Acceso vascular SHCI Gijón 2018

1. ACCESO VASCULAR
José Miguel Vegas Valle
Unidad de Hemodinámica y Cardiología Intervencionista
Hospital Universitario de Cabueñes, Gijón
@JMVegasValle

2. • Arterial access and haemostasis are fundamental aspects of procedures
performed in the cardiac catheterization laboratory.
• Access-site bleeding and vascular access complications remain a substantial
source of morbidity (and, rarely, mortality).
N Engl J Med 2010;363:1597-1607

3. Radial
Femoral
• Angiography
• PCI
• Rota <1,75
• Complex PCI (Rotablator>=1,75, CTO)
• TAVR
• IABP
• Percutaneous VAD

4. FEMORAL ARTERY
ACCESS

5. Traditional anatomical landmark guidance

6. • Antero-posterior projection
• “Double” fluoroscopy technique
Fluoroscopic guidance

7. Descriptive study in a prospective design of 158 patients
undergoing catheterization from the femoral approach
Catheter Cardiovasc Interv. 2005 Jun;65(2):205-7

8. Zoltan G. Turi. 23rd Fellows Course, TCTMeeting, 2017
Landing zone being between the centreline of the femoral head and a 14
mm inferior limit

9. Abu-Fadel, CCI 2009; 74:533-539

10. Micropuncture
technique
• Particularly when large calibre sheath insertion is being
planned.
• The exact clinical impact remains unclear (randomized
trial discontinued, less bleeding, more retroperitoneal
hemorrhage)
Ben-Dor I, Catheter Cardiovasc Interv, 2012, Feb 14
Cardiology 2014;129: 39–43.

12. Ultrasound guidance
• Identify CFA bifurcation and Inferior epigastric
• Optimal access site: avoid calcification, relationship with femoral head,
important i high CFA bifurcation.
• Learning curve. Problem in obesity.

13. Ultrasound guidance
• n =1,004, retrograde femoral arterial access
• Randomized 1:1 to either fluoroscopic or US guidance
J Am Coll Cardiol Intv 2010; 3:751–8

14. Femoral artery access complications (2-10%)

15. Risk Factors for Bleeding
Non-Modifiable Modifiable

16. Haemostasis
devices
Rao SV, Nat Cardiovasc Review, 2016.133

17. No thrombosing agents
Proglide and Prostar pre-closure
Thrombosing agent
High success rate, short learning curve, short deployment time
Vascular occlusion, infection

18. RADIAL ARTERY
ACCESS

19. Karrowni, et al. JACC Cardiovascular Intv. 2013
Katib et al.JACC Cardiovascular Intv. 2015
Radial vs Femoral Access

21. Radial or Campeau Paradox
Azzalini L, et al. JACC Cardiovasc Interv. 2015;8(14):1854-1864
Hulme et al. Circ Cardiovasc Interv 2017;10:e004279

22. Modified Allen’s Test:
Assessing Ulnar Circulation
RADAR: Abnormal Allen’s Test Should Not Prohibit Radial Access
Palpable Radial Artery Is Enough
J Am Coll Cardiol. 2014 May 13;63(18):1833-41

23. • 1-2 cm above styloid process.
• Palpating the artery
• Spin the wire and advance, stop with any resistance

24. Access technique

25. Access technique
RATE Trial:
Counterpuncture vs.AnteriorApproach, Randomized, n = 400.
Catheter Cardiovasc Interv. 2012 Aug 1;80(2):288-91

26. RAUST Trial – multicenter randomized controlled trial, n=698.
JACC Cardiovasc Interv. 2015 Jan 8.(14)
Ultrasound guidance
Less deep

27. Radial Access Complications

28. Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064
Transradial Access: Mechanisms of Failure

29. Access technique:
Understanding the Catheter’s Course

30. Access technique:
Effect of Inspiration

31. Preventing Spasm

32. Radial Occlusion
• Relative clinical significance
• Prevention:
Anticoagulation
Patent Hemostasis
Catheter Size
Pancholy S, et al CCI 2008;72:335-40
Spaulding, et al. Cathet Cardiovasc Diag 1996;39:365-70
Dahm J et al. CCI 2002; 57:172–176