Access Anxiety

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Access Anxiety

• John F Eidt MD
• Ahsan Ali MD
• Mohammed Moursi MD
• University of Arkansas for Medical Sciences

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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

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Deep circumflex iliac
Inferior epigastric
CFA
PFA
SFA
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21 GA
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Trouble-shooting

• Microcatheter will not advance

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Trouble-shooting

• Microcatheter will not advance
• Sheath will not advance

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Trouble-shooting

• Microcatheter will not advance
• Sheath will not advance
• Stiffer wire (short Amplatz)
• Serial dilators
• New access site

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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

• N255
• Radial approach successful 92.2
• One arm hematoma
• No symptomatic radial artery occlusions
• Asymptomatic occlusions 5

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

• Case report U Tenn
• No clinical consequence

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Trouble-shooting

• Microcatheter will not advance
• Sheath will not advance
• Stiffer wire (short Amplatz)
• Serial dilators
• New access site
• Absent pulse

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Absent pulse

• Bony landmarks
• Vein landmark leave wire in place
• Roadmap
• Contrast
• Wire
• Ultrasound
• Transcutaneous
• Smart needle

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Ultrasound DVD
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Trouble-shooting

• Microcatheter will not advance
• Sheath will not advance
• Absent pulse
• Antegrade puncture

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Schneider Endovascular Skills 2nd ed.
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Background data

• 5 million catheterizations per year in US
• 75000 surgical procedures for access site
  complications

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Access site complications

• Bleeding
• Obstruction
• Infection

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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

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Access site hemostasis

• Manual compression
• How long?
• Bed rest?
• Compression devices
• Belt
• C-clamp
• Sand bags

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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))

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Vasoseal Vascular Hemostasis Device

• Datascope Corp, Montvale, NJ
• Approved by FDA September 1995
• 5-8 Fr arteriotomy
• Contraindicated in obese patients (gt2.5 in)
• Extravascular bovine collagen plug 80-100 mg
• 11.5 Fr delivery system
• No repuncture for 4-6 weeks

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Vasoseal
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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

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Perclose Techstar and ProstarPercutaneous
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

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Infection guidelines per IFU Whos 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.

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Duett

• Vascular Solutions, Minnetonka, Minn
• Approved June 2000 - 5-9 Fr arteriotomy
• Collagen and thrombin mixture
• Occlusive lt4 Fr balloon intravascular
• Necrosis of muscle in animal model
• Not for use in lt6mm CFA
• No contraindication to repuncture
• One MDR for popliteal thrombosis

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Surgical Complications
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Femoral Access Site Complications AngioSeal vs.
Manual Compression (not randomized)
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Femoral Access Site Complications Perclose vs.
Manual Compression (not randomized)
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MDRs for Hemostatic Devices thru 9/1999
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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

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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

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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

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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

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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