vascular access in cardiac catheterization

Vascular Access during Cardiac Catheterization

VASCULAR ACCESS,COMPLICATIONS,MERITS

Dr Vikash M,DM(SR).NIMS,Hyderabad,Indiavikasmedep@yahoo.co.in

VASCULAR ACCESS,COMPLICATIONS,MERITS2

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VASCULAR ACCESS

ARTERIAL VENOUS

Retrograde/antegrade.

ARTERIAL

FEMORAL RADIAL BRACHIAL ULNAR

Venous Accesss

VENOUS

FEMORAL IJV SUBCLAVIAN

TOPIC OVERLAY

• SITE

• COMPLICATIONS

• ADVANTAGES

• DIS-ADVANTAGES

• COMPARISON

• HEMOSTASIS

FEMORAL ACCESS - ANATOMY

ARTERIAL ACCESS

• FEMORAL ARTERIAL ACCESS

• Most commonly used access for PCI

• SITE OF PUNCTURE

• Common femoral artery

• 2 cm below the inguinal ligament.

• Inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle

• Some operators rely on the location of the inguinal skin crease to position the skin nicks

• The position of the skin crease itself can be misleading in obese patients

• Localization of the skin nick by fluoroscopy

• Should show the nick to overlie the inferior border of the femoral head

COMPLICATIONS

• VASCULAR

• Hematoma

• Pseudo-aneurysm

• A-V fistula

• Retropertonial hemorrhage

• Thrombosis

• NON VASCULAR

• Infections

VASCULAR ACCESS,COMPLICATIONS,MERITS11Nasser TK, Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheralvascular complications following coronary interventional procedures.Clin Cardiol.1995;18:609–614.

PROCEDURAL RISK STRATIFICATION• Low Risk:(<1% Complication Rate)

• Diagnostic Angiographic Procedures

• Moderate Risk: (1% to 3% Complication Rate)

• Routine Percutaneous Intervention

• High Risk (>3% Complication Rate)

• Primary PCI for acute MI, prolonged multivessel PCI , or procedures that require larger sheath sizes (eg,>8F)

RISK FACTORS

• Modifiable

• Site of puncture

• Number of attempts

• Size of sheath

• Sheath removal

• Medications

• Non modifiable

• Age

• Gender

• BMI

• Associated disorders - CKD

COMPLICATIONS

• NUMBER OF ATTEMPTS

• Best – 1 attempt

• Better – 2 attempts

• Complications - > 2 attempts

• Shift to other side / site.

• SHEATH SIZE

• Greater the size more chances of complications

• Grossman and colleagues found that PCIs performed with 7F and 8F sheath compared with 6F were associated with more vascular compliactions

• SHEATH REMOVAL• Time

• Compression

• Adequate compression just proximal to the site of skin puncture for at least 30 min is ideal.

• MEDICATIONS• Anti platelets – oral , IV

• Anti coagulants.

NON-MODIFIABLE

• AGE – elderly > younger

• SEX – female > male.

• BMI – high > low > normal

• # Delhaye et al – 6% high, 5.1% low, 2.0% normal

• # Delhaye C, Wakabayashi K, Maluenda G, et al. Body mass index and bleeding complications after percutaneous coronary ,AmHeart J.2010;159:1139-1146.

• ASSOCIATED CONDITIONS

• HYPERTENSION.• Manoukian et al, patients with a higher systolic

BP (140 vs 120 mm Hg;P= .02) were significantly more likely to have complications than were patients with lower blood pressures *

• CKD

• *Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial. J Am Coll Cardiol.2007;49:1362-1368

• HEMATOMA

• Definition

• Collection of blood in the soft tissue

• Incidence

• Most common vascular complication

• 5- 20 %

• Clinical features

• Pain, swelling, indurationVASCULAR ACCESS,COMPLICATIONS,MERITS20

Rao SV, O'Grady K,. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J

Cardiol. 2005;96:1200–1206

PSEUDO-ANEURYSM

• Definition

• A contained rupture; with disruption of all 3 layers of the arterial wall.

