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- 1. Vascular Access during CardiacCatheterization VASCULAR ACCESS,COMPLICATIONS,MERITS 1 Dr Vikash M,DM(SR). NIMS,Hyderabad,India vikasmedep@yahoo.co.in
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- 4. Retrograde/antegrade. ARTERIAL FEMORAL RADIAL BRACHIALULNAR VASCULAR ACCESS,COMPLICATIONS,MERITS 4
- 5. Venous Accesss VENOUS FEMORAL IJVSUBCLAVIAN VASCULAR ACCESS,COMPLICATIONS,MERITS 5
- 6. TOPIC OVERLAY • SITE •COMPLICATIONS • ADVANTAGES • DIS-ADVANTAGES • COMPARISON • HEMOSTASIS VASCULAR ACCESS,COMPLICATIONS,MERITS 6
- 7. FEMORAL ACCESS - ANATOMY VASCULARACCESS,COMPLICATIONS,MERITS 7
- 8. ARTERIAL ACCESS • FEMORALARTERIAL 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 8
- 9. • Some operatorsrely 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 9
- 10. COMPLICATIONS • VASCULAR • Hematoma •Pseudo-aneurysm • A-V fistula • Retropertonial hemorrhage • Thrombosis • NON VASCULAR • Infections VASCULAR ACCESS,COMPLICATIONS,MERITS 10
- 11. VASCULAR ACCESS,COMPLICATIONS,MERITS 11Nasser TK,Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheral vascular complications following coronary interventional procedures. Clin Cardiol.1995;18:609–614.
- 13. PROCEDURAL RISK STRATIFICATION • LowRisk:(<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) VASCULAR ACCESS,COMPLICATIONS,MERITS 13
- 14. RISK FACTORS • Modifiable •Site of puncture • Number of attempts • Size of sheath • Sheath removal • Medications • Non modifiable • Age • Gender • BMI • Associated disorders - CKD VASCULAR ACCESS,COMPLICATIONS,MERITS 14
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- 16. • NUMBER OFATTEMPTS • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 16
- 17. • 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 17
- 18. 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 18
- 19. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 19
- 20. • HEMATOMA • Definition •Collection of blood in the soft tissue • Incidence • Most common vascular complication • 5- 20 % • Clinical features • Pain, swelling, induration VASCULAR ACCESS,COMPLICATIONS,MERITS 20
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- 23. VASCULAR ACCESS,COMPLICATIONS,MERITS 23 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
- 24. PSEUDO-ANEURYSM • Definition • Acontained 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 24
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- 26. • One ofthe 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 26
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- 28. • 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 28
- 29. • However, itshould 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 29
- 30. • IMAGING • Duplexultrasound • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 30
- 31.
- 32. • TREATMENT • Untilthe 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 32
- 33. • USG guidedcompression • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 33
- 34. • The verticalangle 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 34
- 35. • In patientson 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 35
- 36. • DISADVANTAGES • Longtime - 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 36
- 37. • Ultrasound-Guided ThrombinInjection • 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 37
- 38. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 38
- 39.
- 40. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 40
- 41. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 41
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- 43. • Disadvantages ofsurgery • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 43
- 44. • Prevention • Morecomplex 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 44
- 45.
- 46. 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 46
- 47. • Retroperitoneal HematomaAfter Percutaneous Coronary Intervention: Prevalence, Risk Factors, Management, Outcomes, and Predictors of Mortality • Volume 3, Issue 8, August 2010 VASCULAR ACCESS,COMPLICATIONS,MERITS 47 Retroperitoneal Hematoma After Percutaneous Coronary Intervention: Prevalence, Risk Factors, Management, Outcomes, and Predictors of Mortality Volume 3, Issue 8, August 2010 , JACC
- 48. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 49
- 49. • Retroperitoneal haematomanear 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 50
- 50. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 51
- 51. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 52
- 52. • MANAGEMENT • Fluidresuscitation, 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 53
- 53. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 54
- 54. • OPEN SURGERY •Indications • Unstable despite adequate fluid and blood product resuscitation, • Failed embloization / stent • Abdominal compartment syndrome VASCULAR ACCESS,COMPLICATIONS,MERITS 55
- 55.
