Neuroradiology
Transfemoral Cerebral Arteriography versus Direct Percutaneous Carotid and Brachial Arteriography: A Comparison of Complication Rates 1 Michael S. Huckman, M.D., Gregory I. Shenk, M.D., Robert L. Neems, B.A., and Thomas Tinor, B.S.
Cerebral arteriograms in 1,141 consecutive patients, which were done either as direct percutaneous carotid or brachial studies or as transfemoro-cerebral catheter studies, were reviewed. While the overall complication rate for the direct percutaneous studies was higher, the incidence of neurologic complications, both transient and permanent, was higher in the transfemoral group. This higher incidence of neurologic complications may be related to the frequent irrigation of the catheter, which increases the probability of embolism. The incidence of serious complications was lower than in previous studies, perhaps because gravely ill patients are more likely to undergo computed tomographic scanning. INDEX TERMS: Cerebral angiography, complications. Cerebral angiography, technique • Cerebral blood vessels, angiography, 1[7] .124 • (Cerebral vessels, complication of catheterization, angiography, 1[7] .440)
Radiology 132:93-97, July 1979
the practice at our institution to include the referring physician when deciding which approach to use for cerebral arteriography. As a result, we have had the opportunity to perform a large number of arteriograms by a variety of routes. These were not necessarily chosen by a specific set of criteria, but rather reflect the preference of the referring physician. The intent of our study was to evaluate and compare the safety of direct percutaneous and transfemoral cerebral arteriography and also to see whether the indications for arteriography and pathology demonstrated by the arteriogram were in any way related to the incidence of complications.
had a complication as a result of the procedure as a whole. Therefore, each procedure was classified as either a direct percutaneous or a transfemoral procedure without regard to the number of injections or vessels injected. All injections performed on a given patient on a given day were considered as one procedure which was then classified as either transternoral or direct percutaneous using the following criteria: (a) An arteriographic examlnation was considered to be transfemoral regardless of the ultimate position or positions of the catheter tip at the time of the injection if the procedure had been done by inserting a catheter into a femoral artery using the Seldinger technique (7) to examine the cerebral circulation. (b) If the examination consisted of one or more percutaneous brachial or common carotid artery injections with the needle remaining in the artery at the time of injection, it was considered a direct percutaneous procedure. Transfemoral studies were done using either a 6- or 7-Fr Torcon Blue-Femoral-Cerebral catheter (Cook Inc., Bloomington, Ind.) or a 7-Fr Femoral-Cerebral catheter or a Femoral-Cerebral-B catheter (Cordis Corp., Miami, Fla.). If only the aortic arch and origins of the great vessels were to be examined, a 7-Fr Multipurpose catheter (Cook Inc.) with end and side holes was used. For direct percutaneous brachial arteriography, a 16- or 18-gauge Potts-Cournand or Longdwell (Becton-Dickinson, Rutherford, N.J.) was used. For direct percutaneous procedures, the needle was inserted and advanced over a guide wire, and a blunt obturator was then left in the needle until the injection of contrast medium; The needle was not irrigated in the in-
I
T HAS BEEN
MATERIALS AND METHODS
The records of 1,141 consecutive patients who had cerebral arteriograms performed in our department between January 1, 1976 and April 1, 1978 were reviewed. Immediately following the performance of each examination, an extensive record of the indications, technique, results, and complications was made. The total number of vessels injected by the direct percutaneous route was 1,256, and 788 vessels were injected by the transfemoral route. However, these figures are difficult to compare, since frequently more than one injection of contrast material was performed with the catheter or needle in a given location, i.e., opposing oblique views during study of an aneurysm. If a study was transfemoral and included the selective injection of several brachial cephal ic vessels and the patient had a subsequent complication, it was not always possible to determine which of the selective injections was responsible for the problem. All that could be determined was that the patient
1 From the Departments of Diagnostic Radiology and Neurologic Sciences, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. Received June 29, 1978; accepted and revision requested Oct. 2; received Feb. 27, 1979. jr
93
94
TABLE I:
MICHAEL S. HUCKMAN AND OTHERS
COMPLICATIONS OF 780 CEREBRAL ARTERIOGRAMS DONE AS DIRECT PERCUTANEOUS STUDIES
Complication
No. of Times Complication Occurred
Per Cent Incidence
35 31 14
12.7% 4.48% 3.97% 1.79%
9 3 2 2 1 1 1
1.15% 0.38% 0.26% 0.26% 0.13% 0.13% 0.13%
10 3 2
2.1% 1.28% 0.38% 0.26%
Minor Non-neurologic (total = 99) Subintimal injection Hematoma Extravasation of contrast material at injection site Chestpain Allergic reaction Local spasm Transient hypotension Broken guide wire Jaw pain Transient hypertension Minor Neurologic (total = 16) Transient stroke Seizures Transient loss of consciousness Transient paresthesia
0.13%
Major Neurologic (total = 1) Permanent hemiparesis
0.13% 0.13%
Total of All Complications-116
14.9%
TABLE II:
COMPLICATIONS OF 361 CEREBRAL ARTERIOGRAMS DONE AS TRANSFEMORAL STUDIES
Complication
No. of Times Complication Occurred
Per Cent Incidence
6 1 1
3.06% 1.66% 0.28% 0.28%
Minor Non-neurologic (total = 11) Hematoma Subintimal injection Extravasation of contrast medium at injection site Chestpain Local spasm Clottedcatheter
