This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
Catheters used in Angiography & angioplastySatya Shukla
Guide catheters are essential tools for Pecutaneous
Coronary Intervention
• Understanding construction, design & performance
characteristics facilitate their appropriate selection
• Selection of Guide catheters seems elementary but
makes the difference between a successful and failed
PCI procedure
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
Catheters used in Angiography & angioplastySatya Shukla
Guide catheters are essential tools for Pecutaneous
Coronary Intervention
• Understanding construction, design & performance
characteristics facilitate their appropriate selection
• Selection of Guide catheters seems elementary but
makes the difference between a successful and failed
PCI procedure
The major driving factor for these markets would be the increasing demand for minimally invasive percutaneous endovascular treatment. As the incidence cases of coronary and peripheral artery diseases continue to rise in the coming years along with increasing trends in co-morbid conditions such as obesity and diabetes, the vascular interventional devices market for treating these diseases would show significant growth in the forecast period. The principal advantage of minimally invasive endovascular procedures over surgery is short recovery time, short length scars, low risk of infection, bleeding, and shorter hospital stays.
Carotid artery disease is commonly seen in association with atherosclerosis and complicate the situation. clearcut guidelines with necessary surgical details are provided in presentations.
The principles of vascular repair with sutures were established in the first decade of the 20th century by Alexis Carrel, who in 1912 was awarded the Nobel Prize for medicine for his work .Since then, technical refinements of suture materials have made possible surgical reconstruction of most arteries from the root of the aorta to microvascular anastomosis or repair of the smallest vessels, e.g., digital arteries or those on the surface of the brain.
Minimal access surgery is a routine surgical practice due to its minimal invasive and associated advantages. It has a lot of advantages but not devoid of complication, one of the major concerned complication is the trocar site herniation (TSH).
Wellens syndrome. Wellens syndrome (also referred to as LAD coronary T-wave syndrome) refers to an ECG pattern specific for critical stenosis of the proximal left anterior descending artery. The anomalies described occur in patients with recent anginal chest pain, and do not have chest pain when the ECG is recorded.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
A post-splenectomy patient suffers from frequent infections due to capsulated bacteria like Streptococcus
pneumoniae, Hemophilus influenzae, and Neisseria meningitidis despite vaccination because of a lack of
memory B lymphocytes. Pacemaker implantation after splenectomy is less common. Our patient underwent
splenectomy for splenic rupture after a road traffic accident. He developed a complete heart block after
seven years, during which a dual-chamber pacemaker was implanted. However, he was operated on seven
times to treat the complication related to that pacemaker over a period of one year because of various
reasons, which have been shared in this case report. The clinical translation of this interesting observation
is that, though the pacemaker implantation procedure is a well-established procedure, the procedural
outcome is influenced by patient factors like the absence of a spleen, procedural factors like septic measures,
and device factors like the reuse of an already-used pacemaker or leads.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
3. Active vs Passive
Passive Active
Enhance hemostasis with
prothrombotic material
or mechanical
compression but do not
achieve prompt
hemostasis or shorten the
time to ambulation
Categorized as suture
devices, collagen plug
devices or clips
5. Features Manual compression Device Closure
Standard of
care
Gold standard alternative
Benefit Best for diagnostic and complex
anatomy
improve patient comfort, free
medical staff resources and
shorten the time needed for
hemostasis, ambulation and
discharge.
Limitation The need to interrupt
anticoagulation, prolonged bed
rest, patient discomfort and
time demands for healthcare
providers
they may increase the risks of
infection and leg ischemia
7. Manual Compression
The sheath can be removed immediately if no heparin or diagnostic
Delayed (often 2–4 hours) after an interventional procedure to allow the activated
clotting time to decrease to < 170 seconds
Firm manual pressure is placed over the femoral artery, typically 2 cm proximal to
the skin entry site
Firm pressure is held for 10 minutes, then slightly less firm pressure for 2–5
minutes
Then light pressure while applying a pressure dressing
Pressure should be maintained longer for larger sheath sizes and in the setting of
anticoagulation
If bleeding persists, MC is maintained for an additional 15 minutes
Once haemostasis is achieved bed rest is recommended for 6–8 hours
When VCDs fail, MC is used to achieve hemostasis.
8. Passive Vascular Closure Devices
Hemostasis pads
Chito-Seal
Clo-Sur PAD
SyvekPatch
Dankers
Neptune Pad
D-Stat Dry
Coated with procoagulant material to enhance coagulation and hemostasis. Technical failure was reported in 5–19% of Clo-Sur PAD cases, and in 8% of D-Stat Dry cases. Compared with MC, no difference in complication rates was
observed with the Chito-Seal, Clo-Sur PAD or SyvekPatch, whereas the D-Stat Dry reuced vascular complication rates and the Neptune Pad increased the risk of minor bleeding (15% vs. 3%). Compared with MC, the Neptune Pad and
Clo-Sur PADimproved patient and physician comfort. Hemostasis pads did not shorten the time to ambulation compared with MC. The clinical utility of hemostasis pads is questionable since their influence on hemostasis is small and
they do not reduce the time to ambulation.