- 56. • DEFINITION • Abnormalconnections 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 57
- 57. • Low groinpuncture – • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 58
- 58. • INCIDENCE • 0.Ito 1 %* • CLINICAL FEATURES • Initially silent. • Two days to several months • Abnormal sensation in the groin, fatigue, new onset or worsened lower extremity ischemia. • *Glaser RL, McKellar D, Scher KS. Arteriovenous fistulas after cardiac catheterization. Arch Surg 1989; 124:1313. VASCULAR ACCESS,COMPLICATIONS,MERITS 59
- 59. • Palpation andauscultation 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 60
- 60. • DIAGNOSIS • Duplexultrasonography • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 61
- 61. • TREATMENT • Mostsmall 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 62
- 62. • Ultrasound-guided compression •Compression of sufficient force to abolish flow through the fistula without unduly reducing distal perfusion • Painful • Failure is frequent because the fistula track is too short or the AV fistula is too large • Chronic AVFs (>2 to 3 weeks) rarely respond to compression. • Ongoing anticoagulation also decreases success rates of UGC. • Endovascular repair • Covered stent placement or embolization techniques • Surgery VASCULAR ACCESS,COMPLICATIONS,MERITS 63
- 63.
- 64.
- 65. • Incidence • 0.5– 1% • Diagnosis • Doppler studies • Peripheral angiogram • Treatment • Small – spontaneous lysis • Large, limb threatening – thrombolysis / thrombectomy VASCULAR ACCESS,COMPLICATIONS,MERITS 66
- 66. • 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;161:2110–2115 VASCULAR ACCESS,COMPLICATIONS,MERITS 67
- 67. • Causes • Impropershaving • Improper scrubbing • TREATMENT • Antibiotics • PREVENTION • Appropriate shaving / scrubbing. • Using sterile drapes. VASCULAR ACCESS,COMPLICATIONS,MERITS 68
- 68. • FEMORAL NEUROPATHY •Incidence • 0.1 – 0.3% • Mechanism • Compression of the femoral nerve during puncture or by hematoma • Clinical features • Tingling, numbness, weakness, • Treatment • Usually self remitting VASCULAR ACCESS,COMPLICATIONS,MERITS 69
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- 73. • 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% VASCULAR ACCESS,COMPLICATIONS,MERITS 74
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- 75.
- 76. • COMPLICATIONS • PROCEDURAL •Vaso vagal reaction • Spasm • Perforation / Dissection. • POST PROCEDURE • Occlusion • Compartment Syndrome • Pseudoaneurysm • VASCULAR ACCESS,COMPLICATIONS,MERITS 77
- 77. • VASOVAGAL REACTIONS •Due to pain, anxiety • PREVENTION • Preprocedural sedation, analgesia, and adequate local infiltration anesthesia decreases pain, anxiety, and associated vagal output VASCULAR ACCESS,COMPLICATIONS,MERITS 78
- 78. • SPASM • Inducedby 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 79
- 79. • Prevention • Adequatevasodilatory 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 80
- 80. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 81
- 81. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 82
- 82. • Causes • Unrecognizedperforation 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,MERITS 83
- 83. • AVULSION • Asheath 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 84
- 84. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 85
- 85. • RADIAL ARTERYOCCLUSION • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 86
- 86. • Consequences • Usuallybenign 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 87
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- 94. VASCULAR ACCESS,COMPLICATIONS,MERITS 95 2011 ACCF/AHA/SCAI/ESCGuideline for Percutaneous Coronary Intervention Class IIa 1. The use of radial artery access can be useful to decrease access site complications.
- 95. • CONDITIONS WHERE READIALACCESS 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 96
- 96. FEMORAL vs RADIAL APPROACH VASCULARACCESS,COMPLICATIONS,MERITS 97
- 97.
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- 102.
- 103. VASCULAR ACCESS,COMPLICATIONS,MERITS 104 Primary andSecondary Outcomes Radial (n=3507) % Femoral (n=3514) % HR HR 95% CI 95% CI P P Primary Outcome Death, MI, Stroke, Major Bleed 3.7 4.0 0.92 0.92 0.72-1.17 0.72-1.17 0.50 0.50 Secondary Outcomes Death, MI, Stroke 3.2 3.2 0.98 0.98 0.77-1.28 0.77-1.28 0.90 0.90 Major Bleeding 0.7 0.9 0.73 0.73 0.43-1.23 0.43-1.23 0.23 0.23
- 104. VASCULAR ACCESS,COMPLICATIONS,MERITS 105 Other Outcomes Radial (n=3507) Femoral (n=3514) P P Accesssite Cross-over (%) 7.6 2.0 <0.0001 <0.0001 PCI Procedure duration (min) 35 34 0.62 0.62 Fluoroscopy time (min) 9.3 8.0 <0.0001 <0.0001 Persistent pain at access site >2 weeks (%) 2.6 3.1 0.22 0.22 Patient prefers assigned access site for next procedure (%) 90 49 <0.0001 <0.0001
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- 106.
