Real-time ultrasound guidance reduces total and major vascular complications in patients undergoing pulmonary vein antral isolation on therapeutic warfarin

  • Christine C. Tanaka-Esposito
  • Mina K. Chung
  • JoEllyn M. Abraham
  • Daniel J. Cantillon
  • Bernard Abi-Saleh
  • Patrick J. TchouEmail author



Vascular complications are a known risk of catheter-based pulmonary vein antral isolation (PVAI). Procedure-related thromboembolic events necessitate full-dose anticoagulation, which worsens outcomes in the event of vascular access injury.


Real-time ultrasound allows direct visualization of vascular structures. We hypothesized that ultrasound use with venipuncture reduces vascular complications associated with PVAI.


Retrospective analysis of all adverse events occurring with PVAI was performed during two periods: 2005–2006 when ultrasound was not used and 2008–2010 when ultrasound was routinely employed. All patients received full-dose IV heparin during PVAI. In the no ultrasound cohort, only 14 % underwent PVAI without stopping warfarin, while 91 % of patients in the ultrasound cohort were on continued warfarin. Only patients deemed at high risk for thromboembolism with a periprocedural international normalized ratio (INR) less than 2 were bridged with subcutaneous low-molecular-weight heparin.


Ultrasound reduced total vascular complications (1.7 vs. 0.5 %, p < 0.01) and decreased the incidence of major vascular complications by sevenfold. Warfarin with INR ≥ 1.2 on the day of PVAI was associated with more vascular complications (4.3 vs. 1.2 %, p < 0.01). Ultrasound guidance overcame the risk associated with warfarin therapy. Vascular complications in anticoagulated patients with INR ≥ 1.2 using ultrasound guidance were two- and ninefold lower than those in patients not using ultrasound with an INR < 1.2 (0.5 vs. 1.2 %, p < 0.05) and INR ≥ 1.2 (0.5 vs. 4.3 %, p < 0.01), respectively.


Ultrasound-guided venipuncture improves the safety profile of PVAI, reducing vascular complications in patients on warfarin to levels below those with no ultrasound and off warfarin.


Vascular complications Ultrasound guidance Pulmonary vein antral isolation Periprocedural anticoagulation Procedure-related thromboembolic events 



Pulmonary vein antral isolation


Atrial fibrillation






Milligram per kilogram








International normalized ratio


Computed tomography


Odds ratio


Milligram per deciliter




Conflict of interest

Dr. Christine C. Tanaka-Esposito, Dr. Patrick J. Tchou, and Dr. Daniel J. Cantillon have received modest honorarium from Medtronic, Inc.


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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Christine C. Tanaka-Esposito
    • 1
  • Mina K. Chung
    • 1
  • JoEllyn M. Abraham
    • 1
  • Daniel J. Cantillon
    • 1
  • Bernard Abi-Saleh
    • 1
  • Patrick J. Tchou
    • 1
    Email author
  1. 1.Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular MedicineHeart and Vascular InstituteClevelandUSA

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