Vascular access in cardiac catheterization

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  • The more distal you are from the inguinal ligament, the closer the vein is to the artery as the femoral vein begins to dive behind the artery and the saphenous vein comes off the femoral vein.
  • Arm abduction flattens the deltoid bulge Trendelenburg reduces incidence of air embolism Shoulders – as the shoulder falls backward, the space between the clavicle and first rib narrows, making the subclavian vein less accessible Right side preferred – lower pleural dome and thoracic duct on left Junction of the middle and medial thirds of the clavicle – here the vein in just posterior to the clavicle and just above the first rib which acts as a barrier to the pleura.
  • Right side preferred – left IJ is more circuitous, thoracic duct on left Trendelenburg – IJ is distensible Central approach is most common Anterior approach has highest risk of puncturing carotid artery
  • UNC preferred site – in the hospital manual
  • Vascular access in cardiac catheterization

    1. 1. Vascular Access duringCardiac CatheterizationVASCULARACCESS,COMPLICATIONS,MERITS1Dr Vikash M,DM(SR).NIMS,Hyderabad,Indiavikasmedep@yahoo.co.in
    2. 2. VASCULAR ACCESS,COMPLICATIONS,MERITS2
    3. 3. ProfileVASCULAR ACCESSARTERIAL VENOUSVASCULARACCESS,COMPLICATIONS,MERITS3
    4. 4. Retrograde/antegrade.ARTERIALFEMORAL RADIAL BRACHIAL ULNARVASCULARACCESS,COMPLICATIONS,MERITS4
    5. 5. Venous AccesssVENOUSFEMORAL IJV SUBCLAVIANVASCULARACCESS,COMPLICATIONS,MERITS5
    6. 6. TOPIC OVERLAY• SITE• COMPLICATIONS• ADVANTAGES• DIS-ADVANTAGES• COMPARISON• HEMOSTASISVASCULAR ACCESS,COMPLICATIONS,MERITS6
    7. 7. FEMORAL ACCESS -ANATOMYVASCULAR ACCESS,COMPLICATIONS,MERITS7
    8. 8. 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 superioriliac spine to the pubic tubercleVASCULAR ACCESS,COMPLICATIONS,MERITS8
    9. 9. • Some operators rely on the location of the inguinalskin crease to position the skin nicks• The position of the skin crease itself can bemisleading in obese patients• Localization of the skin nick byfluoroscopy• Should show the nick to overlie the inferior borderof the femoral headVASCULAR ACCESS,COMPLICATIONS,MERITS9
    10. 10. COMPLICATIONS• VASCULAR• Hematoma• Pseudo-aneurysm• A-V fistula• Retropertonialhemorrhage• Thrombosis• NON VASCULAR• InfectionsVASCULAR ACCESS,COMPLICATIONS,MERITS10
    11. 11. VASCULAR ACCESS,COMPLICATIONS,MERITS11Nasser TK, Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheralvascular complications following coronary interventional procedures.Clin Cardiol.1995;18:609–614.
    12. 12. PROCEDURAL RISKSTRATIFICATION• 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 , orprocedures that require larger sheath sizes (eg,>8F)VASCULAR ACCESS,COMPLICATIONS,MERITS13
    13. 13. RISK FACTORS• Modifiable• Site of puncture• Number of attempts• Size of sheath• Sheath removal• Medications• Non modifiable• Age• Gender• BMI• Associated disorders -CKDVASCULAR ACCESS,COMPLICATIONS,MERITS14
    14. 14. COMPLICATIONSVASCULAR ACCESS,COMPLICATIONS,MERITS15
    15. 15. • 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 7Fand 8F sheath compared with 6F were associated with morevascular compliactionsVASCULAR ACCESS,COMPLICATIONS,MERITS16
    16. 16. • SHEATH REMOVAL• Time• Compression• Adequate compression just proximal to the site of skinpuncture for at least 30 min is ideal.• MEDICATIONS• Anti platelets – oral , IV• Anti coagulants.VASCULAR ACCESS,COMPLICATIONS,MERITS17
    17. 17. 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 andbleeding complications after percutaneous coronary ,AmHeartJ.2010;159:1139-1146.VASCULAR ACCESS,COMPLICATIONS,MERITS18