0.28% 0.28% 0.28%
Minor Neurologic (total = 13) Transient stroke Seizures
11 2
Major Neurologic (total = 1) Deathin ensuing 24 hours
0.28% 0.28%
Total of All Complications-25
TABLE III:
3.60% 3.05% 0.55%
6.9%
OVERALL COMPLICAnON RATES IN 1,141 CEREBRAL ARTERIOGRAMS BY MAJOR GROUPING
Type of Complication Major Non-neurologic Major Neurologic Minor Non-neurologic Minor Neurologic Total
Numberof Complicated Cases
o 2
110 29
141
Per Cent Incidence 0% 0.18% 9.56% 2.64% 12.38%
July 1979
terval. However, during the transfemoral procedures, the catheter was flushed every 30 to 60 seconds with approximately 1 to 2 ml heparinized saline. All injections were done using a Viamonte-Hobbs injector. Conray 60 (iothalamate meglumine 60 %, Mallinckrodt, S1. Louis, Mo.) was used for all studies except arch aortography, for which Renografin 76 (diatrizoate meglumine and diatrizoate sodium, Squibb & Sons, Princeton, N.J.) was used. Complications were divided into three major groups, those being minor non-neurologic complications, minor neurologic complications, and major neurologic complications (TABLES I, II, and III). No major non-neurologic complications were encountered. RESULTS
Of the 1,141 cases analyzed, 780 (68%) were performed as direct percutaneous and 361 (32 % ) as transfemoral studies. TABLE I lists compllcations encountered in the direct percutaneous studies, and TABLE II lists complications encountered in the transfemoral studies. TABLE IV lists the complications from direct percutaneous and transfemoral cerebral arteriography by major groupings. TABLE V lists the various indications for angiography; in some instances there was more than one indication, and therefore the total number of indications is greater than the total number of arteriograms. Percentages in this chart reflect the incidence of a particular complication as a percent of the total number of examinations done for a given indication. Similarly, in TABLE VI angiographic findings in the 1,141 cerebral arteriograms are listed and the incidence of each type of complication for the various findings is also listed. As in TABLE V, the total number of findings is greater than the total number of studies. TABLE VII lists the incidence of transient and permanent neurologic complications in several previous studies as well as those encountered in the present study. Several of the studies did not use the criteria described by Feild et al. (3). For purposes of constructlnq this chart, those studies were categorized case by case according to the criteria used in this study. Since all studies were performed on inpatients, complications were considered to be major if the patient still demonstrated evidence of the complication upon discharge from the hospital, and they were considered minor if no residuum of the complication was present at that time. The single death was considered a major neurologic complication rather than a major non-neurologic complication, since the arteriogram was followed by a stroke prior to the patient's death. DISCUSSION
The safety of cerebral arteriography is felt to be largely a function of the technique employed, the competence of the individuals supervising the study, and the criteria used for classifying complications (1-6,8,9). While most previous studies address the complications due to a particular
Vol. 132
TRANSFEMORAL
VS.
DIRECT PERCUTANEOUS CEREBRAL ARTERIOGRAPHY
type of cerebral angiogram, none, with the exception of the study of Olivecrona (4), compares the complication rates of percutaneous direct carotid, vertebral, and brachial arteriography with the complication rates of transfemoral cerebral arteriography, where all procedures were performed in the same institution under the supervision of a single service. For the purposes of this report, the criteria outlined by Feild et al. (3) were used to classify arteriographic complications into one to four groups. These were minor or transient non-neurologic complications, minor or transient neurologic complications, major or permanent non-neurologic complications, and major or permanent neurologic complications. While the incidence of minor non-neurologic complications (TABLE III) seems high (9.5 %), it includes many things which caused the procedure to be aborted but in no way affected the patient's condition. Twenty-nine of the 37 hematomas (78 %) occurred as a result of direct carotid or brachial artery punctures, and none caused any residual problems or required tracheostomy. The study by Olivecrona (4) also reported a higher incidence of hematoma with direct percutaneous puncture of the carotid artery than with transfemoral arteriography. None of the subintimal injections caused any permanent complication. However, in some instances this necessitated repeating the procedure at another date or settling for a radiographic examination that was less than optimum. In some instances, chest pain was truly angina pectoris, but in most instances the etiology could not be specified. No myocardial infarctions resulted from angiography. Allergic reactions were all mild in nature and usually consisted of hives. The one case of a broken qulde wire was not actually a separation but rather an unraveling of the outer sheath of the wire. This was successfully removed without surgery, although the procedure had to be abandoned and repeated at a later date. The incidence of minor neurologic complications was 2.64 % (TABLE III) and is comparable to that reported by Olivecrona (4), which was 3.75%. Three of the five seizures (60%) occurred during
TABLE
V:
TABLE
IV:
95
Neuroradiology
COMPLICATIONS GROUPED BY TYPE AND ROUTE BY WHICH STUDY WAS PERFORMED
