0:01

Okay, so let's talk about vasospasm

0:03

and extravasation complications.

0:05

It's a 24-year-old female, possibly

0:07

with a traumatic left middle

0:08

meningeal arteriovenous fistula.

0:11

So she presents for a follow up

0:12

up angiogram for embolization.

0:15

So the left common femoral artery

0:16

was selected for the arterial access.

0:19

They used Seldinger technique and the

0:20

left CFA was cannulated with a 6 French

0:22

sheath under ultrasound guidance.

0:23

So the arteries were then cannulated with a

0:26

5 French Envoy catheter with continuous heparinized

0:29

flush attached to the sheath, of course.

0:32

So let's see how this proceeds.

0:34

So serial angiograms were taken

0:36

and the neuro IR sees the following.

0:41

Awesome.

0:42

If you're a neuro IR, you could

0:44

probably say what they saw.

0:46

But what they saw was transient catheter induced

0:47

vasospasm of the cervical ICA,

0:50

leading to extravasation, which was

0:52

ultimately, don't you worry, treated.

0:54

But then again, now, again, with the

0:56

theme of landing our plane, is this,

1:00

what are you concerned about here?

1:02

What are the arrows pointing to?

1:03

Well, here we see a left

1:06

external iliac artery vasospasm.

1:10

That's the yellow artery.

1:11

Little focal sort of narrowing in this region.

1:14

And then what we see here is

1:15

extravasation of the what?

1:18

Common femoral artery.

1:21

So what should you do next?

1:22

So you should perform manual digital compression

1:25

for about 20 to 40 minutes or until resolved.

1:28

And that's actually what was performed.

1:31

And success was achieved.

1:34

So manual compression was applied along with

1:36

reversal of the anticoagulation with protamine

1:40

sulfate with the vascular sheath in place.

1:44

So what we need to know is that protamine actually

1:47

is particularly good at neutralizing heparin.

1:50

For every milligram of protamine, every

1:52

milligram of heparin, rather, we can use one

1:54

milligram of protamine to neutralize it.

1:58

The extravasation that we noted on that

2:00

lower sort of margin of the axis actually

2:03

improved with digital manual pressure.

2:06

And that's with the sheath in place.

2:09

With the sheath in place, they applied that

2:10

digital pressure, did a little contrast

2:12

evaluation, showed that that had improved.

2:15

They obviously reversed the heparin,

2:18

and then, of course, they then removed the

2:20

axis sheath and achieved hemostasis with

2:23

about 35 minutes of manual pressure.