    18. 18. • ASSOCIATED CONDITIONS• HYPERTENSION.• Manoukian et al, patients with a higher systolic BP (140vs 120 mm Hg;P= .02) were significantly more likely tohave complications than were patients with lower bloodpressures *• CKD• *Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-daymortality and clinical outcomes in patients with acute coronary syndromes: ananalysis from the ACUITY Trial. J Am Coll Cardiol.2007;49:1362-1368VASCULAR ACCESS,COMPLICATIONS,MERITS19
    19. 19. • HEMATOMA• Definition• Collection of blood in the soft tissue• Incidence• Most common vascular complication• 5- 20 %• Clinical features• Pain, swelling, indurationVASCULAR ACCESS,COMPLICATIONS,MERITS20
    20. 20. VASCULAR ACCESS,COMPLICATIONS,MERITS21
    21. 21. VASCULAR ACCESS,COMPLICATIONS,MERITS22
    22. 22. VASCULAR ACCESS,COMPLICATIONS,MERITS23Rao SV, OGrady K,. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am JCardiol. 2005;96:1200–1206
    23. 23. PSEUDO-ANEURYSM• Definition• A contained rupture; with disruption of all 3 layers ofthe arterial wall.• Occur when an arterial puncture site does notadequately seal.• Pulsatile blood tracks into the perivascular spaceand is contained by the perivascular structures,which then take on the appearance of a sac. VASCULAR ACCESS,COMPLICATIONS,MERITS24
    24. 24. VASCULAR ACCESS,COMPLICATIONS,MERITS25
    25. 25. • One of the common vascular complications of cardiac andperipheral angiographic procedures.• The incidence after diagnostic catheterization ranges from0.05% to 2%.• When coronary or peripheral intervention is performed, theincidence increases to 2% to 6%.*• *Hessel SJ, Adams DF, Abrams HL. Complications of angiography. Radiology. 1981; 138: 273–281.VASCULAR ACCESS,COMPLICATIONS,MERITS26
    26. 26. VASCULAR ACCESS,COMPLICATIONS,MERITS27
    27. 27. • DIAGNOSIS• CLINICAL• Pain and swelling at puncture site.• Swelling from a large aneurysm may also lead to compressionof nerves and vessels with associated neuropathy, venousthrombosis, 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 pulsatilemass or the presence of a bruit.VASCULAR ACCESS,COMPLICATIONS,MERITS28
    28. 28. • However, it should be noted that none of these physicalfindings may be present.• Pain that is disproportionate to that expectedafter a PCI should undergo an doppler toexclude pseudoaneurysm regardless of thepresence of a bruit.VASCULAR ACCESS,COMPLICATIONS,MERITS29
    29. 29. • IMAGING• Duplex ultrasound• The sensitivity is 94% with a specificity of 97%.• Echolucent sac that expands and contracts with cardiaccontraction .• On color Doppler, there is a swirling flow pattern withturbulence in the chamber(s), there may be 1 or morechambers.• 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 obtainedVASCULAR ACCESS,COMPLICATIONS,MERITS30
    30. 30. VASCULAR ACCESS,COMPLICATIONS,MERITS31
    31. 31. • TREATMENT• Until the early 1990s, the only treatment availablewas surgery.• Since that time, USG compression, USG guidedthrombin injection, FemStop compression devices,coil insertion, fibrin, adhesives, or balloon occlusionhave been used with variable success.VASCULAR ACCESS,COMPLICATIONS,MERITS32
    32. 32. • USG guided compression• In 1991, Fellmeth and associates introduced a safe andnoninvasive method to treat PSA.• Success rate of 75% to 98%.• The ultrasound transducer is positioned and pressure isapplied to compress the chamber and tract while flow in thenative artery is allowed.• Direct ultrasound visualization confirms cessation of flow.• Compression is usually held for cycles of 10 minutesVASCULAR ACCESS,COMPLICATIONS,MERITS33