Incidence in Incidence in Incidence in 780 Direct 361 1,141 Studies of Both Percutaneous Transfemoral Types Type of Complication Studies Studies Minor Non-neurologic Minor Neurologic Major Non-neurologic Major Neurologic Total
12.5% 2.18% 0% 0.13% 14.9%
3.05% 3.60% 0% 0.28% 6.9%
9.56% 2.64% 0% 0.18% 12.38%
direct percutaneous carotid puncture and actually occurred prior to the arteriogram due to the inadvertent injection of local anesthetic into a carotid artery, a problem which seems unique to direct carotid injection. TABLE III shows two major neurologic complications (0.18 %), one resulting in permanent hemiplegia and another in patient death. The patient with hemiplegia suffered symptoms after injection of the left common carotid artery. The arteriogram obtained in this instance demonstrated a 99 % occlusion of the left internal carotid artery. The hemiplegia was still present when the patient was discharged two weeks later following emergency left carotid endarterectomy. The other major neurologic complication occurred in a 58-year-old woman with right arm and leg weakness and aphasia. Following a left common carotid artery injection, the patient became agitated, confused, and unresponsive. The patient died 24 hours later. Presumably in both of these cases, emboli were inadvertently dislodged or introduced during the procedure. Because of the complications, complete arteriographic studies in these patients were not performed, but the examinations were discontinued at the time of the ictus. The death occurred during transfemoral cerebral arteriography and the hemiplegia resulted from a direct carotid arteriogram. Both patients presented with histories of transient ischemic attacks, although only in the patient suffering the hemiplegia
RELATIONSHIP OF TYPE OF COMPLICATION AND MOST COMMON INDICATIONS FOR CEREBRAL ARTERIOGRAPHY
Indication
No. of Cases
Incidence of Minor Neurologic Complications
Transient ischemic attack Bruit Subarachnoid hemorrhage Abnormal CT scan History of previous stroke Status postvascular surgery Extremity weakness Suspected subclavian steal Seizures Neck or face mass Organic brain syndrome Abnormal radionuclide scan Third nerve palsy Abnormal electroencephalogram
390 359 115 102 82 74 65 47 40 24 30 13 11 11
2.8% 1.6% 1.7% 1.9% 2.4% 0% 6.1% 2.1% 5.0% 4.1% 0% 0% 0% 0%
Incidence of Minor Non-neurologic Complications
Incidence of Major Neurologic Complications
19.2% 15.8% 1.7% 3.9% 8.5% 8.1% 6.1% 2.1% 0% 0% 3.3% 15.3% 0% 9.0%
0.5% 0.2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
MICHAEL S. HUCKMAN AND OTHERS
96
TABLE VI:
RELATIONSHIP OF TYPE OF COMPLICATION AND MOST COMMON ARTERIOGRAPHIC FINDINGS IN 1,141 CASES Incidence of Incidence of Minor Major Neurologic Non-neurologic Complications Complications
Arteriographic Findings
No. of Cases
Incidence of Minor Neurologic Complications
Extra-cranial vascular occlusion Normal Intracranial vascular occlusion Atherosclerotic ulceration of extra-cranial vessels Supratentorial tumor Aneurysm Vascular spasm Hydrocephalus Vascular "steal" phenomenon Tortuous or kinked extracranial vessel Status post-vascular surgery Intra- or extracerebral hemorrhage Fibromuscular hyperplasia Primary infratentorial tumor Arteriovenous malformation Cerebral infarct
592 235 166 125
2.3% 4.7% 2.4% 2.4%
13.0% 5.8% 7.8% 14.4%
0.34% 0% 0.60% 0%
71 62 36 33 32 25 19 19 16 15 14 11
1.4% 1.6% 2.7% 3.0% 3.1% 4.0% 5.2% 0% 6.2% 0% 0% 0%
0% 1.6% 5.5% 3.0% 15.6% 8.0% 0% 0% 6.2% 0% 0% 0%
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
were we able to demonstrate radiographic evidence of arteriosclerosis. TABLE III summarizes the first two tables and indicates an overall complication rate of 12.38 % of all kinds of complications, regardless of the route by which the study was performed. While a 12.3% complication rate for cerebral arteriography seems rather high, it should be noted that only 2 of 141 complications were considered major and therefore, of these 141 complications, only
TABLE VII:
July 1979
REPORTED RATES OF NEUROLOGIC COMPLICATIONS OF CEREBRAL ARTERIOGRAPHY
Investigators
Type of Arteriography
Incidence Incidence of Permaof Transient nent Compli- Complications cations
Feild et al., 1962 (3)
Direct percutaneous
1.4%
0.68%
Takahashi and Kawanami, 1972 (8)
TransfemoraJ
1.2%
0.60%
Vitek, 1973 (9)
Transfemoral
1.25%
0.35%
Patterson et et., 1964 (5)
Direct percutaneous
3.8%
0.80%
Scheinberg and Zunker, 1963 (6)
Direct percutaneous
2.1%
0.88%
Olivecrona, 1977 (4)
Both
3.75%
0.63%
Huckrnan et et., 1978 (current study)
Both
2.64%
0.18%
Catheter Direct percutaneous Mean =
2.2% 1.1 % 2.31%
0.27% 0.13% 0.59%
1.4 % resulted in permanent disability for the patient. T ABLES I and II list the incidence of complications encountered in the 780 cases done by direct percutaneous puncture and the 361 done by the transfemoral route. The overall complication rate in the percutaneous cases was 14.9% and in the transfemoral cases 6.9%. However, as can be seen in TABLE IV, there was a higher incidence of minor non-neurologic complications from direct percutaneous puncture (12.5% vs. 3.05%) and a higher incidence of both major and minor neurologic complications during transfemoral studies than during direct percutaneous arteriography (3.88 % vs. 2.31 %). Since most neurologic complications of cerebral arteriography are felt to result from emboli introduced during the examination (4, 6, 8), this difference in incidence might be explained on one hand by the fact that in all transfemoral studies the catheter was frequently flushed with heparinized saline during the procedure. On the other hand, after direct percutaneous punctures, a blunt obturator was inserted into the sheath of the needle and left in place until the time of contrast medium injection. No irrigation of the needle was carried out in the interval between needle insertion and injection of contrast medium nor between contrast injections. 01ivecrona (4) states that there was no difference in the number of neurologic complications between the two routes. However, most of the direct punctures of the carotid artery in his study were injected through a catheter which was inserted directly into the artery replacing the needle. He does not state whether or not there was intermittent irrigation of the needle or catheter, but presumably this was done for most of his transfemoral and direct carotid injections. One explanation of the lower incidence of neurologic complications by direct puncture studies in this series would be that less frequent flushing of the needle or catheter decreased the probability of introducing emboli. TABLES V and VI list the indications for and the angio-
