Vascular access in cardiac catheterization

Vascular Access during
Cardiac Catheterization
VASCULAR
ACCESS,COMPLICATIONS,MERITS
1
Dr Vikash M,DM(SR).
NIMS,Hyderabad,India
vikasmedep@yahoo.co.in

VASCULAR ACCESS,COMPLICATIONS,MERITS2

Profile
VASCULAR ACCESS
ARTERIAL VENOUS
VASCULAR
3

Retrograde/antegrade.
ARTERIAL
FEMORAL RADIAL BRACHIAL ULNAR
VASCULAR
4

Venous Accesss
VENOUS
FEMORAL IJV SUBCLAVIAN
VASCULAR
5

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. Peripheral
vascular 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, induration

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 minutes

• 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 wire

• 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 Mortality
Volume 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.

• 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 spontaneously

• 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

• 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

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 compress

• 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;5:115–120

• 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 IIa
1. The use of radial artery access can be useful to
decrease 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)
PP
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 removal
MAP for 15 minMAP for 15 min
Gradually reduce to 30mmHg over 2 hrs and remove.Gradually reduce to 30mmHg over 2 hrs and remove.

CLAMP-EASE
METAL PAD
C-ARM
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

• 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.

• 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 umbilicus

COMPLICATIONS
Local Hematoma
Retroperitoneal hematoma
Pseudoaneurysm
AV fistula
Femoral neuropathy
Infection
DVT

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 clavicle

• 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
venipuncture

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

Location Advantage Disadvantage
Internal
Jugular
• Bleeding can beBleeding can be
recognizedrecognized
and controlledand controlled
• Malposition is rareMalposition is rare
• Less risk ofLess risk of
pneumothoraxpneumothorax
• Risk of carotid arteryRisk of carotid artery
puncturepuncture
• Pneumothorax possiblePneumothorax possible
Femoral • Easy to find veinEasy to find vein
• No risk ofNo risk of
pneumothoraxpneumothorax
• Preferred site forPreferred site for
emergencies and CPRemergencies and CPR
• Fewer badFewer bad
complicationscomplications
• Highest risk of infectionHighest risk of infection
• Risk of DVTRisk of DVT
• Not good for ambulatoryNot good for ambulatory
patientspatients
Subclavian • Most comfortable forMost comfortable for
conscious patientsconscious patients
• Highest risk ofHighest risk of
pneumothrax,pneumothrax,
• Vein is non-compressibleVein is non-compressible

Thank You.

Vascular access in cardiac catheterization

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