    33. 33. • The vertical angle created by the device does notallow selective compression of the chamber andtract.• Nonselective compression leads to longercompression times, more discomfort to the patient,and a lower success rate, in addition to an increasein complications such as DVT• Body habitus, size, depth, and number ofchambers, as well as concurrent anticoagulationmay limit the successVASCULAR ACCESS,COMPLICATIONS,MERITS34
    34. 34. • In patients on anticoagulation, the success is 30% to 73%.• In 100 cases of pseudoaneurysm, was successful in 94patients (94%), which included 30 (86%) of 35 patients whoreceived anticoagulation and 64 (98%) of 65 patients whowere not on anticoagulation.*• Katzenschlager R, Ugurluoglu A,. Incidence of pseudoaneurysm after diagnostic and therapeutic angiography.Radiology.1995;195:463–466VASCULAR ACCESS,COMPLICATIONS,MERITS35
    35. 35. • DISADVANTAGES• Long time - averagecompression time toachieve occlusion was 33min with a range of 10 to120 min*• Painful• Position• Operator• *Cox GS, Young JR, Gray BR, Grubb MW,Hertzer NR. Ultrasound-guided compressionrepair of postcatheterizationpseudoaneurysms:results of treatment in onehundred cases.J Vasc Surg. 1994;19:683–686• COMPLICATIONS• Vasovagal reactions,• Rupture,• Skin necrosis, and• DVTVASCULAR ACCESS,COMPLICATIONS,MERITS36
    36. 36. • Ultrasound-Guided Thrombin Injection• The principle - thrombin is important in the conversion offibrinogen to fibrin.• Thus a fibrin clot is formed instantaneously (even in thepresence 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 JRoentgenol. 1986;147:383–387.VASCULAR ACCESS,COMPLICATIONS,MERITS37
    37. 37. • Complications• DVT (if the thrombin is inadvertently injected into the vein),• Pulmonary embolism• Thrombosis of the artery.• Allergic reactions and anaphylaxis.• PARA ANEURYSMAL SALINE INJECTIONVASCULAR ACCESS,COMPLICATIONS,MERITS38
    38. 38. VASCULAR ACCESS,COMPLICATIONS,MERITS39------
    39. 39. • ENDOLUMINAL MANAGEMET• serves to exclude a pseudoaneurysm from the circulation• Depends on the size of the pseudoaneurysmal neck and theexpendability of the donor artery .• 2 broad categories: embolization and stent• The width of the neck relative to the diameter of the donorartery is the determining factor.• A vital donor artery may be embolized in certain emergentsituations (eg, rupture with active bleeding); however, distalblood flow must then be restored by means of a surgicalbypass procedureVASCULAR ACCESS,COMPLICATIONS,MERITS40
    40. 40. • COIL CLOSURE• If the neck is narrow,• made of either stainless steel or platinum.• Polyester fibers are incorporated the coil to increase itsthrombogenicity• Disadvantage• Potential for recanalization.• COVERED STENT• Indications Large neck & larger artery• Contraindication – mycotic aneurysmVASCULAR ACCESS,COMPLICATIONS,MERITS41
    41. 41. SURGERYVASCULAR ACCESS,COMPLICATIONS,MERITS42
    42. 42. • Disadvantages of surgery• Requires anesthesia• An incision usually in the groin, an area known tobecome infected easily after a surgical procedure.• Lumsden and colleagues reported a surgicalcomplication rate of 20% repair.• Complications included bleeding, infection, neuralgia,prolonged hospital stayVASCULAR ACCESS,COMPLICATIONS,MERITS43
    43. 43. • Prevention• More complex procedures and more potent antithrombotictherapy have led to the occurrence of more frequentaneurysm formation.• The most important strategies to prevent formation are:• ● Assure a needle puncture in the proper location achievevascular access on the first puncture without access throughthe posterior wall.• ● Appropriate groin compression after sheath removal.VASCULAR ACCESS,COMPLICATIONS,MERITS44
    44. 44. RETRO-PERITONEALHEMATOMAVASCULAR ACCESS,COMPLICATIONS,MERITS45
    45. 45. RETROPERITONEALHEMATOMA• Incidence• 0.1 – 0.2 %• CAUSES• High puncture• Inadvertent puncture of the posterior wall of the femoral oriliac artery• Exacerbated by the fact that patients receive antiplatelets,anticoagulants• Removal of catheter without wireVASCULAR ACCESS,COMPLICATIONS,MERITS46