Vol. 132
TRANSFEMORAL VS. DIRECT PERCUTANEOUS CEREBRAL ARTERIOGRAPHY
graphic findings in the 1,141 examinations. Several studies had more than one indication and more than one arteriographic finding. By far the largest number of indications and findings is related to intra- and extracranial arteriosclerosis and reflects the high volume of cardiovascular surgery performed in our institution. While only 4 patients had trauma as the indication for the study, many patients with trauma would be included in the group having the indication of "abnormal CT scan". TABLES V and VI also show the most common indications and findings associated with the various types of complications. There is a very high incidence of complications in patients with clinical signs and arteriographic findings of arteriosclerotic vascular disease. This is borne out by previous studies (2,5, 6, 8) which showed a higher incidence of all types of complications in patients with cerebral vascular disease. This suggests predisposition not only to the embolic phenomena supposedly from dislodged plaques but also suggests that the vessels involved with arteriosclerosis are more susceptible to local injury at the site of injection and to difficulties in obtaining adequate hemostasis following the procedure. It is interesting to note that the study of Patterson et al. (5) showed a 19% complication rate in patients with migraine. This indication was not encountered in our series and probably reflects the fact that most patients with migraine would not currently undergo arteriography if the CT scan was normal. The fact that the incidence of major complications and angiographic deaths in this study appears lower than in some previous reports (TABLE VII) might reflect the fact that this study was done after CT had become an established diagnostic procedure at our institution. As a result, patients who are acutely ill (e.g., acute intracerebral or extracerebral hemorrhages, contusions, or subarachnoid hemorrhage) would have their diagnosis made by CT and would only undergo arteriography if and when they had sufficiently recovered and arteriography was still indicated. Therefore, although it is difficult to document, we would suspect that the incidence of acutely ill patients undergoing arteriography was probably less in this series than in most previous reports. The incidence of patients dying within 24 hours of arteriography would be less than that which has been reported by other investigators.
97
Neuroradiology
Previous studies (4,8) have confirmed that no significant difference in the occurrence of complications could be discerned between examinations performed by inexperienced and highly experienced persons. As in these studies, all examinations in the current series were performed under the supervision of a neuroradiologist. In many of the cases, both the neuroradiologist and a resident or fellow actually performed part of the examination and, therefore, it was not deemed possible to evaluate whether the actual examination had been performed by a more or less experienced person. By the same token, several of the procedures employed more than one catheter, and in those where there was a complication, it was not always possible to attribute the complication to a particular catheter. While some authors have stated that smaller catheters decrease the possibility of complications, we were not able to evaluate this factor. Department of Diagnostic Radiology 1753 W. Congress Parkway Chicago, III. 60612
REFERENCES 1. Amundsen P, Dietrichson P, Enge I, et al: Cerebral angiography by catheterization-complications and side effects. Acta Radiol 1: 164-172, Mar 1963 2. Feild JR, LeeL, McBurney RF: Complications of 1,000 brachial arteriograms. J Neurosurg 36:324-332, Mar 1972 3. Feild JR, Robertson JT, DeSaussure RL Jr: Complications of cerebral angiography in 2,000 consecutive cases. J Neurosurg 19: 775-781, Sep 1962 4. Olivecrona H: Complications of cerebral angiography. Neuroradiology 14:175-181, Dec 1977 5. Patterson RH Jr, Goodell H, Dunning HS: Complications of carotid arteriography. Arch Neurol 10:513-520, May 1964 6. Scheinberg P, Zunker E: Complications in direct percutaneous carotid arteriography. Arch Neurol 8:676-684, Jun 1963 7. Seldinger SI: Catheter replacement of the needle in percutaneous arteriography: a newtechnique. Acta Radiol 39:368-376, May
1953 8. Takahashi M, Kawanami H: Complications of catheter cerebral angiography: an analysis of 500 examinations. Acta Radiol [Diagn] 13:248-258, Feb 1972 9. Vitek JJ: Femoro-cerebral angiography: analysis of 2,000
consecutive examinations, special emphasis on carotid arteries catheterization in older patients. Am J Roentgenol 118:633-647, Jul 1973
Transfemoral Cerebral Arteriography versus Direct Percutaneous Carotid and Brachial Arteriography: A Comparison of Complication Rates 1 Michael S. Huckman, M.D., Gregory I. Shenk, M.D., Robert L. Neems, B.A., and Thomas Tinor, B.S.
