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Access Site Complications. Nick Cheshire MD FRCS, Professor of Vascular Surgery Imperial College Healthcare St Mary’s Hospital Campus. Interventional Cardiology 2008. ‘Eye of a Hawk, Heart of a Lion & the Hand of a Lady’. Surgeons & Cardiologists. Annual Coronary Intervention.

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access site complications

Access Site Complications

Nick Cheshire MD FRCS, Professor of Vascular Surgery

Imperial College Healthcare

St Mary’s Hospital Campus

surgeons cardiologists

Interventional Cardiology 2008

‘Eye of a Hawk, Heart of a Lion & the Hand of a Lady’

Surgeons & Cardiologists
annual coronary intervention
Annual Coronary Intervention

215,575 diagnostic angiograms in the UK in 20061

73,692 percutaneous coronary interventions in the UK in 20061

Over 1,000,000 coronary interventions in the United States2,3

Probably greater than 2,000,000 worldwide2,3

1. Ludman on behalf of the British Cardiac Intervention Society Audit Returns for Adult Interventional Procedures

January 2006 to December 2006

2. American Heart Association. 2004 Heart and Stroke Statistical Update

3. Smith, S.C., Jr., et al., ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol, 2006. 47(1): p. e1-121

predictors of vascular site complications
Predictors of Vascular Site Complications

Advanced age

Female gender

Renal failure

Lower extremity vascular disease


Longer time to sheath removal

PCI within 24 hours of thrombolytic therapy

Stent implantation

Concomitant placement of venous sheath

Higher heparin doses

Use of thienopyridines and glycoprotein IIb/IIIa inhibitor therapy

  • Mandak, J.S., et al., Modifiable risk factors for vascular access site complications in the IMPACT II Trial of angioplasty with versus without eptifibatide. Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis. J Am Coll Cardiol, 1998. 31(7): p. 1518-24.
  • Piper, W.D., et al., Predicting vascular complications in percutaneous coronary interventions. Am Heart J, 2003. 145(6): p. 1022-9.
types incidence of complications
Types & Incidence of Complications

Boston Experience

Arora et al (Am Heart J 2007): Propensity Analysis

does the use of a closure device reduce complications
Does the use of a closure device reduce complications?

Closure DeviceType Puncture Size Manufacturer

AngioLink EVS Staple 6-8F Medtronic

AngioSeal Collagen Plug 6-8F St. Jude Medical

Duett Collagen Plug 5-9F Vascular Solutions

Elite Collagen Plug 5-8F Vascular Solutions

Perclose Suture 5-10F Abbott Vascular

QuickSeal Gelatin Plug 6-8F Sub-Q

Starclose Staple 6F Abbott Vascular

Prostar XL Suture 8&10F Abbott Vascular

Vasoseal Collagen Plug 4-8F Datascope

X-site Suture 6F Datascope

american college of cardiology national cardiovascular data registry
American College of CardiologyNational Cardiovascular Data Registry

Tavris et al. J Invasive Cardiol 2004;16:459-464

Largest series reported to date

166,200 patients with 53,655 devices

Lower incidence of vascular complications with ACDs in diagnostic angiograms but NOT PCI cases

Lower vascular complication rate with collagen-based and suture-based products than manual compression in all patients

nikolsky et al systematic review
Nikolsky et al: Systematic Review

30 Studies, 37,0766 Patients Identified

Primary endpoint was cumulative vascular complications

No difference in complication incidence between Angio-Seal and mechanical compression

Diagnostic setting (odds ratio [OR] 1.08, 95% confidence interval [CI] 0.11 to 10.0)

PCI (OR 0.86, 95% CI 0.65 to 1.12)

A trend toward less complications using Angio-Seal in a PCI setting

(OR 0.46, 95% CI 0.20 to 1.04; p=0.062)

types incidence of complications13
Types & Incidence of Complications

Boston Experience

Arora et al (Am Heart J 2007): Propensity Analysis

managing complications
Managing Complications

Duplex Guided Thrombin Injection

  • Lennox, A.F., et al., Treatment of an iatrogenic femoral artery pseudoaneurysm with percutaneous duplex-guided injection of thrombin. Circulation, 1999. 100(6): p. e39-41.
  • Lennox, A.F., et al., Duplex-guided thrombin injection for iatrogenic femoral artery pseudoaneurysm is effective even in anticoagulated patients. Br J Surg, 2000. 87(6): p. 796-801
  • >300 Cases Imperial
  • 1 in-situ thrombosis
  • 2-3% failure/repeat rate
managing complications17
Managing Complications

Surgery for leg ischaemia

Embolisation; ensure macro disease corrected

summary conclusions
Summary & Conclusions

Latest data: ACDs seem to be associated with a reduction in vascular complications

Earlier data possibly reflected new devices, less experience etc

Likely highest impact

in PCI

on bleeding

Consider closure in higher risk interventions

Multi-disciplinary approach and early referral