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“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

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Access anxiety

“Access Anxiety”

John F Eidt MD

Ahsan Ali MD

Mohammed Moursi MD

University of Arkansas for Medical Sciences


Primary access
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


Deep circumflex iliac

Inferior epigastric

CFA

PFA

SFA



Trouble shooting
Trouble-shooting

  • Microcatheter will not advance


Trouble shooting1
Trouble-shooting

  • Microcatheter will not advance

  • Sheath will not advance


Trouble shooting2
Trouble-shooting

  • Microcatheter will not advance

  • Sheath will not advance

    • Stiffer wire (short Amplatz)

    • Serial dilators

    • New access site


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%


Eversion endarterectomy complicating radial artery access for left heart catheterizationCatheterization & Cardiovascular Interventions. 58(4):478-80, 2003

  • Case report U Tenn

  • No clinical consequence


Trouble shooting3
Trouble-shooting for left heart catheterization

  • Microcatheter will not advance

  • Sheath will not advance

    • Stiffer wire (short Amplatz)

    • Serial dilators

    • New access site

  • Absent pulse


Absent pulse
Absent pulse for left heart catheterization

  • Bony landmarks

  • Vein landmark – leave wire in place

  • Roadmap

    • Contrast

    • Wire

  • Ultrasound

    • Transcutaneous

    • Smart needle


Ultrasound dvd

Ultrasound DVD for left heart catheterization


Trouble shooting4
Trouble-shooting for left heart catheterization

  • Microcatheter will not advance

  • Sheath will not advance

  • Absent pulse

  • Antegrade puncture


Schneider for left heart catheterization

Endovascular Skills

2nd ed.


Background data
Background data for left heart catheterization

  • 5 million catheterizations per year in US

  • 75000 surgical procedures for access site complications


Access site complications
Access site complications for left heart catheterization

  • Bleeding

  • Obstruction

  • Infection


Access site complications1
Access site complications for left heart catheterization

  • 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


Access site hemostasis
Access site hemostasis for left heart catheterization

  • Manual compression

    • How long?

    • Bed rest?

  • Compression devices

    • Belt

    • C-clamp

  • Sand bags


Access site hemostatic devices
Access Site Hemostatic Devices for left heart catheterization

  • 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))


Vasoseal vascular hemostasis device
Vasoseal Vascular Hemostasis Device for left heart catheterization

  • 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


Vasoseal
Vasoseal for left heart catheterization


Angio seal hemostatic puncture closure device
Angio-Seal Hemostatic Puncture Closure Device for left heart catheterization

  • 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


Perclose techstar and prostar percutaneous vascular surgery systems
Perclose Techstar and Prostar: for left heart catheterizationPercutaneous 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


Infection guidelines per ifu who s at risk
Infection guidelines per IFU: Who’s at risk? for left heart catheterization

  • 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.


Duett
Duett for left heart catheterization

  • 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


Surgical complications
Surgical Complications for left heart catheterization


Femoral Access Site Complications: for left heart catheterization

AngioSeal vs. Manual Compression (not randomized)


Femoral Access Site Complications: for left heart catheterization

Perclose vs. Manual Compression (not randomized)


MDRs for Hemostatic Devices thru 9/1999 for left heart catheterization


Summary adverse events mdrs
Summary: Adverse Events (MDRs) for left heart catheterization

  • 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


Summary
Summary for left heart catheterization

  • 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


Guidelines
Guidelines for left heart catheterization

  • 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”


Guidelines1
Guidelines for left heart catheterization

  • 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


Guidelines for closure devices
Guidelines for closure devices for left heart catheterization

  • 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


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