Cerebral arteriograms in 1,141 consecutive patients, which were done either as direct percutaneous carotid or brachial studies or as transfemoro-cerebral catheter studies, were reviewed. While the overall complication rate for the direct percutaneous studies was higher, the incidence of neurologic complications, both transient and permanent, was higher in the transfemoral group. This higher incidence of neurologic complications may be related to the frequent irrigation of the catheter, which increases the probability of embolism. The incidence of serious complications was lower than in previous studies, perhaps because gravely ill patients are more likely to undergo computed tomographic scanning. INDEX TERMS: Cerebral angiography, complications. Cerebral angiography, technique • Cerebral blood vessels, angiography, 1[7] .124 • (Cerebral vessels, complication of catheterization, angiography, 1[7] .440)
Radiology 132:93-97, July 1979
the practice at our institution to include the referring physician when deciding which approach to use for cerebral arteriography. As a result, we have had the opportunity to perform a large number of arteriograms by a variety of routes. These were not necessarily chosen by a specific set of criteria, but rather reflect the preference of the referring physician. The intent of our study was to evaluate and compare the safety of direct percutaneous and transfemoral cerebral arteriography and also to see whether the indications for arteriography and pathology demonstrated by the arteriogram were in any way related to the incidence of complications.
had a complication as a result of the procedure as a whole. Therefore, each procedure was classified as either a direct percutaneous or a transfemoral procedure without regard to the number of injections or vessels injected. All injections performed on a given patient on a given day were considered as one procedure which was then classified as either transternoral or direct percutaneous using the following criteria: (a) An arteriographic examlnation was considered to be transfemoral regardless of the ultimate position or positions of the catheter tip at the time of the injection if the procedure had been done by inserting a catheter into a femoral artery using the Seldinger technique (7) to examine the cerebral circulation. (b) If the examination consisted of one or more percutaneous brachial or common carotid artery injections with the needle remaining in the artery at the time of injection, it was considered a direct percutaneous procedure. Transfemoral studies were done using either a 6- or 7-Fr Torcon Blue-Femoral-Cerebral catheter (Cook Inc., Bloomington, Ind.) or a 7-Fr Femoral-Cerebral catheter or a Femoral-Cerebral-B catheter (Cordis Corp., Miami, Fla.). If only the aortic arch and origins of the great vessels were to be examined, a 7-Fr Multipurpose catheter (Cook Inc.) with end and side holes was used. For direct percutaneous brachial arteriography, a 16- or 18-gauge Potts-Cournand or Longdwell (Becton-Dickinson, Rutherford, N.J.) was used. For direct percutaneous procedures, the needle was inserted and advanced over a guide wire, and a blunt obturator was then left in the needle until the injection of contrast medium; The needle was not irrigated in the in-
I
T HAS BEEN
MATERIALS AND METHODS
The records of 1,141 consecutive patients who had cerebral arteriograms performed in our department between January 1, 1976 and April 1, 1978 were reviewed. Immediately following the performance of each examination, an extensive record of the indications, technique, results, and complications was made. The total number of vessels injected by the direct percutaneous route was 1,256, and 788 vessels were injected by the transfemoral route. However, these figures are difficult to compare, since frequently more than one injection of contrast material was performed with the catheter or needle in a given location, i.e., opposing oblique views during study of an aneurysm. If a study was transfemoral and included the selective injection of several brachial cephal ic vessels and the patient had a subsequent complication, it was not always possible to determine which of the selective injections was responsible for the problem. All that could be determined was that the patient
1 From the Departments of Diagnostic Radiology and Neurologic Sciences, Rush-Presbyterian-St. Luke's Medical Center, Chicago, III. Received June 29, 1978; accepted and revision requested Oct. 2; received Feb. 27, 1979. jr
93
94
TABLE I:
MICHAEL S. HUCKMAN AND OTHERS
COMPLICATIONS OF 780 CEREBRAL ARTERIOGRAMS DONE AS DIRECT PERCUTANEOUS STUDIES
Complication
No. of Times Complication Occurred
Per Cent Incidence
35 31 14
12.7% 4.48% 3.97% 1.79%
9 3 2 2 1 1 1
1.15% 0.38% 0.26% 0.26% 0.13% 0.13% 0.13%
10 3 2
2.1% 1.28% 0.38% 0.26%
Minor Non-neurologic (total = 99) Subintimal injection Hematoma Extravasation of contrast material at injection site Chestpain Allergic reaction Local spasm Transient hypotension Broken guide wire Jaw pain Transient hypertension Minor Neurologic (total = 16) Transient stroke Seizures Transient loss of consciousness Transient paresthesia
0.13%
Major Neurologic (total = 1) Permanent hemiparesis
0.13% 0.13%
Total of All Complications-116
14.9%
TABLE II:
COMPLICATIONS OF 361 CEREBRAL ARTERIOGRAMS DONE AS TRANSFEMORAL STUDIES
Complication
No. of Times Complication Occurred
Per Cent Incidence
6 1 1
3.06% 1.66% 0.28% 0.28%
Minor Non-neurologic (total = 11) Hematoma Subintimal injection Extravasation of contrast medium at injection site Chestpain Local spasm Clottedcatheter
0.28% 0.28% 0.28%
Minor Neurologic (total = 13) Transient stroke Seizures
11 2