    46. 46. • Retroperitoneal Hematoma After PercutaneousCoronary Intervention: Prevalence, Risk Factors,Management, Outcomes, and Predictors ofMortality• Volume 3, Issue 8, August 2010VASCULAR ACCESS,COMPLICATIONS,MERITS47Retroperitoneal Hematoma After Percutaneous Coronary Intervention: Prevalence, Risk Factors,Management, Outcomes, and Predictors of MortalityVolume 3, Issue 8, August 2010 , JACC
    47. 47. • 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 transientlyimproves with administration of fluids• Unable to mount tachycardia because of beta-blockers, andthese patients usually become hypotensive with no change intheir heart rateVASCULAR ACCESS,COMPLICATIONS,MERITS49
    48. 48. • Retroperitoneal haematoma near or within theiliopsoas muscle presents as femoral neuropathy,begins with groin pain or leg weakness• Sudden onset severe pain in the affected groin andhip• Iliopsoas spasm often results in the flexion andexternal rotation of the hip, attempt to extend thehip results in severe pain.VASCULAR ACCESS,COMPLICATIONS,MERITS50
    49. 49. • DIAGNOSIS• CBP – fall in Hb• IMAGING• Ultrasonography of the abdomen and pelvis may detecthaematoma,.• Limited by patients discomfort, body habitus, underlyingbowel gas .• Free fluid or blood in the retroperitoneum pass into theabdominal or pelvic cavityVASCULAR ACCESS,COMPLICATIONS,MERITS51
    50. 50. • CT SCAN• Type, site and extent of the fluid collections.• Active bleeding can be seen as extravasation of contrastmaterial,• CT angiography may show the site of the bleed and contrastoutside the vessels.• MRI• Useful in patients presenting with femoral neuropathy, as MRIhelps to rule out nerve root compression or spinal problems.• Shows the site of the bleed.• ANGIOGRAPHY• Haemodynamically unstable, view to selective embolisation orplacement of a stent graft is indicatedVASCULAR ACCESS,COMPLICATIONS,MERITS52
    51. 51. • MANAGEMENT• Fluid resuscitation, blood transfusion and normalisationof coagulation factor.• No specific guidelines to suggest when to intervene withendovascular or open surgery to stop the bleeding.• If the patient is haemodynamically stable with noevidence of on-going bleeding, conservativemanagement is recommended.VASCULAR ACCESS,COMPLICATIONS,MERITS53
    52. 52. • ENDOVASCULAR TREATMENT• Indications - Panetta et al*• Hemodynamic instablitiy• Hemodynamiclly stable- four or more units of bloodtransfusion 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 themanagement of retroperitoneal haematoma• * Panetta T, Sclafani SJ, Goldstein AS et al. Percutaneous transcatheter embolization for massivebleeding from pelvic fractures. J Trauma 1985; 25: 1021-9VASCULAR ACCESS,COMPLICATIONS,MERITS54
    53. 53. • OPEN SURGERY• Indications• Unstable despite adequate fluid and blood productresuscitation,• Failed embloization / stent• Abdominal compartment syndromeVASCULAR ACCESS,COMPLICATIONS,MERITS55
    54. 54. A-V FISTULAVASCULAR ACCESS,COMPLICATIONS,MERITS56
    55. 55. • DEFINITION• Abnormal connections between the arterial and venoussystem that bypass the normal anatomic capillary beds• RISK FACTORS• Female Hypertension• Anticoagulation , Low or multiple punctures• Obesity Advanced age.VASCULAR ACCESS,COMPLICATIONS,MERITS57
    56. 56. • Low groin puncture –• Likely to access SFA just distal to the CFA bifurcation.• The profunda femoris vein passes between the SFA and theprofunda femoris artery• Punctures to the proximal SFA are particularly vulnerable tocausing AVF because the needle tip frequently punctures theunderlying profunda vein.• Sheath placement –• Dilation of the tract between an artery and vein reduces thelikelihood that the communication will close.• The larger the sheath size, the greater the risk for AVFVASCULAR ACCESS,COMPLICATIONS,MERITS58