• Occur when an arterial puncture site does not adequately seal.

• Pulsatile blood tracks into the perivascular space and is contained by the perivascular structures, which then take on the appearance of a sac.

• One of the common vascular complications of cardiac and peripheral angiographic procedures.

• The incidence after diagnostic catheterization ranges from 0.05% to 2%.

• When coronary or peripheral intervention is performed, the incidence increases to 2% to 6%.*

• *Hessel SJ, Adams DF, Abrams HL. Complications of angiography. Radiology. 1981; 138: 273–281.

• DIAGNOSIS

• CLINICAL

• Pain and swelling at puncture site.

• Swelling from a large aneurysm may also lead to compression of nerves and vessels with associated neuropathy, venous thrombosis, claudication, or, rarely, critical limb ischemia.

• Local ischemia of the skin may lead to necrosis and infection.

• On physical examination, there may be a palpable pulsatile mass or the presence of a bruit.

• However, it should be noted that none of these physical findings may be present.

• Pain that is disproportionate to that expected after a PCI should undergo an doppler to exclude pseudoaneurysm regardless of the presence of a bruit.

• IMAGING

• Duplex ultrasound

• The sensitivity is 94% with a specificity of 97%.

• Echolucent sac that expands and contracts with cardiac contraction .

• On color Doppler, there is a swirling flow pattern with turbulence in the chamber(s), there may be 1 or more chambers.

• A tract connects the chamber to the feeding vessel.

• When a pulsed wave Doppler is placed within the track, a “to-and-fro” signal is obtained

• TREATMENT

• Until the early 1990s, the only treatment available was surgery.

• Since that time, USG compression, USG guided thrombin injection, FemStop compression devices, coil insertion, fibrin, adhesives, or balloon occlusion have been used with variable success.

• USG guided compression

• In 1991, Fellmeth and associates introduced a safe and noninvasive method to treat PSA.

• Success rate of 75% to 98%.

• The ultrasound transducer is positioned and pressure is applied to compress the chamber and tract while flow in the native artery is allowed.

• Direct ultrasound visualization confirms cessation of flow.

• Compression is usually held for cycles of 10 minutesVASCULAR ACCESS,COMPLICATIONS,MERITS33

• The vertical angle created by the device does not allow selective compression of the chamber and tract.

• Nonselective compression leads to longer compression times, more discomfort to the patient, and a lower success rate, in addition to an increase in complications such as DVT

• Body habitus, size, depth, and number of chambers, as well as concurrent anticoagulation may limit the success

• In patients on anticoagulation, the success is 30% to 73%.

• In 100 cases of pseudoaneurysm, was successful in 94 patients (94%), which included 30 (86%) of 35 patients who received anticoagulation and 64 (98%) of 65 patients who were not on anticoagulation.*

• Katzenschlager R, Ugurluoglu A,. Incidence of pseudoaneurysm after diagnostic and therapeutic angiography.Radiology. 1995;195:463–466

• DISADVANTAGES

• Long time - average compression time to achieve occlusion was 33 min with a range of 10 to 120 min*

• Painful

• Position

• Operator

• *Cox GS, Young JR, Gray BR, Grubb MW, Hertzer NR. Ultrasound-guided compression repair of postcatheterization pseudoaneurysms:results of treatment in one hundred cases.J Vasc Surg. 1994;19:683–686

• COMPLICATIONS

• Vasovagal reactions,

• Rupture,

• Skin necrosis, and

• DVT

• Ultrasound-Guided Thrombin Injection

• The principle - thrombin is important in the conversion of fibrinogen to fibrin.

• Thus a fibrin clot is formed instantaneously (even in the presence of antiplatelet therapy or anticoagulation therapy.

• Success ranges from 91% to 100%*

• *Cope C, Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection. Am J Roentgenol. 1986;147:383–387.

