Vascular Access for Left Heart Catheterization
While traditionally viewed as benign when compared with nonaccess-site complications, vascular access-site complications are associated with a short- and long-term risk of morbidity or mortality as well as increased costs. In a study of 17,901 consecutive patients undergoing transfemoral PCI at the Mayo Clinic, Doyle et al. demonstrated that major femoral complications (including major hematoma, external bleeding, and retroperitoneal bleeding) were independently associated with a 30-day adjusted hazard ratio (HR) for a mortality of 9.96 (95% confidence interval [95% CI]: 6.94–14.3, p < 0.001). Similarly, Yatskar et al. reported that hematomas requiring transfusions were associated with an increased 1-year mortality (HR 1.65, 95% CI 1.01–2.70, p = 0.048) among patients undergoing PCI during the NHLBI Dynamic registry recruitment waves. While relatively uncommon, retroperitoneal bleeding remains a catastrophic vascular access-site complication, with 73.5% requiring transfusion and 10.4% dying during hospitalization. Furthermore, in an era of increasing public concern regarding healthcare costs, it is also worth noting that even after adjustments for baseline differences among patients enrolled in an economic sub-study of Gusto IIb, each moderate or severe bleeding event increased costs by $3770 and each transfusion event increased costs by $2080. In current practice, while the risk of major bleeding is dependent on patient characteristics and to an extent the choice of antithrombotic agent, the choice of vascular access strategy (transfemoral vs. transradial) and a meticulous attention to good technique, proper equipment, and skilled operators may reduce major bleeding and thereby reduce morbidity, mortality, as well as costs.