    57. 57. • INCIDENCE• 0.I to 1 %*• CLINICAL FEATURES• Initially silent.• Two days to several months• Abnormal sensation in the groin, fatigue, new onset orworsened lower extremity ischemia.• *Glaser RL, McKellar D, Scher KS. Arteriovenous fistulas after cardiac catheterization. Arch Surg 1989; 124:1313.VASCULAR ACCESS,COMPLICATIONS,MERITS59
    58. 58. • Palpation and auscultation of the affected vesseldemonstrates a machinery-like murmur, bruit, hematomaor pulsatile mass.• The patient may exhibit lower extremity edema• CONSEQUENCES• DVT, nerve compression and new onset or worsenedvaricose veins• The most significant condition related to AVF is high-output heart failureVASCULAR ACCESS,COMPLICATIONS,MERITS60
    59. 59. • 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 veinVASCULAR ACCESS,COMPLICATIONS,MERITS61
    60. 60. • TREATMENT  • Most small asymptomatic AVFs thrombose spontaneously and thusshould be observed• INDICATIONS:• Clinical symptoms related to the AVF• Steal syndrome causing claudication or distal limb ischemia• Significant edema or venous insufficiency due to venoushypertension• Heart failure due to a high-flow fistula• Progressive enlargement under ultrasound surveillance• Iatrogenic AVFs that do not seal spontaneouslyVASCULAR ACCESS,COMPLICATIONS,MERITS62
    61. 61. • Ultrasound-guided compression• Compression of sufficient force to abolish flow through the fistulawithout unduly reducing distal perfusion• Painful• Failure is frequent because the fistula track is too short or the AVfistula 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• SurgeryVASCULAR ACCESS,COMPLICATIONS,MERITS63
    62. 62. VASCULAR ACCESS,COMPLICATIONS,MERITS64
    63. 63. VASCULAR ACCESS,COMPLICATIONS,MERITS65
    64. 64. • Incidence• 0.5 – 1%• Diagnosis• Doppler studies• Peripheral angiogram• Treatment• Small – spontaneous lysis• Large, limb threatening – thrombolysis / thrombectomyVASCULAR ACCESS,COMPLICATIONS,MERITS66
    65. 65. • INFECTIONS• Incidence <1%,• Bacterial infections occurred in 0.11% at a median of 1.7 days after the procedure*• CLINICAL FEATURES• 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;161:2110–2115VASCULAR ACCESS,COMPLICATIONS,MERITS67
    66. 66. • Causes• Improper shaving• Improper scrubbing• TREATMENT• Antibiotics• PREVENTION• Appropriate shaving / scrubbing.• Using sterile drapes.VASCULAR ACCESS,COMPLICATIONS,MERITS68
    67. 67. • FEMORAL NEUROPATHY• Incidence• 0.1 – 0.3%• Mechanism• Compression of the femoral nerve during puncture or byhematoma• Clinical features• Tingling, numbness, weakness,• Treatment• Usually self remittingVASCULAR ACCESS,COMPLICATIONS,MERITS69
    68. 68. RADIAL ACCESSVASCULAR ACCESS,COMPLICATIONS,MERITS70
    69. 69. VASCULAR ACCESS,COMPLICATIONS,MERITS71
    70. 70. VASCULAR ACCESS,COMPLICATIONS,MERITS72
    71. 71. PRE -REQUISITESVASCULAR ACCESS,COMPLICATIONS,MERITS73
    72. 72. • Diagnostic Accuracy• Ruengsakulrach et al.compared the Modified Allen’s Test withDoppler and found the Modified Allen’s Test to have asensitivity of 100% and specificity of 97%.• Glavin and Jones compared the Modified Allen’s Test withDoppler a sensitivity of 87% to correctly diagnose thepresence of ulnar artery blood flow and a negative predictivevalue of only 0.18; i.e., 80% of all abnormal Modified Allen’sTest results in their study were incorrect.• The diagnostic accuracy of the Modified Allen’s Test,compared with ultrasound, was only 80%, with a sensitivity of76% and a specificity of 82%VASCULAR ACCESS,COMPLICATIONS,MERITS74
    73. 73. BARBEAU TESTVASCULAR ACCESS,COMPLICATIONS,MERITS75