• Complications

• DVT (if the thrombin is inadvertently injected into the vein),

• Pulmonary embolism

• Thrombosis of the artery.

• Allergic reactions and anaphylaxis.

• PARA ANEURYSMAL SALINE INJECTION

• ENDOLUMINAL MANAGEMET

• serves to exclude a pseudoaneurysm from the circulation

• Depends on the size of the pseudoaneurysmal neck and the expendability of the donor artery .

• 2 broad categories: embolization and stent

• The width of the neck relative to the diameter of the donor artery is the determining factor.

• A vital donor artery may be embolized in certain emergent situations (eg, rupture with active bleeding); however, distal blood flow must then be restored by means of a surgical bypass procedure

• COIL CLOSURE

• If the neck is narrow,

• made of either stainless steel or platinum.

• Polyester fibers are incorporated the coil to increase its thrombogenicity

• Disadvantage

• Potential for recanalization.

• COVERED STENT

• Indications Large neck & larger artery

• Contraindication – mycotic aneurysm

SURGERY

• Disadvantages of surgery

• Requires anesthesia

• An incision usually in the groin, an area known to become infected easily after a surgical procedure.

• Lumsden and colleagues reported a surgical complication rate of 20% repair.

• Complications included bleeding, infection, neuralgia, prolonged hospital stay

• Prevention

• More complex procedures and more potent antithrombotic therapy have led to the occurrence of more frequent aneurysm formation.

• The most important strategies to prevent formation are:

• ● Assure a needle puncture in the proper location achieve vascular access on the first puncture without access through the posterior wall.

• ● Appropriate groin compression after sheath removal.

RETRO-PERITONEAL HEMATOMA

RETROPERITONEAL HEMATOMA

• Incidence

• 0.1 – 0.2 %

• CAUSES

• High puncture

• Inadvertent puncture of the posterior wall of the femoral or iliac artery

• Exacerbated by the fact that patients receive antiplatelets, anticoagulants

• Removal of catheter without wireVASCULAR ACCESS,COMPLICATIONS,MERITS46

• Retroperitoneal Hematoma After Percutaneous Coronary Intervention: Prevalence, Risk Factors, Management, Outcomes, and Predictors of Mortality

• Volume 3, Issue 8, August 2010

VASCULAR ACCESS,COMPLICATIONS,MERITS47Retroperitoneal Hematoma After Percutaneous Coronary Intervention: Prevalence, Risk Factors, Management, Outcomes, and Predictors of MortalityVolume 3, Issue 8, August 2010 , JACC

• CLINICAL FEATURES

• High index of suspicion

• Very subtle clinical signs of haemorrhage

• Back, lower abdominal or groin discomfort and swelling,

• Pallor, sweating.

• Relative hypotension and mild tachycardia that transiently improves with administration of fluids

• Unable to mount tachycardia because of beta-blockers, and these patients usually become hypotensive with no change in their heart rate

• Retroperitoneal haematoma near or within the iliopsoas muscle presents as femoral neuropathy, begins with groin pain or leg weakness

• Sudden onset severe pain in the affected groin and hip

• Iliopsoas spasm often results in the flexion and external rotation of the hip, attempt to extend the hip results in severe pain.

• DIAGNOSIS

• CBP – fall in Hb

• IMAGING

• Ultrasonography of the abdomen and pelvis may detect haematoma,.

• Limited by patient's discomfort, body habitus, underlying bowel gas .

• Free fluid or blood in the retroperitoneum pass into the abdominal or pelvic cavity

• CT SCAN

• Type, site and extent of the fluid collections.

• Active bleeding can be seen as extravasation of contrast material,

• CT angiography may show the site of the bleed and contrast outside the vessels.

• MRI

• Useful in patients presenting with femoral neuropathy, as MRI helps to rule out nerve root compression or spinal problems.

• Shows the site of the bleed.

