.
- Lack of data on:
- Number of puncture attempts
- Bleeding after access
- Standardization in early cases
- Variability in post-procedural holding pressure
Conclusion:
This valuable study highlights a rare but important complication of carotid and axillary artery access, a common practice in cardiac catheterization labs. It encourages multicenter studies to establish guidelines for managing such complications.