Arterial and Venous Complications Early After Cardiac Catheterization in Children and Adolescents: A Prospective Study

AUTHORS

Hamid Amoozgar 1 , Amir Naghshzan 1 , Mohammad Reza Edraki 1 , 2 , * , Hamed Jafari 3 , Gholam Hossein Ajami 4 , Hamid Mohammadi 1 , Nima Mehdizadegan 4 , Mohammad Borzouee 4 , Kambiz Keshavarz 4

1 Cardiac Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

2 Pediatric Cardiology Ward, Shiraz University of Medical Sciences, Shiraz, Iran

3 Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

4 Neonatal Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

How to Cite: Amoozgar H, Naghshzan A, Edraki M R, Jafari H, Ajami G H, et al. Arterial and Venous Complications Early After Cardiac Catheterization in Children and Adolescents: A Prospective Study, Iran J Pediatr. Online ahead of Print ; In Press(In Press):e91965. doi: 10.5812/ijp.91965.

ARTICLE INFORMATION

Iranian Journal of Pediatrics: In Press (In Press); e91965
Published Online: October 9, 2019
Article Type: Research Article
Received: April 4, 2019
Revised: May 17, 2019
Accepted: August 9, 2019
Uncorrected Proof scheduled for 29 (5)
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Abstract

Objectives: This prospective study was designed with the aim to evaluate the prevalence and risk factors of arterial and venous complications among children and adolescents during cardiac catheterization.

Methods: All patients younger than 18 years who underwent cardiac catheterization from April 2016 to April 2017 were consecutively enrolled in this study.

Results: A total of 179 vascular accesses were performed, and most (70%) cases were interventional procedures. Totally 17 (14%) arterial and 16 (13%) venous events occurred, while 4% and 5% of them, respectively, were more serious. Half of the patients who underwent axillary artery access developed major or minor trauma, and these subtracted from total events of artery accesses, only 9% of femoral arteries developed minor or major complications. The more serious arterial complications were dissection, pseudo-aneurysm and fistula whereas in venous access they were pseudo-aneurysm and thrombosis. Serious and non-serious complications considered together, the mean age of those without complication was 1.9 ± 3.6 years and in complicated group it was 1.7 ± 2.6 years (P = 0.33), and the mean weight of non-complicated cases was 9.27 ± 7.9 kg and 8.51 ± 8.12 kg in the complicated group with no significant difference (P = 0.41), whereas the incidence of more serious vascular complications was highest among patients younger than 1 year of age, and less than 9 kilograms. 23% of the cases who underwent more than 3 tries for arterial and 100% for venous access showed the complications. Also few arterial tries resulted in unintentional venous complications and vice versa. None of the cases needed surgical or interventional therapy.

Conclusions: Our study showed that venous complications are as high as arterial complications, although most of them are self-limited.

Keywords

Cardiac Catheterization Congenital Heart Disease Arterial Injury Venous Injury Children

Copyright © 2019, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Cardiac catheterization (CC) is a mainstay of diagnosis and treatment of many children with congenital and acquired cardiovascular diseases. Due to their invasive nature, both therapeutic and diagnostic CC is associated with vascular risks and complications, including pseudo-aneurysm, arteriovenous fistula, hematoma, transient loss of pulse, thrombosis, and vessel occlusion (1-8). Indeed the most frequent and relevant complications in childhood after CC are vascular injuries (1, 2).

There are several risk factors regarding these complications such as lower weight, longer duration of cannulation, larger catheter diameter, cyanosis and arterial access (6-11).

Vessel thrombosis after CC might jeopardize future diagnostic or interventional cardiac procedures. Physical examination is the initial method to evaluate post catheterization complications at the site of vascular access, but some injuries are subtle and subclinical, which are not recognizable by physical examination; hence, color Doppler ultrasound can be a useful and reliable noninvasive tool for diagnosis and exclusion of vessel complications even in young children (1).

2. Objectives

The aim of this study was to determine prevalence and risk factors of the arterial and venous complications early after CC among children and adolescents via ultrasound.

3. Methods

This prospective study included all diagnostic and interventional CC, performed at Namazi Hospital, affiliated to Shiraz University of Medical Sciences (SUMS), as the main referral center in Southern Iran, April 2016 to April 2017.

We explained the study for the patients or their guardians and informed consent was obtained of them.

The database consisted of case type (diagnostic or interventional), age, weight, gender, diagnosis, site of vascular access, number of tries for vascular access (single try, second or third tries, more than 3 tries are indicated as multiple tries), size and provider of inserted sheaths.