• ANGIOGRAPHY

• Haemodynamically unstable, view to selective embolisation or placement of a stent graft is indicated

• MANAGEMENT

• Fluid resuscitation, blood transfusion and normalisation of coagulation factor.

• No specific guidelines to suggest when to intervene with endovascular or open surgery to stop the bleeding.

• If the patient is haemodynamically stable with no evidence of on-going bleeding, conservative management is recommended.

• ENDOVASCULAR TREATMENT

• Indications - Panetta et al*

• Hemodynamic instablitiy

• Hemodynamiclly stable- four or more units of blood transfusion within 24 h, or six or more units within 48 h

• Selective intra-arterial embolisation

• Stent-grafts

• Very few heterogeneous case series on stent-grafts in the management of retroperitoneal haematoma

• * Panetta T, Sclafani SJ, Goldstein AS et al. Percutaneous transcatheter embolization for massive bleeding from pelvic fractures. J Trauma 1985; 25: 1021-9

• OPEN SURGERY

• Indications

• Unstable despite adequate fluid and blood product resuscitation,

• Failed embloization / stent

• Abdominal compartment syndrome

A-V FISTULA

• DEFINITION

• Abnormal connections between the arterial and venous system that bypass the normal anatomic capillary beds

• RISK FACTORS

• Female Hypertension

• Anticoagulation , Low or multiple punctures

• Obesity Advanced age.

• Low groin puncture –

• Likely to access SFA just distal to the CFA bifurcation.

• The profunda femoris vein passes between the SFA and the profunda femoris artery

• Punctures to the proximal SFA are particularly vulnerable to causing AVF because the needle tip frequently punctures the underlying profunda vein.

• Sheath placement –

• Dilation of the tract between an artery and vein reduces the likelihood that the communication will close.

• The larger the sheath size, the greater the risk for AVF

• INCIDENCE

• 0.I to 1 %*

• Initially silent.

• Two days to several months

• Abnormal sensation in the groin, fatigue, new onset or worsened lower extremity ischemia.

• *Glaser RL, McKellar D, Scher KS. Arteriovenous fistulas after cardiac catheterization. Arch Surg 1989; 124:1313. VASCULAR ACCESS,COMPLICATIONS,MERITS59

• Palpation and auscultation of the affected vessel demonstrates a machinery-like murmur, bruit, hematoma or pulsatile mass.

• The patient may exhibit lower extremity edema

• CONSEQUENCES

• DVT, nerve compression and new onset or worsened varicose veins

• The most significant condition related to AVF is high-output heart failure

• DIAGNOSIS

• Duplex ultrasonography

• Current diagnostic test of choice

• High frequency, low resistance flow

• is typical ,with a mosaic color pattern.

• Often the specific artery and vein involved can be identified

• CT ANGIO

• Picks up the defect

• CONVENTIONAL ANGIO

• Appears as a blush with rapid filling of the adjacent deep vein

• TREATMENT

• Most small asymptomatic AVFs thrombose spontaneously and thus should be observed

• INDICATIONS:

• Clinical symptoms related to the AVF

• Steal syndrome causing claudication or distal limb ischemia

• Significant edema or venous insufficiency due to venous hypertension

• Heart failure due to a high-flow fistula

• Progressive enlargement under ultrasound surveillance

• Iatrogenic AVFs that do not seal spontaneouslyVASCULAR ACCESS,COMPLICATIONS,MERITS62

• Ultrasound-guided compression

• Compression of sufficient force to abolish flow through the fistula without unduly reducing distal perfusion

• Painful

• Failure is frequent because the fistula track is too short or the AV fistula is too large

• Chronic AVFs (>2 to 3 weeks) rarely respond to compression.

• Ongoing anticoagulation also decreases success rates of UGC.

