An educational video: Managing PAD access complications

Access-related complications are among the most common challenges in the treatment of peripheral arterial disease (PAD). In this educational video, Drs. Peña and McMackin examine why access complications occur, strategies to reduce risk, and treatment options to consider when complications arise.

The discussion covers a range of access complications, including pseudoaneurysms and arterial dissections, and explores contributing factors such as access site selection, patient anatomy, and procedural technique. The speakers emphasize the importance of access planning, noting that access-related issues remain the most frequent complication in PAD interventions, occurring in approximately 5–7% of cases.

By focusing on prevention, early recognition, and management strategies, this video reinforces how thoughtful access planning can reduce risk and support more consistent procedural outcomes in PAD care.

Jeremy Andrews (00:11):
What are some of the most common complications you encounter with an access site?

Constantino Peña – (00:17):
So, I think an access site complication can range from a lot of different things. It could start from the very beginning, when you start accessing the artery. You may get spasm, you may have your needle that isn’t really in the lumen, maybe in the wall, and you may get a focal dissection. You may even get some bleeding around the wall during your puncture. And I think that’s something that, a lot of times, we can see with ultrasound. A lot of these are very treatable. You can basically take the needle out, restick, get back into the artery. A lot of those are self-limited to heal by themselves. You may end up in a situation where when you’re puncturing the artery, you actually go through the vein to get to the artery. This can create a fistula or communication between the artery and the vein. We try to minimize these now with ultrasound. I think the use of ultrasound helps minimize a lot of these access complications. It allows us to see the artery or the vein, whatever we’re puncturing, it allows us to see the quality. Is it clean, is there plaque? And I pick an ideal place to puncture it and watch—actually watch—the needle go in. So, when I look at access site complications, those are the ones, the general ones.When we finish a procedure, we may have, again, a fistula. You may have a pseudoaneurysm, which means the artery where we place the hole may not have healed completely. And a lot of times we can treat that with compression or by injecting that area where that pseudoaneurysm is so that it will thrombose or clot off and heal.

Jeremy Andrews (01:42):
Dr. McMackin?

Katherine McMackin (01:43):
Yeah. The access site complications are something you think of every time you’re planning your case, you know? Because all of the wonderful things we do downstream that you think might be more dangerous, all of those large series tell us that 5–7% of cases are going to have access complications. So, all of those serious access complications are your number one complication. And it’s clotting, it’s bleeding, it’s anything you can do, dissection to a blood vessel, all of those things that you can damage. And you would just want to watch that through your procedure. I agree, it starts with the first stick. Did you back wall it?If you have a little intimal flap there, maybe you don’t want to use a closure device, cause it’s going to flap and then cause a bigger problem. So, knowing exactly what your needle is doing, how it’s doing it, can help minimize the potential risk for those complications, but then also just having everyone on the team know what they’re looking out for when they’re in the recovery area, trying to make sure if there is a complication, they can catch it early.

Jeremy Andrews (02:35):
So, I’ll go ahead and stay with you. So now, what have you found or what do you utilize to help mitigate or reduce those risks that we just talked about in complications, Dr. McMackin?

Katherine McMackin (02:46):
So, in any access, I think ultrasound is extremely helpful. You know, there’s no reason to guess where the artery is when you can see it on ultrasound. You can see your needle tip entering exactly into that vessel. You can help identify, is the vessel healthy? Is the vessel spasming or moving when I’m hitting it with my needle? The ultrasound is really the number one guide for that. If you have preoperative imaging, that can also give you a good idea. You know, is there a plaque burden? Is it a short common or a long common? That may— If it’s a long common, you have an increased risk of sticking too low because you actually think that you’re higher than you are, but you’re still in the common. Or if you have a short common, are you accidentally sticking in the iliac because you’re trying to make sure you’re above the profunda. So, all of those things that are specific to the patient can help you think about to prevent an access complication.

Jeremy Andrews (03:32):
Okay, Dr. Peña?