Major Neurologic (total = 1) Deathin ensuing 24 hours
0.28% 0.28%
Total of All Complications-25
TABLE III:
3.60% 3.05% 0.55%
6.9%
OVERALL COMPLICAnON RATES IN 1,141 CEREBRAL ARTERIOGRAMS BY MAJOR GROUPING
Type of Complication Major Non-neurologic Major Neurologic Minor Non-neurologic Minor Neurologic Total
Numberof Complicated Cases
o 2
110 29
141
Per Cent Incidence 0% 0.18% 9.56% 2.64% 12.38%
July 1979
terval. However, during the transfemoral procedures, the catheter was flushed every 30 to 60 seconds with approximately 1 to 2 ml heparinized saline. All injections were done using a Viamonte-Hobbs injector. Conray 60 (iothalamate meglumine 60 %, Mallinckrodt, S1. Louis, Mo.) was used for all studies except arch aortography, for which Renografin 76 (diatrizoate meglumine and diatrizoate sodium, Squibb & Sons, Princeton, N.J.) was used. Complications were divided into three major groups, those being minor non-neurologic complications, minor neurologic complications, and major neurologic complications (TABLES I, II, and III). No major non-neurologic complications were encountered. RESULTS
Of the 1,141 cases analyzed, 780 (68%) were performed as direct percutaneous and 361 (32 % ) as transfemoral studies. TABLE I lists compllcations encountered in the direct percutaneous studies, and TABLE II lists complications encountered in the transfemoral studies. TABLE IV lists the complications from direct percutaneous and transfemoral cerebral arteriography by major groupings. TABLE V lists the various indications for angiography; in some instances there was more than one indication, and therefore the total number of indications is greater than the total number of arteriograms. Percentages in this chart reflect the incidence of a particular complication as a percent of the total number of examinations done for a given indication. Similarly, in TABLE VI angiographic findings in the 1,141 cerebral arteriograms are listed and the incidence of each type of complication for the various findings is also listed. As in TABLE V, the total number of findings is greater than the total number of studies. TABLE VII lists the incidence of transient and permanent neurologic complications in several previous studies as well as those encountered in the present study. Several of the studies did not use the criteria described by Feild et al. (3). For purposes of constructlnq this chart, those studies were categorized case by case according to the criteria used in this study. Since all studies were performed on inpatients, complications were considered to be major if the patient still demonstrated evidence of the complication upon discharge from the hospital, and they were considered minor if no residuum of the complication was present at that time. The single death was considered a major neurologic complication rather than a major non-neurologic complication, since the arteriogram was followed by a stroke prior to the patient's death. DISCUSSION
The safety of cerebral arteriography is felt to be largely a function of the technique employed, the competence of the individuals supervising the study, and the criteria used for classifying complications (1-6,8,9). While most previous studies address the complications due to a particular
Vol. 132
TRANSFEMORAL
VS.
DIRECT PERCUTANEOUS CEREBRAL ARTERIOGRAPHY
type of cerebral angiogram, none, with the exception of the study of Olivecrona (4), compares the complication rates of percutaneous direct carotid, vertebral, and brachial arteriography with the complication rates of transfemoral cerebral arteriography, where all procedures were performed in the same institution under the supervision of a single service. For the purposes of this report, the criteria outlined by Feild et al. (3) were used to classify arteriographic complications into one to four groups. These were minor or transient non-neurologic complications, minor or transient neurologic complications, major or permanent non-neurologic complications, and major or permanent neurologic complications. While the incidence of minor non-neurologic complications (TABLE III) seems high (9.5 %), it includes many things which caused the procedure to be aborted but in no way affected the patient's condition. Twenty-nine of the 37 hematomas (78 %) occurred as a result of direct carotid or brachial artery punctures, and none caused any residual problems or required tracheostomy. The study by Olivecrona (4) also reported a higher incidence of hematoma with direct percutaneous puncture of the carotid artery than with transfemoral arteriography. None of the subintimal injections caused any permanent complication. However, in some instances this necessitated repeating the procedure at another date or settling for a radiographic examination that was less than optimum. In some instances, chest pain was truly angina pectoris, but in most instances the etiology could not be specified. No myocardial infarctions resulted from angiography. Allergic reactions were all mild in nature and usually consisted of hives. The one case of a broken qulde wire was not actually a separation but rather an unraveling of the outer sheath of the wire. This was successfully removed without surgery, although the procedure had to be abandoned and repeated at a later date. The incidence of minor neurologic complications was 2.64 % (TABLE III) and is comparable to that reported by Olivecrona (4), which was 3.75%. Three of the five seizures (60%) occurred during
TABLE
V:
TABLE
IV:
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Neuroradiology
COMPLICATIONS GROUPED BY TYPE AND ROUTE BY WHICH STUDY WAS PERFORMED