• Endovascular repair

• Covered stent placement or embolization techniques

• Surgery VASCULAR ACCESS,COMPLICATIONS,MERITS63

• Incidence

• 0.5 – 1%

• Diagnosis

• Doppler studies

• Peripheral angiogram

• Treatment

• Small – spontaneous lysis

• Large, limb threatening – thrombolysis / thrombectomy

• INFECTIONS

• Incidence <1%,

• Bacterial infections occurred in 0.11% at a median of 1.7 days after the procedure*

• Pain, erythema, swelling at puncture site

• Purulent discharge

• Fever

• *Munoz P, Blanco JR, Rdoriguez-Creixems M, et al. Blood stream infections after invasive nonsurgical cardiology procedures. Arch Intern Med 2001;161:2110–2115

• Causes

• Improper shaving

• Improper scrubbing

• TREATMENT

• Antibiotics

• PREVENTION

• Appropriate shaving / scrubbing.

• Using sterile drapes.

• FEMORAL NEUROPATHY

• Incidence

• 0.1 – 0.3%

• Mechanism

• Compression of the femoral nerve during puncture or by hematoma

• Clinical features

• Tingling, numbness, weakness,

• Treatment

• Usually self remitting VASCULAR ACCESS,COMPLICATIONS,MERITS69

RADIAL ACCESS

PRE -REQUISITES

• Diagnostic Accuracy

• Ruengsakulrach et al.compared the Modified Allen’s Test with Doppler and found the Modified Allen’s Test to have a sensitivity of 100% and specificity of 97%.

• Glavin and Jones compared the Modified Allen’s Test with Doppler a sensitivity of 87% to correctly diagnose the presence of ulnar artery blood flow and a negative predictive value of only 0.18; i.e., 80% of all abnormal Modified Allen’s Test results in their study were incorrect.

• The diagnostic accuracy of the Modified Allen’s Test, compared with ultrasound, was only 80%, with a sensitivity of 76% and a specificity of 82%

BARBEAU TEST

COMPLICATIONS

• COMPLICATIONS• PROCEDURAL • Vaso vagal reaction• Spasm• Perforation / Dissection.• POST PROCEDURE• Occlusion• Compartment Syndrome • Pseudoaneurysm•

• VASOVAGAL REACTIONS

• Due to pain, anxiety

• PREVENTION

• Preprocedural sedation, analgesia, and adequate local infiltration anesthesia decreases pain, anxiety, and associated vagal output

• SPASM• Induced by the introduction of a sheath or catheter • Mechanism

• Prominent medial layer that is largely dominated by alpha-1 receptors.

• Increased levels of catecholamines cause spasm

• Risk factors

• Female young age small artery

• Anxiety Unsuccessful guide wire passage

• Multiple catheter exchanges, prolonged procedure

• Prevention

• Adequate vasodilatory cocktail containing

• NTG 100 – 200 mcg + 2.5 mg verapamil, + 40 U/Kg heparin max 5000 u

• Hydrophilic catheters

• Smaller sheaths

• TREATMENT

• Additional doses of CCB, NTG,

• More analgesia / sedation

• Warm compressVASCULAR ACCESS,COMPLICATIONS,MERITS80

• HEMATOMA

• Rare , Easily compressed against bone

• Grades of hematoma *

• <5 cm (grade I),

• <10 cm (grade II),

• Distal to the elbow (grade III), and

• Proximal to elbow (grade IV).

• Hematomas grade III and IV are not directly related to the puncture site, but result from wire damage to vessels and small perforations

• Hamon M, Rasmussen LH, Manoukian SV, et al. Choice of arterial access site and outcomes in patients with acute coronary syndromes managed with an early invasive strategy: The ACUITY trial. EuroIntervention 2009;5:115–120VASCULAR ACCESS,COMPLICATIONS,MERITS81

• COMPARTMENT SYNDROME

• Limb threatening condition

• Foremarm hematoma compressing the ulnar & radial artery – ischemia.