Compression devices: FemoStop and Clamp Ease.
The FemoStop plus Compression System
A belt that wraps around the patient and a transparent, inflatable pneumatic bubble.A hemostatic dressing is placed on the arteriotomy site, then the bubble is positioned 1 cm above the arteriotomy. The bubble is
inflated to ~70 mmHg while the sheath is removed, then to suprasystolic pressure for ~2 minutes, and it is deflated to the mean arterial pressure for 15 minutes (pedal pulse is palpable), then slowly deflated to 30
mmHg for 1–2 hours, and is finally carefully removed.
The Clamp Ease device
A flat metal pad that is placed under the patient for stability, and a C-arm clamp with a translucent pressure pad.As the sheath is removed, the C-arm clamp is lowered so that the pressure pad compresses the access
site. These compression devices have high technical success rates approaching 100%, but do not shorten the time to hemostasis, ambulation or discharge compared with MC
Major complication
Less
9. Active Vascular Closure Devices
The Cardiva Catalyst (Cardiva Medical, Inc., Sunnyvale, California)
Hemostasis through the existing arterial sheath
MC is still required
indicated for diagnostic or interventional procedures with sheath sizes up to 7 Fr
The device is inserted through the existing sheath. Once the tip is within the arterial lumen, a
conformable 6.5 mm disk is deployed similar to an umbrella. The sheath is removed and the disk
is gently pulled against the arterial wall where it is held in place by a tension clip. The disk,
which is coated with protamine sulfate, provides temporary intravascular tamponade, facilitating
physiologic vessel contraction and thrombosis. After 15 minutes of “dwell time” (120 minutes for
interventional cases) the device is withdrawn and light MC is held for 5 minutes. The Cardiva
Catalyst successfully facilitated hemostasis in 99% of 96 patients undergoing diagnostic
catheterization with a 5 Fr sheath without any major vascular complications and with minor
complications in 5% (rebleeding during bed rest).Most patients can ambulate 90 minutes after a
diagnostic procedure with this device. The Cardiva Catalyst device does not leave any material
behind in the body which minimizes the risk of ischemic and infectious complications and allows
for repeat vascular access.
10. The Angio-Seal device
a small, flat, absorbable rectangular anchor (2 x 10 mm) an absorbable collagen plug and an
absorbable suture . First, the existing arterial sheath is exchanged for a specially designed 6 Fr or 8
Fr sheath with an arteriotomy locator. Once blood return confirms proper positioning within the
arterial lumen, the sheath is held firmly in place while the guidewire and arteriotomy locator are
removed. The Angio-Seal device is inserted into the sheath until it snaps in place. Next, the anchor
is deployed and pulled back against the arterial wall. As the device is withdrawn further the
collagen plug is exposed just outside the arterial wall and the remainder of the device is removed
from the tissue track. Finally, the suture which connects the anchor, the collagen plug, and the
device is cut below skin level leaving behind only the anchor, collagen plug and suture, all of which
are absorbable. Although Angio-Seal labeling indicates compatibility with 8 Fr or smaller procedural
sheaths, the Angio-Seal has been used successfully to close 10 Fr arteriotomies utilizing a “double
wire” technique. With this technique, at the conclusion of the procedure the Angio-Seal wire and a
second, additional wire are placed through the sheath. The Angio-Seal is deployed in standard
fashion using the Angio-Seal wire, leaving the second wire in place. If hemostasis is achieved, the
second wire is carefully removed while maintaining pressure on the collagen plug. If hemostasis is
not achieved, the second wire serves as a “back up/safety” to allow deployment of a second Angio-
Seal device. Using this “double wire” technique, arteriotomies > 8 Fr (17 were 10 Fr) were
successfully closed (18 with a single device, 3 required a second device). In 4525 patients
undergoing interventional procedures (89% with 8–9 Fr sheaths) the Angio-Seal had a device success
of 97%.The Angio-Seal device significantly improved patient comfort at the time of discharge
compared with MC.
11.
12. The Mynx Vascular Closure Device
a polyethylene glycol sealant (“hydrogel”) that deploys outside the artery
while a balloon occludes the arteriotomy site within the artery
The Mynx device is inserted through the existing procedural sheath and a
small semicompliant balloon is inflated within the artery and pulled back to
the arterial wall, serving as an anchor to ensure proper placement. The
sealant is then delivered just outside the arterial wall where it expands to
achieve hemostasis. Finally, the balloon is deflated and removed through the
tract leaving behind only the expanded, conformable sealant.
13.
14.