Constantino Peña (03:34):
Yeah, very similar answer. And I think it’s: no matter what we do, you can still have a complication, right? So, we try to minimize it the best we can. Understand where we puncture, use our landmarks.Are we where we think the common femoral is going to be? Confirm that with ultrasound. Find a good target. When your wire goes in, is it going freely? All these things— Using fluoroscopy as you advance your wire. All these things add up to try to minimize the chance of getting a complication. But I’d say the strongest one is using your ultrasound, using your fluoroscopy, and then using all the other cues that we have while we do the procedure.

Jeremy Andrews (04:07):
Gotcha. So, that’s all good. I do want to ask one question because I know you both use this, right? And I think one of the things is starting smaller first, right? So, in that case, whether it’s like instead of an 18 gage direct stick, you’re using a microsystem. Do you think that aids in reducing some of those complications, Dr. Peña?

Constantino Peña (04:27):
Yeah, I think that a microsystem helps reduce complications with access. It allows you to start with a smaller-gage needle, so your access into the artery is actually smaller. So, as you get in, you can then actually see that you’re in. When you have a smaller needle, you may not get the same back bleeding that you would get, let’s say with an 18 gage needle. But with ultrasound, you know, you’re in, you can see that you have blood that’s coming back, that you’re in the vessel. And then you can slowly advance the wire, with fluoroscopy with ultrasound, to see that you’re in the vessel. And that’s kind of minimized what I think is the most, the highest part of the complications, which is that access and getting your wire started into intraluminal location. In the old days, I don’t want to date myself, but, you know, 25 years ago we went—everything was 18 gage punctures with an 0.035 wire. And yeah, you can do it. And there’s reasons or sometimes now that you may do that. But I would say for the most part, 99.9% of our accesses now start with micro access system, an introducer system, and ultrasound guidance and fluoroscopic guidance.

Jeremy Andrews (05:33):
Dr. McMackin?

Katherine McMackin (05:34):
Yeah, the microsystem, you know, I echo that of knowing exactly where you are with a small system and a small needle, a small wire, having that tactile feel of that 0.018 wire, you know, is it running freely? You still need to have that tactile feel. It won’t be quite as strong as if you have an 0.035 wire. But knowing that is, oh, this isn’t where I want it to be with a small system, much better than a large system. And the other thing is with the microsystem: I like to do a hand injection just to make sure I know where I am. And some people I’ve seen do that with the needle. And you just want to make sure your operator’s hands are outside because you need to protect yourself long term. You don’t want your hands underneath the image intensifier. So, the microsystem allows you to keep your hands out of the ionizing radiation and protect the interventionalist or the vascular surgeon in addition to the patient.

Jeremy Andrews (06:21):
Very good. Thank you. So, next question. When it comes to advancing of catheters or reinforced sheaths, such as coiled like the Flexor® or braided, whatever they may be, during a treatment of PAD, how often do you encounter resistance, like due to stenosis or challenges, or whether it may be stenosis or plaque or whatever it may be.

Katherine McMackin (06:45):
So, when you’re thinking about the vascular system, you know, we mentioned before, the disease is diffuse. So, you know, even though a wire goes through it easily or a catheter goes through it easily, that doesn’t necessarily mean the sheath is going to track over it easily. So, you do want to have flexibility so it can make turns, but also that stiffness. So, once you’re set up for success and you’ve got everything in place and your sheath is just above your lesion, it has that stiffness so that it’s not going to back out or push out as you’re trying to push forward through the lesion.

Jeremy Andrews (07:13):
Okay. Dr. Peña.

Constantino Peña (07:15):
I think that it’s really important that once we get a wire to where we want to go and you’re following it with a sheath, you have to understand what you’re feeling and what that tactile feel is like. It’s very common that you may feels some resistance. I think the first thing I always tell: Don’t push, stop, and figure out, why are you having this resistance? Do I need a stiffer wire? Am I hitting something or am I at an angle? You know, is it because of tortuosity? Is it an area where I just have a small area of stenosis that I need to cross with my sheaths and then, you know, manage it? So, at that point, my number one thing would be like, okay, stop and reassess. What’s going on? Is it something that I need, a wire? Or maybe you have everything ready. You just— the way you’re pushing, you need to kind of maybe come back and advance again. So, all these things, again with experience, as we start dealing with tortuosity access that you can overcome with your sheath.