• incidence of 0.4%*

• *Tizon-Marcos H, Barbeau GR. Incidence of compartment syndrome of the arm in a large series of transradial approach. J Interv Cardiol. 2008;21:380-384

• Causes

• Unrecognized perforation at a distance from the puncture site,

• Unsuccessful compression at the puncture site, or

• Radial artery laceration induced at sheath insertion

• Prevention

• Early recognition and management of hematoma

• Treatment

• Surgical decompression.

• AVULSION• A sheath entrapped by arterial spasm should never be

forcibly removed because traumatic eversion radial artery may result.

• Prevention• Repeat intra-arterial vasodilators,

• Additional patient sedation and/or analgesia, and

• Reinsertion of the introducer and guidewire may be necessary.

• In refractory cases, axillary nerve blocks or general anesthesia may be required for catheter removal

• DISSECTION / PERFORATION

• Angiography of the arm should be performed if there is difficulty with wire or catheter advancement since failure to identify the problem may lead to vessel perforation or dissection.

• Rather than aborting the procedure, it is worth trying to carefully re-cross them with a soft 0.014 angioplasty wire.

• If this attempt is successful, the catheter will usually seal the dissection or perforation, an

• Aborting the procedure will leave an unsealed dissection or perforation that may be difficult to control

• RADIAL ARTERY OCCLUSION• Incidence

• 2% to 10% of patients*

• Risk factors**

• Lack of Heparin therapy

• Large artery-catheter mismatch,

• Female sex,

• Lack of pretreatment with clopidogrel,

• Diabetes, and

• Occlusive hemostasis

• Wu CJ, Lo PH, Chang KC, et al. * Transradial coronary angiography and angioplasty. Cathet Cardiovasc Diagn. 1997;40:159-163.

• **Stella PR, Kiemeneij F, Laarman GJ, Odekerken D,. Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty.Cathet Cardiovasc Diagn 2007;40:156–158

• Consequences

• Usually benign and asymptomatic due to the dual blood supply to the hand

• Hand ischemia, gangrene

• Spontaneous recanalizaton appears to occur in 50% of patients

• Prevention

• Pre-procedural heparin > 5000u, without heparin 60-70%, with 2-6%*

• Immediate sheath removal

• Vascular devices better than manual compression.

• *Spaulding C, Lefevre T, Funck F, et al. Left radial approach for coronary angiography: results of a prospective study. Cathet Cardiovasc Diagn. 2010;39:365-370.

2011 ACCF/AHA/SCAI/ESC Guideline for Percutaneous Coronary Intervention Class IIa1. The use of radial artery access can be useful todecrease access site complications.

• CONDITIONS WHERE READIAL ACCESS SHOULD BE PREFERRED

• Absent femoral pulses

• Femoral bruit

• Femoral artery graft surgery

• Extensive inguinal scarring from past surgery

• Surgery / radiation treatment near inguinal area

• Extensively tortuous iliac system / lower abdominal aorta

• Abdominal aortic aneurysm

• Patient request

• CONDITIONS WHERE READIAL ACCESS SHOULD BE AVOIDED

• Radial artery being considered for CABG / AV fistula

• Upper limb atherosclerosis, extreme tortuosity, Raynaud’s or Burger’s disease.

• Need for 7F or larger sheath.

FEMORAL vs RADIAL APPROACH

Primary and Secondary Outcomes

Radial(n=3507)

Femoral (n=3514)

%HRHR 95% CI95% CI PP

Primary Outcome

Death, MI, Stroke, Major Bleed 3.7 4.0 0.920.92 0.72-1.170.72-1.17 0.500.50

Secondary Outcomes

Death, MI, Stroke 3.2 3.2 0.980.98 0.77-1.280.77-1.28 0.900.90

Major Bleeding 0.7 0.9 0.730.73 0.43-1.230.43-1.23 0.230.23

Other Outcomes Radial(n=3507)

Femoral (n=3514)

Access site Cross-over (%) 7.6 2.0 <0.0001<0.0001

PCI Procedure duration (min) 35 34 0.620.62

Fluoroscopy time (min) 9.3 8.0 <0.0001<0.0001

Persistent pain at access site >2 weeks (%) 2.6 3.1 0.220.22

Patient prefers assigned access site for next procedure (%)

