1 / 50

“Access Anxiety”

“Access Anxiety”. John F Eidt MD Ahsan Ali MD Mohammed Moursi MD University of Arkansas for Medical Sciences. Primary access. Think before you stick – case planning! Remember your lead Raise the table – be comfortable Identify topographic landmarks Feel pulse

iolana
Download Presentation

“Access Anxiety”

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. “Access Anxiety” John F Eidt MD Ahsan Ali MD Mohammed Moursi MD University of Arkansas for Medical Sciences

  2. Primary access • Think before you stick – case planning! • Remember your lead • Raise the table – be comfortable • Identify topographic landmarks • Feel pulse • Fluoroscopic location of femoral head • Limited amount of lidocaine • Skin nick • Micropuncture technique

  3. Deep circumflex iliac Inferior epigastric CFA PFA SFA

  4. 21 GA

  5. Trouble-shooting • Microcatheter will not advance

  6. Trouble-shooting • Microcatheter will not advance • Sheath will not advance

  7. Trouble-shooting • Microcatheter will not advance • Sheath will not advance • Stiffer wire (short Amplatz) • Serial dilators • New access site

  8. Transradial Access for Coronary Angiography and Angioplasty: A Novel ApproachV Y T Lim, C N S Chan, V Kwok, K H Mak, T H KohSingapore Med J 2003 Vol 44(11) : 563-569 • N=255 • Radial approach successful 92.2% • One arm hematoma • No symptomatic radial artery occlusions • Asymptomatic occlusions 5%

  9. Eversion endarterectomy complicating radial artery access for left heart catheterizationCatheterization & Cardiovascular Interventions. 58(4):478-80, 2003 • Case report U Tenn • No clinical consequence

  10. Trouble-shooting • Microcatheter will not advance • Sheath will not advance • Stiffer wire (short Amplatz) • Serial dilators • New access site • Absent pulse

  11. Absent pulse • Bony landmarks • Vein landmark – leave wire in place • Roadmap • Contrast • Wire • Ultrasound • Transcutaneous • Smart needle

  12. Ultrasound DVD

  13. Trouble-shooting • Microcatheter will not advance • Sheath will not advance • Absent pulse • Antegrade puncture

  14. Schneider Endovascular Skills 2nd ed.

  15. Background data • 5 million catheterizations per year in US • 75000 surgical procedures for access site complications

  16. Access site complications • Bleeding • Obstruction • Infection

  17. Access site complications • Bleeding • External • Internal • Retroperitoneal hematoma – puncture above inguinal ligament • Groin hematoma – puncture below inguinal ligament • Pseudoaneurysm • Obstruction • Local injury • Embolism • Infection • Local – arteritis • Systemic – endocarditis etc

  18. Access site hemostasis • Manual compression • How long? • Bed rest? • Compression devices • Belt • C-clamp • Sand bags

  19. Access Site Hemostatic Devices • Angio-Seal (Market leader – 70%) • Perclose ProGlide, Closer, Prostar, Techstar • Vasoseal (first approved by FDA 1993) • Duett Vascular Solutions • Staplers (Medtronic angiolink EVS, Abbott Starclose) • Topicals (Syvek, Chito-seal))

  20. Vasoseal Vascular Hemostasis Device • Datascope Corp, Montvale, NJ • Approved by FDA September 1995 • 5-8 Fr arteriotomy • Contraindicated in obese patients (>2.5 in) • Extravascular bovine collagen plug 80-100 mg • 11.5 Fr delivery system • No repuncture for 4-6 weeks

  21. Vasoseal

  22. Angio-Seal Hemostatic Puncture Closure Device • Kensey-Nash Development Corporation(Patent)/ St Jude Medical/ Daig Corp distribution • Approved by FDA Sept 1996 • Intravascular • 5-8 Fr. Delivery Sheath • Absorbable anchor (polylactic and polyglycolic acid co-polymer) and collagen plug (24 mg.) with traction suture • No contraindication to ipsilateral re-puncture

  23. Perclose Techstar and Prostar:Percutaneous Vascular Surgery Systems • Perclose, Inc., Redwood City CA (John Simpson) sold to Abbott 2000 • Approved in April, 1997 • 6,8 and 10 Fr. delivery sheath • Intravascular • One or two non-absorbable 3-0 braided sutures directly into artery wall • No contraindication to repuncture

  24. Infection guidelines per IFU: Who’s at risk? • diabetic patients • renal dialysis patients, • obese patients with skin folds, • patients undergoing prolonged procedures, • patients with multiple sheath exchanges and multiple device exchanges, • patients with prolonged sheath insertion, • immunocompromised patients, • patients with prosthetic heart valves or significant valvular lesions, • patients with prosthetic joints, • patients with prolonged hospitalization, • patients with ipsilateral groin access within two weeks, • patients with poor hygiene, • Patients with co-existent infection at a remote body site, • patients with femoral grafts, and • home health care patients/nursing home patients.

  25. Duett • Vascular Solutions, Minnetonka, Minn • Approved June 2000 - 5-9 Fr arteriotomy • Collagen and thrombin mixture • Occlusive <4 Fr balloon intravascular • Necrosis of muscle in animal model • Not for use in <6mm CFA • No contraindication to repuncture • One MDR for popliteal thrombosis

  26. Surgical Complications

  27. Femoral Access Site Complications: AngioSeal vs. Manual Compression (not randomized)

  28. Femoral Access Site Complications: Perclose vs. Manual Compression (not randomized)

  29. MDRs for Hemostatic Devices thru 9/1999

  30. Summary: Adverse Events (MDRs) • Vasoseal - SQ infection rare • No harm – No foul • risk of graft/ patch infection unknown • Angio-Seal - arterial occlusion • anchor should be retrieved • Perclose - Device/ operator failure requiring surgical removal of device • Infection – infected pseudoaneurysm • New generation “Closer” may be improved • Duett - one report of popliteal artery thrombosis • Sutura - No MDRs at this time • Biodisc - Europe only

  31. Summary • Arterial occlusive complications were more frequent following the use of Angio-Seal in comparison to manual compression at our institution • Arterial infectious complications were more frequent following the use of Perclose in comparison to manual compression at our institution • Vasoseal and Duett have not been associated with increased risk of surgical complications in our hands

  32. Guidelines • Check peripheral pulses before you start • Stick CFA • Use ultrasound for puncture • Advance wire under fluoroscopy • Point compression is more effective than diffuse compression • Sandbags are useless • Spasm is spelled “CLOT”

  33. Guidelines • Check pulses at the end of case • Numerous lawsuits for access site complications • Groin abnormality – get ultrasound • Most small pseudoaneurysms thrombose • Persistent pseudoaneurysms can usually be treated by thrombin injection

  34. Guidelines for closure devices • Have a reason to use (e.g. anticoagulation, large sheath) • Avoid infection (change gloves, fresh drapes, antibiotics, sterile technique) • A-gram femoral artery (all contraindicated if other than CFA) • Know the device – be able to trouble shoot

More Related