Jeremy Andrews (08:09):
So, and I’ll stay with you, Dr. Peña, is there ever a case or a time when you, like, access multiple sites, like at the beginning? Right? So, in other words, do you plan to access multiple sites?

Constantino Peña (08:24):
Yeah, I think it is not a routine where you say, I’m going to start with three accesses, or two accesses, or three accesses. But it is common where you may have a treatment plan where you need two wires. You may be looking at two accesses, whether it’s femoral going and reconstructing, let’s say, an aorto-iliac segment and you want to have wires from both sides. And that’s something where you initially will start. So, let me get my access set and then start working on how I’m going to do that. Sometimes we may have access from a radial and a pedal access and use the radial access to inject. And then we only really use the pedal for other types of manipulations. So, there’s a lot of reasons why you may do that.It’s not every case, but there’s probably 10–15% of the cases, complex cases, that you have multiple access sites.

Jeremy Andrews (09:11):
Dr. McMackin.

Katherine McMackin (09:12):
Yeah, the benefit of multi-access, it does allow you to be looking at it from one end and treating it from the other, and vice versa. The other thing is, if you’re having issues tracking through a difficult lesion, sometimes having that through-and-through wire, meaning it’s going in one access and coming out the other access, and it’s outside the body on both ends, really gives you a rail that you don’t have when the access– when the wire is free on one side. So, you can really track something across a lesion that maybe you couldn’t get across before. So, sometimes having the two access sites, even if you’re not intervening from both access sites, allows you to have that stiffer segment for wire to get different treatment modalities across that lesion.

Jeremy Andrews (09:52):
Very good. So, the next thing is, we talked about planning it, right? Like, you’re going to need two access sites. How often do you have to pivot? I think one of you mentioned that earlier, right? You always have to be prepared to pivot. So, you plan on going one, but mid-case, you have to go into another. Dr. Peña, how often do you encounter those?

Constantino Peña (10:11):
You know, I think it’s much more common now than it was in the past, because now we have access sheaths and access devices that help us access other arteries that we wouldn’t have accessed a decade ago. And a lot of times we see that in the lower extremities. Being able to do a quick pedal access, a tibial access, so we can get a retrograde wire that you may snare and then use as a rail to help us with our therapies and stuff. That we now do much more commonly. So, I would say we do that pretty common. A lot of times we use the secondary access for a function. Hey, we need to recanalize from a retrograde approach, or we want to have a rail so we can bring up our devices. But we’re seeing that much more, particularly in the lower extremities.

Jeremy Andrews (10:53):
Okay. Dr. McMackin?

Katherine McMackin (10:53):
I think the more you get comfortable with multiple access, the more you see the utility in it. And it’s the same thing with the whole team. The first time you’re like, okay, we’re going to stick the pedal. It’s a 30-minute production and everyone’s trying to figure out where do you put the ultrasound and how does that bump into the II. And it’s a huge production and then you do it more and more and it’s a streamline. All of a sudden, it’s an extra 90 seconds and you have access. So, the more the whole team gets used to multi-access cases, the easier the flow is for the patient.

Jeremy Andrews (11:23):
Yeah, yeah, I would agree. I think like what you said Dr. Peña, and also you, Dr. McMackin, it’s the more you do those different sites, the more easier it is to say, oh, you know what, I’m just going to— I’m having trouble here, I’m going to get this one instead and see. So, great information. Well, it’s been great. I really appreciate you both, lots of great information. I thank you for your time and I’m sure the viewers will enjoy it as well. So, with that, we’ll be done and thank you. Until next time.

Drs. Peña and McMackin are paid consultants of Cook Medical.