90 49 <0.0001<0.0001

BRACHIAL ARTERY ACCESS

• SITE OF PUNCTURE

• Medial aspect of cubital fossa, 2-3 cm above the elbow crease

• INDICATIONS

• Renal / lower limb artery angioplasty

• COMPLICATIONS

• Hematoma

• Hand ischemia

• Due to thrombosis

• Compartment syndrome

• Hematoma extends into forearm

• Median nerve injury

• 0.2 and 1.4%

• Orator’s hand posture

• ACCESS trial – radial vs brachial access

• More complications with brachial approach ( 0.2% vs 2.6% p 0.03 )

ULNAR ARTERY ACCESS• SITE

• 2-3 cm above the crease of wrist

• ADVANTAGES

• Preservation of radial artery for CABG

• PREREQUISITE

• Reverse Allen’s test

• COMPLICATIOS

• Same as with radial artery access

• EVIDENCE – PCVI-CUBA trial radial vs ulnar

• Success rate - access 96% vs 93%, PCI – 96% vs 95%,

complication rate 1% vs 1.2 % .

HEMOSTASIS

• MANUAL COMPRESSION

• MECHANICAL COMPRESSION

• TOPICAL HEMOSTATIC AIDS

• VASCULAR CLOSURE DEVICES

1. Active

2. Passive .

• MANUAL COMPRESSION

• Remains the “gold standard”

• Timing

• Diagnostic procedure - Immediately

• Interventions - 4-6 hrs, ACT < 170 sec

• Site

• 2 cm proximal to skin puncture site

• Duration

• 15 – 30 min, larger sheath, longer time

• 3-4 min compression / french.

• Dis advantage

• Ineffective compression due to fatigue

FEM-STOP

VASCULAR ACCESS,COMPLICATIONS,MERITS11670mmHg while sheath removal70mmHg while sheath removalMAP for 15 minMAP for 15 minGradually reduce to 30mmHg over 2 hrs and remove.Gradually reduce to 30mmHg over 2 hrs and remove.

CLAMP-EASE

METAL PAD

PRESSURE PAD

• Advantages

• More effective compression

• Dis-advantages

• Doesn’t decrease time to hemostasis / ambulation.

• Patient discomfort

TOPICAL HEMOSTATIC AIDS

• A variety of topical patches, pads, bandages, and powders are available for use to assist with hemostasis with manual compression.

• Accelerate the clotting process and thus accelerate hemostasis

• Advantages

• Topical agents leave no foreign body behind, and act by

• Accelerating natural hemostasis.

• Topical agents still require manual compression

VASCULAR CLOSURE DEVICES• Introduced in 1995 to decrease vascular

complications and reduce the time to hemostasis and ambulation.

• CLASSIFICATION

• PASSIVE

• enhance hemostasis with prothrombotic material or mechanical compression, but do not achieve prompt hemostasis or shorten the time to ambulation

• ACTIVE

ANGIO-SEAL

• Success rate – • 90 - 97%*

• Advantages • One of the easiest devices to learn and use. •

• Has a very high initial success rate. •

• The collagen plug in the tract also acts to reduce oozing from the site.

• The retained components of the device are completely resorbed

• *Applegate RJ, Grabarczyk MA, Little WC et al. Vascular closure devices during percutaneous revascularization. J Am Coll Cardiol 2002;40:78–83.

• Disadvantages

• The intravascular anchor has the potential to further obstruct a heavily diseased vessel.

• Embolization of the intravascular anchor.

• Repeat access of the same vessel within 90 days of device deployment should be avoided using the same puncture site.

• Infection.

STAR CLOSE DEVICE

• Success rate

• 87%–97%*

• Advantages

• deploys on the outside of the artery, leaving nothing in the lumen.

• Re-puncture through a deployed Starclose clip performed safely at any time.