Incidence in Incidence in Incidence in 780 Direct 361 1,141 Studies of Both Percutaneous Transfemoral Types Type of Complication Studies Studies Minor Non-neurologic Minor Neurologic Major Non-neurologic Major Neurologic Total
12.5% 2.18% 0% 0.13% 14.9%
3.05% 3.60% 0% 0.28% 6.9%
9.56% 2.64% 0% 0.18% 12.38%
direct percutaneous carotid puncture and actually occurred prior to the arteriogram due to the inadvertent injection of local anesthetic into a carotid artery, a problem which seems unique to direct carotid injection. TABLE III shows two major neurologic complications (0.18 %), one resulting in permanent hemiplegia and another in patient death. The patient with hemiplegia suffered symptoms after injection of the left common carotid artery. The arteriogram obtained in this instance demonstrated a 99 % occlusion of the left internal carotid artery. The hemiplegia was still present when the patient was discharged two weeks later following emergency left carotid endarterectomy. The other major neurologic complication occurred in a 58-year-old woman with right arm and leg weakness and aphasia. Following a left common carotid artery injection, the patient became agitated, confused, and unresponsive. The patient died 24 hours later. Presumably in both of these cases, emboli were inadvertently dislodged or introduced during the procedure. Because of the complications, complete arteriographic studies in these patients were not performed, but the examinations were discontinued at the time of the ictus. The death occurred during transfemoral cerebral arteriography and the hemiplegia resulted from a direct carotid arteriogram. Both patients presented with histories of transient ischemic attacks, although only in the patient suffering the hemiplegia
RELATIONSHIP OF TYPE OF COMPLICATION AND MOST COMMON INDICATIONS FOR CEREBRAL ARTERIOGRAPHY
Indication
No. of Cases
Incidence of Minor Neurologic Complications
Transient ischemic attack Bruit Subarachnoid hemorrhage Abnormal CT scan History of previous stroke Status postvascular surgery Extremity weakness Suspected subclavian steal Seizures Neck or face mass Organic brain syndrome Abnormal radionuclide scan Third nerve palsy Abnormal electroencephalogram
390 359 115 102 82 74 65 47 40 24 30 13 11 11
2.8% 1.6% 1.7% 1.9% 2.4% 0% 6.1% 2.1% 5.0% 4.1% 0% 0% 0% 0%
Incidence of Minor Non-neurologic Complications
Incidence of Major Neurologic Complications
19.2% 15.8% 1.7% 3.9% 8.5% 8.1% 6.1% 2.1% 0% 0% 3.3% 15.3% 0% 9.0%
0.5% 0.2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
MICHAEL S. HUCKMAN AND OTHERS
96
TABLE VI:
RELATIONSHIP OF TYPE OF COMPLICATION AND MOST COMMON ARTERIOGRAPHIC FINDINGS IN 1,141 CASES Incidence of Incidence of Minor Major Neurologic Non-neurologic Complications Complications
Arteriographic Findings
No. of Cases
Incidence of Minor Neurologic Complications
Extra-cranial vascular occlusion Normal Intracranial vascular occlusion Atherosclerotic ulceration of extra-cranial vessels Supratentorial tumor Aneurysm Vascular spasm Hydrocephalus Vascular "steal" phenomenon Tortuous or kinked extracranial vessel Status post-vascular surgery Intra- or extracerebral hemorrhage Fibromuscular hyperplasia Primary infratentorial tumor Arteriovenous malformation Cerebral infarct
592 235 166 125
2.3% 4.7% 2.4% 2.4%
13.0% 5.8% 7.8% 14.4%
0.34% 0% 0.60% 0%
71 62 36 33 32 25 19 19 16 15 14 11
1.4% 1.6% 2.7% 3.0% 3.1% 4.0% 5.2% 0% 6.2% 0% 0% 0%
0% 1.6% 5.5% 3.0% 15.6% 8.0% 0% 0% 6.2% 0% 0% 0%
0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
were we able to demonstrate radiographic evidence of arteriosclerosis. TABLE III summarizes the first two tables and indicates an overall complication rate of 12.38 % of all kinds of complications, regardless of the route by which the study was performed. While a 12.3% complication rate for cerebral arteriography seems rather high, it should be noted that only 2 of 141 complications were considered major and therefore, of these 141 complications, only
TABLE VII:
July 1979
REPORTED RATES OF NEUROLOGIC COMPLICATIONS OF CEREBRAL ARTERIOGRAPHY
Investigators
Type of Arteriography
Incidence Incidence of Permaof Transient nent Compli- Complications cations
Feild et al., 1962 (3)
Direct percutaneous
1.4%
0.68%
Takahashi and Kawanami, 1972 (8)
TransfemoraJ
1.2%
0.60%
Vitek, 1973 (9)
Transfemoral
1.25%
0.35%
Patterson et et., 1964 (5)
Direct percutaneous
3.8%
0.80%
Scheinberg and Zunker, 1963 (6)
Direct percutaneous
2.1%
0.88%
Olivecrona, 1977 (4)
Both
3.75%
0.63%
Huckrnan et et., 1978 (current study)
Both
2.64%
0.18%
Catheter Direct percutaneous Mean =
2.2% 1.1 % 2.31%
0.27% 0.13% 0.59%
1.4 % resulted in permanent disability for the patient. T ABLES I and II list the incidence of complications encountered in the 780 cases done by direct percutaneous puncture and the 361 done by the transfemoral route. The overall complication rate in the percutaneous cases was 14.9% and in the transfemoral cases 6.9%. However, as can be seen in TABLE IV, there was a higher incidence of minor non-neurologic complications from direct percutaneous puncture (12.5% vs. 3.05%) and a higher incidence of both major and minor neurologic complications during transfemoral studies than during direct percutaneous arteriography (3.88 % vs. 2.31 %). Since most neurologic complications of cerebral arteriography are felt to result from emboli introduced during the examination (4, 6, 8), this difference in incidence might be explained on one hand by the fact that in all transfemoral studies the catheter was frequently flushed with heparinized saline during the procedure. On the other hand, after direct percutaneous punctures, a blunt obturator was inserted into the sheath of the needle and left in place until the time of contrast medium injection. No irrigation of the needle was carried out in the interval between needle insertion and injection of contrast medium nor between contrast injections. 