    74. 74. COMPLICATIONSVASCULAR ACCESS,COMPLICATIONS,MERITS76
    75. 75. • COMPLICATIONS• PROCEDURAL• Vaso vagal reaction• Spasm• Perforation / Dissection.• POST PROCEDURE• Occlusion• Compartment Syndrome• Pseudoaneurysm•VASCULAR ACCESS,COMPLICATIONS,MERITS77
    76. 76. • VASOVAGAL REACTIONS• Due to pain, anxiety• PREVENTION• Preprocedural sedation, analgesia, and adequatelocal infiltration anesthesia decreases pain, anxiety,and associated vagal outputVASCULAR ACCESS,COMPLICATIONS,MERITS78
    77. 77. • SPASM• Induced by the introduction of a sheath or catheter• Mechanism• Prominent medial layer that is largely dominated by alpha-1receptors.• Increased levels of catecholamines cause spasm• Risk factors• Female young age small artery• Anxiety Unsuccessful guide wire passage• Multiple catheter exchanges, prolonged procedureVASCULAR ACCESS,COMPLICATIONS,MERITS79
    78. 78. • Prevention• Adequate vasodilatory cocktail containing• NTG 100 – 200 mcg + 2.5 mg verapamil, + 40 U/Kg heparinmax 5000 u• Hydrophilic catheters• Smaller sheaths• TREATMENT• Additional doses of CCB, NTG,• More analgesia / sedation• Warm compressVASCULAR ACCESS,COMPLICATIONS,MERITS80
    79. 79. • 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 thepuncture site, but result from wire damage to vessels andsmall perforations• Hamon M, Rasmussen LH, Manoukian SV, et al. Choice of arterial access site andoutcomes in patients with acute coronary syndromes managed with an early invasivestrategy: The ACUITY trial. EuroIntervention 2009;5:115–120VASCULAR ACCESS,COMPLICATIONS,MERITS81
    80. 80. • 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 oftransradial approach. J Interv Cardiol. 2008;21:380-384VASCULAR ACCESS,COMPLICATIONS,MERITS82
    81. 81. • 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.VASCULAR ACCESS,COMPLICATIONS,MERITS83
    82. 82. • AVULSION• A sheath entrapped by arterial spasm should never be forciblyremoved 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 benecessary.• In refractory cases, axillary nerve blocks or generalanesthesia may be required for catheter removalVASCULAR ACCESS,COMPLICATIONS,MERITS84
    83. 83. • DISSECTION / PERFORATION• Angiography of the arm should be performed if there isdifficulty with wire or catheter advancement since failure toidentify the problem may lead to vessel perforation ordissection.• Rather than aborting the procedure, it is worth trying tocarefully re-cross them with a soft 0.014 angioplasty wire.• If this attempt is successful, the catheter will usually seal thedissection or perforation, an• Aborting the procedure will leave an unsealed dissection orperforation that may be difficult to controlVASCULAR ACCESS,COMPLICATIONS,MERITS85
    84. 84. • 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.CathetCardiovasc Diagn 2007;40:156–158VASCULAR ACCESS,COMPLICATIONS,MERITS86
    85. 85. • Consequences• Usually benign and asymptomatic due to the dual bloodsupply to the hand• Hand ischemia, gangrene• Spontaneous recanalizaton appears to occur in 50% ofpatients• Prevention• Pre-procedural heparin > 5000u, without heparin 60-70%, with2-6%*• 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.VASCULAR ACCESS,COMPLICATIONS,MERITS87
    86. 86. VASCULAR ACCESS,COMPLICATIONS,MERITS88
    87. 87. VASCULAR ACCESS,COMPLICATIONS,MERITS90
    88. 88. VASCULAR ACCESS,COMPLICATIONS,MERITS91
    89. 89. VASCULAR ACCESS,COMPLICATIONS,MERITS92
    90. 90. VASCULAR ACCESS,COMPLICATIONS,MERITS93
    91. 91. VASCULAR ACCESS,COMPLICATIONS,MERITS94
    92. 92. VASCULAR ACCESS,COMPLICATIONS,MERITS952011 ACCF/AHA/SCAI/ESC Guideline for PercutaneousCoronary InterventionClass IIa1. The use of radial artery access can be useful todecrease access site complications.