• Disadvantages

• Oozing.• *Applegate RJ, Grabarczyk MA, Little WC et al. Vascular closure devices during percutaneous

revascularization. J Am Coll Cardiol 2002;40:78–83.

• Devices:2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention Recommendations

• Class I

• 1. Patients considered for vascular closure devices should undergo a femoral angiogram to ensure their anatomic suitability for deployment.

• Class IIa

• 1. The use of vascular closure devices is reasonable for the purposes of achieving faster hemostasis and earlier ambulation

• Class III: NO BENEFIT

• 1. The routine use of vascular closure devices is not recommended for the purpose of decreasing vascular complications

TR band

FEMORAL VENOUS ACCESS

ANATOMY

• INDICATIONS

• Right heart study TPI

• IVC filter Venous access

• Puncture site

• Medial to femoral artery

• Needle held at 45 degree angle

• Skin insertion 2 cm below inguinal ligament

• Aim toward umbilicusVASCULAR ACCESS,COMPLICATIONS,MERITS138

COMPLICATIONS

Local Hematoma

Retroperitoneal hematoma

Pseudoaneurysm

AV fistula

Femoral neuropathy

Infection

SUBCLAVIAN VENOUS ACCESS

• INDICATIONS

• PPI leads

• TPI

• IVC filter

• Central venous access

• Chemoport

• Positioning• Right side preferred

• Supine position, head neutral, arm abducted

• Trendelenburg (10-15 degrees)

• Shoulders neutral with mild retraction

• Puncture site• Junction of middle and medial thirds of clavicle

• At the small tubercle in the medial deltopectoral groove

• Needle should be parallel to skin

• Aim towards the supraclavicular notch and just under the clavicleVASCULAR ACCESS,COMPLICATIONS,MERITS141

• COMPLICATIONS

• Infection Bleeding Pneumothorax

• Thrombosis Air embolization Brachial plexus injury

• AVOIDED IN

• Coagulopathy Thrombloysis Chest wall deformity

IJV ACCESS

• INDICATIONS

• TPI

• Central venous line

• Positioning• Right side preferred

• Trendelenburg position

• Head turned slightly away from side of venipunctureVASCULAR ACCESS,COMPLICATIONS,MERITS144

Needle placement

• Central approach• Locate the triangle formed by the clavicle and

the sternal and clavicular heads of the SCM muscle

• Place 3 fingers of left hand on carotid artery

• Place needle at 30 to 40 degrees to the skin, lateral to the carotid artery

• Aim toward the ipsilateral nipple under the medial border of the lateral head of the SCM muscle

• Vein is 1-1.5 cm deep, avoid deep probing in the neck

COMPLICATIONS

• Infection Bleeding – airway compression

• Thrombosis Air embolization Pneumothorax

• AVOIDED IN

• Trendelenburg tilt is not possible – pulmonary edema

• Child < 1 yr who cannot be sedated / paralysed

COMPLICATIONS

Location Advantage DisadvantageInternal Jugular

• Bleeding can be Bleeding can be recognizedrecognized

and controlledand controlled

• Malposition is rareMalposition is rare

• Less risk of Less risk of pneumothoraxpneumothorax

• Risk of carotid artery Risk of carotid artery puncturepuncture

• Pneumothorax possiblePneumothorax possible

Femoral • Easy to find veinEasy to find vein

• No risk of No risk of pneumothoraxpneumothorax

• Preferred site for Preferred site for

emergencies and CPRemergencies and CPR

• Fewer bad Fewer bad complicationscomplications

• Highest risk of infectionHighest risk of infection

• Risk of DVTRisk of DVT

• Not good for ambulatory Not good for ambulatory

patientspatients

Subclavian • Most comfortable forMost comfortable for

conscious patientsconscious patients

• Highest risk of Highest risk of pneumothrax, pneumothrax,

• Vein is non-compressibleVein is non-compressible

Thank You.

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