Catheterizations were performed under conscious sedation or general anesthesia based on patient’s condition, but the access points were completely immobile during procedure. Subcutaneous injection of 1% lidocaine without epinephrine was used as local anesthesia. Arterial and venous accesses were obtained percutaneously, using the Seldinger technique [8]. Once the proper position of the wire was confirmed by fluoroscopy, dilator/sheath assembly was gently inserted into the vessel over the wire. For older patients an incision was made with an appropriate size blade. Stepwise pre-dilatation technique was used for larger delivery systems or sheaths. In some neonates, especially for balloon angioplasty of coarctation of the aorta and stenting of the ductus arteriosus, axillary artery was accessed.

Based on the case features various vascular sheath sizes from different manufacturer were used, such as VasCard introducer sheath, Merit Medical Company and Terumo Europe NV.

If we had to use a delivery system more than 2 French bigger than the first sheath, we initially chose a sheath size larger than the first one sequentially, and the proper size delivery system was inserted.

All sheaths and catheters were routinely flushed with one international unit per milliliter of heparinized saline.

Manual compression was applied in all cases following sheath removal by a special nurse. The pressure was enough to stop bleeding and after cessation of bleeding, pressure dressing was carried out. All patients were kept under close observation for any possible complication of vascular access site after catheterization.

Ultrasound examination was done prior to vascular access in CC laboratory, and post-procedure was done the day after, to rule out any unknown vascular or soft tissue injuries. Before the CC procedure, shape, patency and maximum velocity of the arteries and veins in the site of vascular access were evaluated, and after CC ultrasound examination was done to recognize shape, patency and maximum velocity of the vessels, venous thrombosis, minor or major hematoma, pseudoaneurysm, and any fistula. We extended the ultrasound about 40 millimeters on both sides of the entering points.

Most of the access procedures were guided by ultrasound set especially among patients who were under 10 kilograms, and cases in whom we could not palpate arterial pulses well.

We categorized the arterial complications as more serious, such as dissection, pseudoaneurysm and fistula and less serious, such as acute transient loss of arterial pulse and minor hematoma.

Also venous injuries were stratified as more serious such as major hematoma, pseudoaneurysm and venous thrombosis and less serious such as minor hematoma. Minor hematoma was defined as benign transient hematoma with no need for lab tests or invasive procedures, and major hematoma was defined when a patient developed hypotension or required close monitoring or blood transfusion.

Acute loss of pulse was defined as transient arterial spasm with no serious complication.

Ultrasound examination was performed by an expert sonographer who was not aware of the sheath size and the patients’ conditions. He used a 12-MHz linear ultrasound probe, which included two-dimensional, color and pulsed-wave Doppler modes.

Unfractionated heparin was applied as anticoagulant during CC, and we administered initial bolus of 50 and 100 units/kg for venous or arterial access, respectively. Then, we repeated half of bolus doses every 60 minutes during CC. Prophylactic anticoagulation after procedure was not continued, but aspirin or continuous heparin injection were administered in ductus stenting to prevent stent occlusion.

The entire data after collection was expressed as mean ± standard deviation or number or percentage.

Statistical analyses were performed using IBM SPSS® version 23 and values were considered to be statistically significant when P ≤ 0.05. The independent sample t-test was used to make comparison between the two independent groups and Mann Whitney-U test for nonparametric values and Pearson’s chi-squared test for categorical data to evaluate unpaired data.

4. Results

Totally 173 right or left CCs were performed and 6 patients had more than one arterial or venous access simultaneously. Thus, there were 179 entrance points, and 88 arterial and 91 venous sites were accessed. Of the total, 116 (63.5%) patients underwent both arterial and venous cannulations, besides 33 (19%) cases underwent only arterial, and 30 (17.5%) cases only venous cannulation.

Nearly 70% of the CCs were interventional procedures and 30% were diagnostic (Table 1), and 17 (14%) arterial and 16 (13%) venous access injury occurred while 4% and 5% of them were more serious respectively (Table 2).

Table 1. Types and Frequency of Cardiac Catheterization Procedures
ProcedureFrequency (%)
1ASD closure8 (6.6)
2VSD closure5 (4.1)
3PDA closure28 (23.1)
4Balloon valvuloplasty of valvar PS10 (8.3)
5Balloon valvuloplasty of valvar AS2 (1.7)
6Balloon angioplasty of CoA10 (8.3)
7Right diagnostic catheterization2 (1.7)
8Left diagnostic catheterization6 (5)
9Right and left catheterization40 (33.1)
10PDA stenting6 (5)
11RVOT stenting1 (0.8)
12CoA stenting2 (1.7)
13Coronary artery fistula closure1 (0.8)

Abbreviations: AS, aortic valve stenosis; ASD, atrial septal defect; COA, coarctation of aorta; PDA, patent ductus arteriosus; PS, pulmonary valve stenosis; RVOT, right ventricular outflow tract; VSD, Ventricular septal defect.