15. The FISH device
Diagnostic procedures using 5–8 Fr procedural sheaths
bioabsorbable extracellular matrix “patch” made from porcine small
intestinal submucosa
Inserted through the arteriotomy so that it straddles the arterial wall, then a
wire is pulled to release the “patch” from the device
compression suture is pulled which incorporates the patch firmly in
16. Oozing
Oozing of blood contributed to a significantly lower rate of successful
hemostasis (Starclose 94%, Angio-Seal 99%, MC 100%; p = 0.002).
17. ProGlide Insertion
The device is inserted over a guide wire until blood return indicates positioning
within the lumen . Then, a lever is pulled which deploys “feet” within the arterial
lumen. The device is gently pulled back positioning the feet against the anterior
arterial wall. Needle deployment and formation of a suture loop is fully automated
by depressing a plunger on the device. As the plunger is depressed, two needles
are deployed within the tissue track and directed towards the feet. As the plunger
is depressed further the needles are advanced through the arterial wall and into
the feet. The feet capture the needles, creating a suture loop. The device
(containing the needles) is then removed, leaving behind the two suture tails. A
knot is tied and pushed toward the arteriotomy to achieve hemostasis. The 6 Fr
ProGlide is designed for procedures using 5–8 Fr sheaths, whereas the Prostar is
used with 8.5–10 Fr sheaths. The Prostar uses 4 needles (two sutures) directed
outward from within the arterial lumen. First, the Prostar is advanced over a
guidewire until blood return indicates proper placement, which is confirmed
visually. By pulling on the device handle, the needles are deployed and pulled
through the arterial wall.
18.
19.
20. Benefits of VasoSeal, Angio-Seal and
Perclose
The VasoSeal, Angio-Seal and Perclose devices each decreased the time to
hemostasis, ambulation and discharge compared with MC
21. Risks of Individual Vascular Complications in
Relation to VCDs
Bleeding is the most common vascular complication-70%
Pseudoaneurysm-20%
VCDs increase local bleeding
Significantly influence hematoma, pseudoaneurysm or arteriovenous fistula
formation
22. Vascular Closure Device Related
Complications
Leg ischemia and groin infections
Pseudoaneurysm (71%), hemorrhage (32%) and arterial venous fistula (15%)
more with MC compared with VCDs
Infection and limb ischemia more with VCD
VCDs can cause severe complications related to device misuse or malfunction.
23. Reduce Complications
The benefit of VCDs is reduced if early ambulation is not desired
aseptic technique, including a cap, mask, sterile gown, sterile gloves, and a
large sterile sheet
antibiotic coverage is recommended for patients with diabetes receiving a
VCD
pre-procedure fluoroscopy and ultrasound imaging have been advocated to
reduce the risk of inaccurate sheath insertion and vascular complications,
with expected benefits in the small percentage of patients with unusual
anatomy
25. Predictors of complications
Female gender
Advanced age (≥ 70 years)
Low body surface area (< 1.6 m2)
More complex ,more is bleeding complications
MC is preferred in complex anatomy
Active VCDs carry numerous cautions and warnings for restricted use, including
non-common femoral sheath location, small femoral artery size (< 4 mm),
bleeding diathesis, morbid obesity, inflammatory disease, uncontrolled
hypertension, and significant peripheral vascular disease.
The safety and efficacy of VCDs in high risk patients is unknown
Use of active VCDs is cautioned against in the presence of peripheral vascular
disease because of higher complication rates
27. Learning Curve
The Angio-Seal device is easy to use and has high technical success
The Star close device is also simple to use, but since oozing occurs frequently, the Starclose
device is better suited for diagnostic procedures than interventional procedures with full
anticoagulation.
The Boomerang device can be used in the presence of peripheral vascular disease and is
preferred by many vascular surgeons because nothing is left behind in the artery
With Perclose, access to the artery is maintained (guide wire remains in place), even with
device failure, and complications generally become evident immediately, as opposed to
delayed complications that may occur with other VCDs. The Perclose devices allow for repeat
vascular access immediately (this has not been studied), whereas the same site cannot be
accessed for several weeks or months following deployment of collagen plug devices
The Prostar and ProGlide, using the “pre-close” technique, are the only active VCD commonly
used to close arteriotomies larger than 8 Fr; the ProGlide is preferred by many cardiologists
whereas many surgeons favor the Prostar. Using a “double wire” technique, the Angio-Seal
has been used successfully to close 10 Fr arteriotomies.
28. Conclusion
MC remains the gold standard
The FemoStop and Clamp Ease have high success rates in achieving
hemostasis and can be used safely in most patients
All active VCDs shorten the time to hemostasis and ambulation
The incidence of major complications is increased by VasoSeal, reduced by
Angio-Seal, and reduced by Perclose in diagnostic cases.
VCDs increase the risk of leg ischemia, groin infection, and complications
requiring surgical repair, which are rare with MC
Screening with femoral angiography prior to VCD placement and avoidance of
VCDs in the presence of puncture site-related risk factors might reduce the
risk of vascular complications.