Abstract and Introduction
Abstract
Introduction. The most frequent complications of AF ablation (AFA) are related to vascular access, but there is little evidence as to how these can be minimized.
Methods. Consecutive patients undergoing AFA at a high-volume center received either standard care (Group S) or routine ultrasound-guided vascular access (Group U). Vascular complications were assessed before hospital discharge and by means of postal questionnaire 1 month later. Outcome measures were BARC 2+ bleeding complications, postprocedural pain, and prolonged bruising.
Results. Patients in Group S (n = 146) and U (n = 163) were well matched at baseline. Follow-up questionnaires were received from 92.6%. Patients in Group U were significantly less likely to have a BARC 2+ bleed, 10.4% versus 19.9% P = 0.02, were less likely to suffer groin pain after discharge (27.1% vs. 42.8%; P = 0.006) and were less likely to experience prolonged local bruising (21.5% vs. 40.4%; P = 0.001). Multivariable logistic regression analysis revealed a significant association of vascular complications with nonultrasound guided access (OR 3.12 95%CI 1.54–5.34; P = 0.003) and increasing age (OR 1.05 95%CI 1.01–1.09; P = 0.02).
Conclusion. Routine use of ultrasound-guided vascular access for AFA is associated with a significant reduction in bleeding complications, postprocedural pain, and prolonged bruising when compared to standard care.
Introduction
Atrial fibrillation (AF) is an emerging medical epidemic.[1] For patients whose symptoms persist despite medical therapy, percutaneous AF ablation (AFA) is now an established treatment option.[2–4] Numerous studies have shown superior efficacy of AFA over medical therapy in terms of maintenance of sinus rhythm.[5–7] Two large worldwide surveys of the methods, efficacy, and safety of AFA[8,9] published in 2005 and 2010 showed a dramatic increase in the number of AFA procedures being performed over this period. This increase in operator experience, accompanied by improved techniques and technology, led to a reduction in the overall procedural complication rate from 5.9% to 4.5%. However, complications relating to vascular access actually increased from 0.9% to 1.5% of procedures. Furthermore, published surveys/registries reported only the most serious of vascular complications, unavoidably leading to an underreporting of the true incidence. A previous study found that physicians significantly underreported procedural complications when compared to what patients themselves perceived (4.5% vs. 24%) and that patient reported complication rate rose even further (32%) if postdischarge reporting was encouraged.[10] In 2012, the European Society of Cardiology clearly stated in their updated guidelines on the management of AF that "improving safety of catheter ablation should be a primary goal in the further development of this therapy."[3]
The use of 2-dimensional ultrasound has become standard practice within fields such as anesthesia and nephrology to improve the safety and success rates of venous cannulation.[11] Three prospective studies using ultrasound compared to an anatomical approach have all showed reduced complications and improved success rates in a diverse spectrum of patients.[12–14] A number of retrospective studies showed improved procedural outcomes, such as time to cannulation or successful cannulation and nonsignificant trends toward reduced complications.[15–17] None showed any detrimental effect of ultrasound guidance. Vascular ultrasound has not, however, been widely adopted in interventional electrophysiology and consequently there are no studies investigating its potential safety benefits for AFA.
We hypothesized that the conventional definition of vascular complications underestimates the true incidence of patient-reported significant vascular access events following AFA, and that the routine use of ultrasound to guide venous access would decrease the incidence of these events.
J Cardiovasc Electrophysiol. 2014;25(7):680-685. © 2014 Blackwell Publishing