Table 2. Summary of Arterial and Venous Access Point Complications
Access Point ComplicationsFrequency (%)
Venous access complication
No vascular complication105 (86.8)
Pseudo aneurysm3 (2.5)
Minor local hematoma8 (6)
Major local hematoma2 (1.7)
Venous thrombosis3 (2.5)
Arterial access complication
No vascular complication 104 (85.9)
Pseudoaneurysm2 (1.7)
Minor local hematoma3 (2.5)
Arteriovenous fistula1 (0.8)
Arterial dissection2 (1.7)
Transient loss of arterial pulse (arterial spasm)9 (7.4)

We stratified the patients in two groups, with and without vascular complications with respect to all complications. The mean age in complicated group was 1.67 ± 1.6 years and amongst without complication was 1.9 ± 3.6 years (P = 0.49), and the mean weight in complicated group was 8.51 ± 8.12 kg and in non-complicated cases it was 9.87 ± 5.9 kg (P = 0.61). Thus, neither age nor weight had significant differences in this group, whereas the incidence of more serious vascular complications was highest among patients younger than 1 year of age, and less than 9 kilograms (87.5%) as shown in Tables 3 and 4.

Table 3. Data of the 17 Cases with Post Procedure Arterial Complications
Patient No.Age (y)Body Weight (kg)DiagnosisSheath Size (F)Site of ArteryNo. of PuncturesDoppler US
129VSD closure5Right femoral1Acute loss of arterial pulse
20.65.6Rt & Lt catheterization5Right femoral2Arterial dissection
30.255.2CoA Balloon5Right femoral1Acute loss of arterial pulse
42.511.3CoA Balloon6Right femoral1Minor local hematoma
52.512.5Lt heart catheterization10Right femoral1Pseudoaneurysm
60.163.5CoA Balloon5Right femoral2Acute loss of arterial pulse
71.611RVOT stentingRight femoralVein accessAcute loss of arterial pulse
81244CoA stenting10Right femoral2Pseudoaneurysm
91.29CoA Balloon5Right femoral3Minor local hematoma
100.667PDA closure5Right femoral1Acute loss of arterial pulse
111143PDA stenting6Right femoral2Minor local hematoma
120.56.5Lt heart catheterization6Right femoral1Acute loss of arterial pulse
130.164PDA stenting5Right Axillary2Arteriovenous fistula
140.013CoA Balloon5Right Axillary3Acute loss of arterial pulse
150.65PDA closure5Right femoral1Acute loss of arterial pulse
160.665.6Rt & Lt catheterization5Right femoral3Acute loss of arterial pulse
170.013PDA stenting5left femoral3Arterial dissection

Abbreviations: ASD, atrial septal defect; COA, coarctation of the aorta; PDA, patent ductus arteriosus; RVOT, right ventricular outflow tract; VSD, ventricular septal defect.

Table 4. Axillary Arterial Access and Related Complications
AgeWeight (kg)ProcedureVascular Complication
14 months5PDA stentingNo complication
22 months4PDA stentingAV fistula
3< 1 month3balloon angioplasty of CoAAcute Loss of Impulse
4< 1 month2.9PDA stentingNo complication
5< 1 month3PDA stentingVenous thrombosis (unintentionally)
6< 1 month2.8PDA stentingNo complication

Abbreviations: AV fistula, arteriovenous fistula; CoA, coarctation of the aorta; PDA, patent ductus arteriosus.

Femoral arteries were preferred as access point in 94.3% followed by right and left axillary arteries in 5.7% 0f the patients. Also, femoral veins were preferred except one case who underwent ASD closure from right jugular vein due to abnormal anatomy of right and left femoral veins (Figure 1). Furthermore, 84.5% of arterial short sheaths were 5 French and 14.5% of the arterial sheaths were 6 French, and we only used one 10 French delivery system for aortic coarctation stenting that became complicated. Diameter of the most introducer short sheaths for venous access was 6 French, while delivery systems were used in 33 cases according to interventional procedures (Table 5).

