Chapter 63 Endovascular Interventions
OPERATIVE STEPS
Operative Procedure
Contrast Toxicity
Performance of catheter-based techniques requires the use of contrast agents and digital subtraction imagery. Contrast toxicity can affect many organs and have a profound detrimental effect. Many minor reactions of contrast have been reduced with the lower-osmolality agents now available.1 One of the major adverse effects of contrast agents is nephrotoxicity, which is generally defined as a rise in the creatinine of greater than 25% above baseline in the absence of other inciting events2 (grade 1 complication). The event usually occurs within 48 hours of the procedure. For most patients, it is nonoliguric and resolves over time. The most important risk factor for the development of contrast-induced nephropathy is preexisting renal insufficiency. Other contributing factors are dehydration, diabetes, and the amount of contrast used.
The treatment for contrast-induced nephrotoxicity is hydration, with less than 1% of patients progressing on to the need for dialysis. Prevention of nephrotoxicity is accomplished via the following methods: hydration, especially in patients with renal insufficiency, has been shown to be the most effective preventive measure; N-acetylcysteine has been shown to reduce the risk of contrast-induced nephropathy in patients with renal insufficiency3; and alkalinization of the urine has also been found to be beneficial in patients with renal insufficiency.4
Access Site Complications
Although simplistic in nature, the puncture and access of the arterial system can lead to serious complications. In infrainguinal procedures, the common femoral artery is accessed above the bifurcation of the superficial femoral artery (SFA) and the profunda femoris artery (PFA) and below the inferior epigastric artery. The access site is identified via fluoroscopic imaging and palpation of the femoral artery.5 The ideal location is over the femoral head6 (Fig. 63-1). After the procedure, manual pressure is applied to achieve hemostasis of the puncture site or a closure device is used to mechanically seal the area. Numerous complications can occur during this part of the procedure.
High Arterial Puncture (Fig. 63-2)
• Consequence
Poorly Angled Puncture
• Consequence
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