- 107. BRACHIAL ARTERY ACCESS • SITEOF PUNCTURE • Medial aspect of cubital fossa, 2-3 cm above the elbow crease • INDICATIONS • Renal / lower limb artery angioplasty • COMPLICATIONS • Hematoma VASCULAR ACCESS,COMPLICATIONS,MERITS 109
- 108. • 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,MERITS 110
- 109.
- 110. 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,MERITS 112
- 111. HEMOSTASIS • MANUAL COMPRESSION •MECHANICAL COMPRESSION • TOPICAL HEMOSTATIC AIDS • VASCULAR CLOSURE DEVICES 1. Active 2. Passive . VASCULAR ACCESS,COMPLICATIONS,MERITS 113
- 112. • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 114
- 113.
- 114. FEM-STOP VASCULAR ACCESS,COMPLICATIONS,MERITS 116 70mmHg whilesheath removal 70mmHg while sheath removal MAP for 15 min MAP for 15 min Gradually reduce to 30mmHg over 2 hrs and remove. Gradually reduce to 30mmHg over 2 hrs and remove.
- 115.
- 116. • Advantages • Moreeffective compression • Dis-advantages • Doesn’t decrease time to hemostasis / ambulation. • Patient discomfort VASCULAR ACCESS,COMPLICATIONS,MERITS 118
- 117. TOPICAL HEMOSTATIC AIDS • Avariety 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 ACCESS,COMPLICATIONS,MERITS 119
- 118.
- 119. VASCULAR CLOSURE DEVICES • Introducedin 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 121
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- 121.
- 122. • 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 124
- 123. • Disadvantages • Theintravascular 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 125
- 124.
- 126. • 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. VASCULAR ACCESS,COMPLICATIONS,MERITS 128
- 127. • Devices:2011 ACCF/AHA/SCAIGuideline 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
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- 129.
- 130. FEMORAL VENOUS ACCESS ANATOMY VASCULARACCESS,COMPLICATIONS,MERITS 137
- 131. • INDICATIONS • Rightheart 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 138
- 132. COMPLICATIONS Local Hematoma Retroperitoneal hematoma Pseudoaneurysm AVfistula Femoral neuropathy Infection DVT VASCULAR ACCESS,COMPLICATIONS,MERITS 139
- 133. SUBCLAVIAN VENOUS ACCESS • INDICATIONS •PPI leads • TPI • IVC filter • Central venous access • Chemoport VASCULAR ACCESS,COMPLICATIONS,MERITS 140
- 134. • Positioning • Rightside 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 141
- 136. • COMPLICATIONS • InfectionBleeding Pneumothorax • Thrombosis Air embolization Brachial plexus injury • AVOIDED IN • Coagulopathy Thrombloysis Chest wall deformity VASCULAR ACCESS,COMPLICATIONS,MERITS 143
- 137. IJV ACCESS • INDICATIONS •TPI • Central venous line • Positioning • Right side preferred • Trendelenburg position • Head turned slightly away from side of venipuncture VASCULAR ACCESS,COMPLICATIONS,MERITS 144
- 138. Needle placement • Centralapproach • 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 145
- 140. 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 VASCULAR ACCESS,COMPLICATIONS,MERITS 147
- 141.
- 142. VASCULAR ACCESS,COMPLICATIONS,MERITS 149 Location AdvantageDisadvantage Internal Jugular • Bleeding can be Bleeding can be recognized recognized and controlled and controlled • Malposition is rare Malposition is rare • Less risk of Less risk of pneumothorax pneumothorax • Risk of carotid artery Risk of carotid artery puncture puncture • Pneumothorax possible Pneumothorax possible Femoral • Easy to find vein Easy to find vein • No risk of No risk of pneumothorax pneumothorax • Preferred site for Preferred site for emergencies and CPR emergencies and CPR • Fewer bad Fewer bad complications complications • Highest risk of infection Highest risk of infection • Risk of DVT Risk of DVT • Not good for ambulatory Not good for ambulatory patients patients Subclavian • Most comfortable for Most comfortable for conscious patients conscious patients • Highest risk of Highest risk of pneumothrax, pneumothrax, • Vein is non-compressible Vein is non-compressible
- 143.