01ivecrona (4) states that there was no difference in the number of neurologic complications between the two routes. However, most of the direct punctures of the carotid artery in his study were injected through a catheter which was inserted directly into the artery replacing the needle. He does not state whether or not there was intermittent irrigation of the needle or catheter, but presumably this was done for most of his transfemoral and direct carotid injections. One explanation of the lower incidence of neurologic complications by direct puncture studies in this series would be that less frequent flushing of the needle or catheter decreased the probability of introducing emboli. TABLES V and VI list the indications for and the angio-
Vol. 132
TRANSFEMORAL VS. DIRECT PERCUTANEOUS CEREBRAL ARTERIOGRAPHY
graphic findings in the 1,141 examinations. Several studies had more than one indication and more than one arteriographic finding. By far the largest number of indications and findings is related to intra- and extracranial arteriosclerosis and reflects the high volume of cardiovascular surgery performed in our institution. While only 4 patients had trauma as the indication for the study, many patients with trauma would be included in the group having the indication of "abnormal CT scan". TABLES V and VI also show the most common indications and findings associated with the various types of complications. There is a very high incidence of complications in patients with clinical signs and arteriographic findings of arteriosclerotic vascular disease. This is borne out by previous studies (2,5, 6, 8) which showed a higher incidence of all types of complications in patients with cerebral vascular disease. This suggests predisposition not only to the embolic phenomena supposedly from dislodged plaques but also suggests that the vessels involved with arteriosclerosis are more susceptible to local injury at the site of injection and to difficulties in obtaining adequate hemostasis following the procedure. It is interesting to note that the study of Patterson et al. (5) showed a 19% complication rate in patients with migraine. This indication was not encountered in our series and probably reflects the fact that most patients with migraine would not currently undergo arteriography if the CT scan was normal. The fact that the incidence of major complications and angiographic deaths in this study appears lower than in some previous reports (TABLE VII) might reflect the fact that this study was done after CT had become an established diagnostic procedure at our institution. As a result, patients who are acutely ill (e.g., acute intracerebral or extracerebral hemorrhages, contusions, or subarachnoid hemorrhage) would have their diagnosis made by CT and would only undergo arteriography if and when they had sufficiently recovered and arteriography was still indicated. Therefore, although it is difficult to document, we would suspect that the incidence of acutely ill patients undergoing arteriography was probably less in this series than in most previous reports. The incidence of patients dying within 24 hours of arteriography would be less than that which has been reported by other investigators.
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Neuroradiology
Previous studies (4,8) have confirmed that no significant difference in the occurrence of complications could be discerned between examinations performed by inexperienced and highly experienced persons. As in these studies, all examinations in the current series were performed under the supervision of a neuroradiologist. In many of the cases, both the neuroradiologist and a resident or fellow actually performed part of the examination and, therefore, it was not deemed possible to evaluate whether the actual examination had been performed by a more or less experienced person. By the same token, several of the procedures employed more than one catheter, and in those where there was a complication, it was not always possible to attribute the complication to a particular catheter. While some authors have stated that smaller catheters decrease the possibility of complications, we were not able to evaluate this factor. Department of Diagnostic Radiology 1753 W. Congress Parkway Chicago, III. 60612
REFERENCES 1. Amundsen P, Dietrichson P, Enge I, et al: Cerebral angiography by catheterization-complications and side effects. Acta Radiol 1: 164-172, Mar 1963 2. Feild JR, LeeL, McBurney RF: Complications of 1,000 brachial arteriograms. J Neurosurg 36:324-332, Mar 1972 3. Feild JR, Robertson JT, DeSaussure RL Jr: Complications of cerebral angiography in 2,000 consecutive cases. J Neurosurg 19: 775-781, Sep 1962 4. Olivecrona H: Complications of cerebral angiography. Neuroradiology 14:175-181, Dec 1977 5. Patterson RH Jr, Goodell H, Dunning HS: Complications of carotid arteriography. Arch Neurol 10:513-520, May 1964 6. Scheinberg P, Zunker E: Complications in direct percutaneous carotid arteriography. Arch Neurol 8:676-684, Jun 1963 7. Seldinger SI: Catheter replacement of the needle in percutaneous arteriography: a newtechnique. Acta Radiol 39:368-376, May
1953 8. Takahashi M, Kawanami H: Complications of catheter cerebral angiography: an analysis of 500 examinations. Acta Radiol [Diagn] 13:248-258, Feb 1972 9. Vitek JJ: Femoro-cerebral angiography: analysis of 2,000
consecutive examinations, special emphasis on carotid arteries catheterization in older patients. Am J Roentgenol 118:633-647, Jul 1973
