Access Site Complications

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Access Site Complications

• Nick Cheshire MD FRCS, Professor of Vascular
  Surgery
• Imperial College Healthcare
• St Marys Hospital Campus

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Surgeons Cardiologists
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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

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Groin Haematoma, False aneurysm, Skin Necrosis
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Lower Limb Ischaemia
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Predictors of Vascular Site Complications

• Advanced age
• Female gender
• Renal failure
• Lower extremity vascular disease
• Shock
• 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.

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Types Incidence of Complications
Boston Experience
Arora et al (Am Heart J 2007) Propensity Analysis
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Does the use of a closure device reduce
complications?
Closure DeviceType Puncture Size Manufacturer An
gioLink EVS Staple 6-8F Medtronic AngioSeal Coll
agen Plug 6-8F St. Jude Medical Duett Collagen
Plug 5-9F Vascular Solutions Elite Collagen
Plug 5-8F Vascular Solutions Perclose Suture 5-10
F Abbott Vascular QuickSeal Gelatin
Plug 6-8F Sub-Q Starclose Staple 6F Abbott
Vascular Prostar XL Suture 810F Abbott
Vascular Vasoseal Collagen Plug 4-8F Datascope X-
site Suture 6F Datascope
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American College of CardiologyNational
Cardiovascular Data Registry

• Tavris et al. J Invasive Cardiol 200416459-464
• 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

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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
  con?dence 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 p0.062)

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Arora et al (Am Heart J 2007) Propensity Analysis
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Arora et al (Am Heart J 2007)Propensity Analysis
Results
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Types Incidence of Complications
Boston Experience
Arora et al (Am Heart J 2007) Propensity Analysis
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Arora et al (Am Heart J 2007) Propensity Analysis
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Arora et al (Am Heart J 2007) Propensity Analysis
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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

• gt300 Cases Imperial
• 1 in-situ thrombosis
• 2-3 failure/repeat rate

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Managing Complications

• Surgery for leg ischaemia

Embolisation ensure macro disease corrected
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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