Table 5. Delivery Systems and Associated Venous Complications
Delivery System FrenchFrequencyNumber of ComplicationsPercent
No need8471.2
6 F81 (PDA closure)6.6
7 F142 (one PDA closure, one VSD closure)11.6
8 F3No complication2.5
9 F61 (PDA closure)5
10 or 12 F3No complication2.5
Five year old girl underwent ASD closure from right jugular vein due to abnormal anatomy of the right and left femoral veins
Figure 1. Five year old girl underwent ASD closure from right jugular vein due to abnormal anatomy of the right and left femoral veins

One to three puncture tries were done in 61% of arterial and 60% of venous cases and only 12% and 7% of these cases had complications respectively, whereas more than 3 puncture tries were done in the rest of which 23% showed post procedure arterial and 100% venous complications.

Cross tab analysis for sheath size and frequency of arterial and venous complications showed no statistically significant correlation. On the other hand, 3 arterial and 1 venous complication occurred, due to unintentional needle entry into the artery or vein and without insertion of sheath in the associated vessel (Table 6).

Table 6. Relation Between the Sheath Size and Arterial and Venous Access Complications
Arterial Sheath Size (F)Arterial Access Number (%)Arterial Complications Number (%)Venous Sheath Size (F)Venous Access Number (%)Venous Complications Number (%)
No (venous access and unintentional arterial access)Less than 30 (25)1 (3)No (arterial access and unintentional venous access)Less than 33 (26.5)3 (2.4)
French 574 (63.2)12 (16)French 516 (13)3 (2.4)
French 613 (11)4 (30)French 671 (57.2)9 (7)
French 101 (0.8)1 (100)French 7 - 94 (3.3)1 (0.8)

Seventeen out of 119 patients (14%) with arterial access by means of short sheath and delivery system had vascular injury on Doppler ultrasound, which is demonstrated in Table 3. While 12 procedures were not seriously complicated with acute transient loss of arterial pulse and minor hematoma, 5 patients had complications with more serious injuries including 2 dissections, 2 pseudoaneurysms and 1 fistula. Consequently 4% of them suffered more serious injuries and one of these 5, underwent delivery system insertion (Tables 2 and 3).

Axillary arterial access was done in 6 patients with sheath size 5 F of whom 4 cases were neonates and 2 cases were 2 and 3 months old, while one of them underwent balloon angioplasty of aortic coarctation and rest of them underwent patent ductus arteriosus stenting. Post procedure arterial complications happened for 2 and vein complication for one of the cases unintentionally (Table 4; thus 50% of them developed major or minor complications, and if we subtract axillary access from femoral access injuries, there remain only 9% of femoral arteries that developed minor or major complications.

Sixteen out of 121 patients (13%) with venous access by means of short and long sheaths had some findings on Doppler ultrasound, as demonstrated in Table 4, of whom 8 (6%) patients had complications like non-serious minor hematoma, 2 patients had major hematoma that resolved with packed cell infusion, 3 patients had pseudoaneurysms, and 2 patients developed venous thrombosis due to triple venous lumen insertion after procedure (that was not a direct complication of CC), and 1 patient developed venous thrombosis accidentally because of aortic coarctation ballooning with unintentionally venous needling. Consequently 6 patients (5% of all patients) had more serious venous complications (Tables 2 and 7).

Table 7. Data of the 16 Cases with Post Procedure Venous Complications
Patient No.Age (y)Body Weight (Kg)DiagnosisSheath Size (F)Delivery System in VeinNo. of PuncturesDoppler Ultrasound
10.48PDA closure6Yes1Pseudoaneurysm
20.255.2Balloon CoA-NoArterial accessVein thrombosis
31.666.5Rt & Lt catheterization6No1Pseudoaneurysm
40.57Rt & Lt catheterization6No4Pseudoaneurysm
511.522Rt & Lt catheterization6No1Minor local hematoma
60.665.5Rt & Lt catheterization6No1Minor local hematoma
71.667.3Rt & Lt catheterization5No2Minor local hematoma
80.45Balloon PS7No4Minor local hematoma
91134PDA closure6Yes1Minor local hematoma
100.754.5PDA closure6Yes2Major local hematoma
110.348VSD closure6Yes1Minor local hematoma
123 d/o3CoA balloon-NoArterial accessMinor local hematoma
135 d/o3PDA stenting5No1Vein thrombosis after triple lumen
140.79PDA closure6Yes1Minor local hematoma
150.665.2Rt & Lt catheterization-NoFailed vein accessMajor local hematoma
165 d/o3CoA balloon5No_Vein thrombosis after triple lumen

Abbreviations: ASD, atrial septal defect; CoA, coarctation of the aorta; PDA, patent ductus arteriosus; PS, pulmonary valve stenosis; RVOT, right ventricular outflow tract, VSD, ventricular septal defect.