    93. 93. • CONDITIONS WHEREREADIAL ACCESS SHOULD BEPREFERRED• Absent femoral pulses• Femoral bruit• Femoral artery graft surgery• Extensive inguinal scarring from pastsurgery• Surgery / radiation treatment nearinguinal area• Extensively tortuous iliac system / lowerabdominal aorta• Abdominal aortic aneurysm• Patient request• CONDITIONS WHEREREADIAL ACCESS SHOULD BEAVOIDED• Radial artery being considered forCABG / AV fistula• Upper limb atherosclerosis, extremetortuosity, Raynaud’s or Burger’sdisease.• Need for 7F or larger sheath.VASCULAR ACCESS,COMPLICATIONS,MERITS96
    94. 94. FEMORAL vs RADIALAPPROACHVASCULAR ACCESS,COMPLICATIONS,MERITS97
    95. 95. VASCULAR ACCESS,COMPLICATIONS,MERITS98
    96. 96. VASCULAR ACCESS,COMPLICATIONS,MERITS99
    97. 97. VASCULAR ACCESS,COMPLICATIONS,MERITS100
    98. 98. VASCULAR ACCESS,COMPLICATIONS,MERITS101
    99. 99. VASCULAR ACCESS,COMPLICATIONS,MERITS102
    100. 100. VASCULAR ACCESS,COMPLICATIONS,MERITS103
    101. 101. VASCULAR ACCESS,COMPLICATIONS,MERITS104Primary and Secondary OutcomesRadial(n=3507)%Femoral(n=3514)%HRHR 95% CI95% CI PPPrimary OutcomeDeath, MI, Stroke,Major Bleed3.7 4.0 0.920.92 0.72-1.170.72-1.17 0.500.50Secondary OutcomesDeath, MI, Stroke 3.2 3.2 0.980.98 0.77-1.280.77-1.28 0.900.90Major Bleeding0.7 0.9 0.730.73 0.43-1.230.43-1.23 0.230.23
    102. 102. VASCULAR ACCESS,COMPLICATIONS,MERITS105Other OutcomesRadial(n=3507)Femoral(n=3514)PPAccess site Cross-over (%) 7.6 2.0 <0.0001<0.0001PCI Procedure duration (min) 35 34 0.620.62Fluoroscopy time (min) 9.3 8.0 <0.0001<0.0001Persistent pain at access site>2 weeks (%)2.6 3.1 0.220.22Patient prefers assignedaccess site for nextprocedure (%)90 49 <0.0001<0.0001
    103. 103. VASCULAR ACCESS,COMPLICATIONS,MERITS106
    104. 104. VASCULAR ACCESS,COMPLICATIONS,MERITS107
    105. 105. BRACHIAL ARTERYACCESS• SITE OF PUNCTURE• Medial aspect of cubital fossa, 2-3 cm above theelbow crease• INDICATIONS• Renal / lower limb artery angioplasty• COMPLICATIONS• HematomaVASCULAR ACCESS,COMPLICATIONS,MERITS109
    106. 106. • 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 )VASCULAR ACCESS,COMPLICATIONS,MERITS110
    107. 107. VASCULAR ACCESS,COMPLICATIONS,MERITS111
    108. 108. 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 % .VASCULAR ACCESS,COMPLICATIONS,MERITS112
    109. 109. HEMOSTASIS• MANUAL COMPRESSION• MECHANICAL COMPRESSION• TOPICAL HEMOSTATIC AIDS• VASCULAR CLOSURE DEVICES1. Active2. Passive .VASCULAR ACCESS,COMPLICATIONS,MERITS113
    110. 110. • 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 fatigueVASCULAR ACCESS,COMPLICATIONS,MERITS114
    111. 111. VASCULAR ACCESS,COMPLICATIONS,MERITS115
    112. 112. FEM-STOPVASCULAR 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.
    113. 113. CLAMP-EASEVASCULAR ACCESS,COMPLICATIONS,MERITS117METAL PADC-ARMPRESSURE PAD
    114. 114. • Advantages• More effective compression• Dis-advantages• Doesn’t decrease time to hemostasis / ambulation.• Patient discomfortVASCULAR ACCESS,COMPLICATIONS,MERITS118
    115. 115. TOPICAL HEMOSTATICAIDS• A variety of topical patches, pads, bandages, and powders areavailable for use to assist with hemostasis with manualcompression.• 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 compressionVASCULAR ACCESS,COMPLICATIONS,MERITS119
    116. 116. VASCULAR ACCESS,COMPLICATIONS,MERITS120
    117. 117. VASCULAR CLOSUREDEVICES• Introduced in 1995 to decrease vascularcomplications and reduce the time tohemostasis and ambulation.• CLASSIFICATION• PASSIVE• enhance hemostasis with prothromboticmaterial or mechanical compression, but do notachieve prompt hemostasis or shorten the timeto ambulation• ACTIVEVASCULAR ACCESS,COMPLICATIONS,MERITS121
    118. 118. VASCULAR ACCESS,COMPLICATIONS,MERITS122
    119. 119. ANGIO-SEAL
    120. 120. • 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 thesite.• 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.VASCULAR ACCESS,COMPLICATIONS,MERITS124