Arteriovenous fistula was a rare complication of CC, and it only happened in one case after PDA stenting via right axillary artery access in a neonate (Figure 2).

Right basilic arteriovenous fistula after cardiac catheterization from right axillary site in a neonate
Figure 2. Right basilic arteriovenous fistula after cardiac catheterization from right axillary site in a neonate

The overall incidence of acute loss of pulse was 7.4% (9 patients) and all were transient. Loss of arterial pulses due to transient arterial spasm happened after diagnostic catheterization in 2 patients, and after interventional catheterization in 7 patients. Three patients had aortic coarctation balloon angioplasty, 2 patients had PDA closure with Amplatzer, one patient underwent VSD closure with Amplatzer, and the last one had PDA stenting for pulmonary atresia. In these cases, spontaneous pulsation recovery did not occur and intravenous heparin loading and maintenance infusion over a period of 12 to 24 hours was administered. Pedal pulse recovery was established by clinical examination that was confirmed by the Doppler US examination. None of the patients with arterial and venous complications needed short-term surgical or interventional therapy, although more attention is necessary in the future to avoid particularly arteriovenous fistulas and pseudoaneurysms.

5. Discussion

In this study, we were looking to identify the incidence and factors affecting the development of vascular access complications in children and adolescents undergoing congenital cardiac catheterization.

In our study, the incidence of arterial and venous complications were similar to some previous studies (4, 5), but there were some differences between types of venous complications, such as local hematoma, venous thrombosis and pseudo-aneurysm formation. The most frequent arterial complication was acute loss of pulse due to transient arterial spasm.

In recent studies there were different and heterogeneous reports on complications after CC (2-8). However, most of them have focused on arterial complications (1, 4, 9, 12) and only few studies evaluated and dealt with venous complications (10, 11). Due to increased interventional procedures, it seemed necessary to evaluate CC venous complications more precisely, especially with new introducer sheaths.

While we had no permanent arterial thrombosis, the reported prevalence of arterial thrombosis after CC varied between 0.8% and 40% (6, 9). One study showed that the rate of femoral artery thrombosis in young infants after CC might be underestimated; hence, it is recommended to use Doppler ultrasound after each procedure (1). According to this study and Danish National Patient Registry, routine Doppler ultrasound the day after cardiac catheterization, is recommended in some centers (1, 3) to establish life-long patency of arterial vessel access, and to avoid impaired limb growth. Clearly this recommendation was for arterial thrombosis and there was no suggestion for venous thrombosis.

Some researchers reported that acute occlusive arterial injury was more prevalent in younger children (6, 13), which was in accordance with our study that revealed this inverse relationship for low body weight and arterial and venous access point complications.

The lower age was an influential factor regarding the complications in some researches (6), as in the present study that revealed more prevalence of the serious complications among younger cases.

Several studies showed significant risk differences between interventional and diagnostic catheterizations, in such a way that interventional procedures carried the highest risk (6, 8). In our study, there were no statically significant differences between diagnostic and interventional procedures.

One study on factors affecting vascular access complication in children stated a relatively high incidence of transient loss of pulse after balloon pulmonary valvuloplasty without any attempt to establish an arterial access (8). This unusual complication happened in one of our cases after several attempts for venous access of balloon valvuloplasty of pulmonic stenosis, which might have been due to unwanted entry of the needle into the artery during venous trial.

Arteriovenous fistulas are very rare complications after pediatric CC (14, 15), and fortunately it was resolved by itself without any surgical intervention.

On the other side, 50% of axillary arteries in low weight children, developed major or minor complications, even though they were self-limited, while only 9% of femoral arterial accesses developed minor or major complications.

Some authors evaluated the complications after CC and categorized the severity of adverse events and showed that young age, low body weight and cyanotic or complex congenital heart disease appeared to be risk factors for adverse effects (5, 9). In our study, there was no difference between cyanotic and acyanotic CHD for arterial and venous complications.

5.1. Limitation of the Study

One limitation in our study was paucity of patients and heterogeneity of the procedures, device sizes and profiles; hence, further studies should be performed on more patients.

5.2. Conclusions

Despite great care during vascular access with new low profile equipment, vascular events are still high after CC in children and adolescents, although incidence of serious injuries is low, and venous complications were as high as arterial complications. In summary early detection and long term follow up of these events seems essential, and we might suggest color Doppler ultrasonography after CC in children and adolescents to recognize vascular access point complications.

Footnotes

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