    121. 121. • Disadvantages• The intravascular anchor has the potential to furtherobstruct a heavily diseased vessel.• Embolization of the intravascular anchor.• Repeat access of the same vessel within 90 days ofdevice deployment should be avoided using thesame puncture site.• Infection.VASCULAR ACCESS,COMPLICATIONS,MERITS125
    122. 122. STAR CLOSE DEVICE
    123. 123. • 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 atany 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.VASCULAR ACCESS,COMPLICATIONS,MERITS128
    124. 124. • Devices:2011 ACCF/AHA/SCAI Guideline for PercutaneousCoronary Intervention Recommendations• Class I• 1. Patients considered for vascular closure devices should undergo a femoralangiogram to ensure their anatomic suitability for deployment.• Class IIa• 1. The use of vascular closure devices is reasonable for the purposes ofachieving faster hemostasis and earlier ambulation• Class III: NO BENEFIT• 1. The routine use of vascular closure devices is not recommended for thepurpose of decreasing vascular complications
    125. 125. VASCULAR ACCESS,COMPLICATIONS,MERITS134TR band
    126. 126. VASCULAR ACCESS,COMPLICATIONS,MERITS136
    127. 127. FEMORAL VENOUS ACCESSANATOMYVASCULAR ACCESS,COMPLICATIONS,MERITS137
    128. 128. • 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
    129. 129. COMPLICATIONSLocal HematomaRetroperitoneal hematomaPseudoaneurysmAV fistulaFemoral neuropathyInfectionDVTVASCULAR ACCESS,COMPLICATIONS,MERITS139
    130. 130. SUBCLAVIAN VENOUSACCESS• INDICATIONS• PPI leads• TPI• IVC filter• Central venous access• ChemoportVASCULAR ACCESS,COMPLICATIONS,MERITS140
    131. 131. • 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 deltopectoralgroove• Needle should be parallel to skin• Aim towards the supraclavicular notch and just underthe clavicleVASCULAR ACCESS,COMPLICATIONS,MERITS141
    132. 132. • COMPLICATIONS• Infection Bleeding Pneumothorax• Thrombosis Air embolization Brachial plexusinjury• AVOIDED IN• Coagulopathy Thrombloysis Chest walldeformityVASCULAR ACCESS,COMPLICATIONS,MERITS143
    133. 133. IJV ACCESS• INDICATIONS• TPI• Central venous line• Positioning• Right side preferred• Trendelenburg position• Head turned slightly away from side ofvenipunctureVASCULAR ACCESS,COMPLICATIONS,MERITS144
    134. 134. Needle placement• Central approach• Locate the triangle formed by the clavicle and thesternal 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 medialborder of the lateral head of the SCM muscle• Vein is 1-1.5 cm deep, avoid deep probing in theneckVASCULAR ACCESS,COMPLICATIONS,MERITS145
    135. 135. COMPLICATIONS• Infection Bleeding – airway compression• Thrombosis Air embolization Pneumothorax• AVOIDED IN• Trendelenburg tilt is not possible – pulmonaryedema• Child < 1 yr who cannot be sedated / paralysedVASCULAR ACCESS,COMPLICATIONS,MERITS147
    136. 136. COMPLICATIONS
    137. 137. VASCULAR ACCESS,COMPLICATIONS,MERITS149Location Advantage DisadvantageInternalJugular• Bleeding can beBleeding can berecognizedrecognizedand controlledand controlled• Malposition is rareMalposition is rare• Less risk ofLess risk ofpneumothoraxpneumothorax• Risk of carotid arteryRisk of carotid arterypuncturepuncture• Pneumothorax possiblePneumothorax possibleFemoral • Easy to find veinEasy to find vein• No risk ofNo risk ofpneumothoraxpneumothorax• Preferred site forPreferred site foremergencies and CPRemergencies and CPR• Fewer badFewer badcomplicationscomplications• Highest risk of infectionHighest risk of infection• Risk of DVTRisk of DVT• Not good for ambulatoryNot good for ambulatorypatientspatientsSubclavian • Most comfortable forMost comfortable forconscious patientsconscious patients• Highest risk ofHighest risk ofpneumothrax,pneumothrax,• Vein is non-compressibleVein is non-compressible
    138. 138. Thank You.VASCULAR ACCESS,COMPLICATIONS,MERITS150

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