Vascular Access Management of Complications Ppt Powerpoint Presentation slides-Medical Slideshow Bleeding Complications of PCI Vascular Access Complications

Vascular Access Management of Complications

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Slide 1 :

Vascular Access: Management of Complications Chris Burrell, South West Cardiothoracic Centre, Plymouth

Slide 2 :

Alternative Vascular Access Sites Femoral Axillary Brachial Radial Ulnar Femoral v Radial

Slide 3 :

Vascular Complications: Definitions Bleeding requiring transfusion Complication requiring “surgical” repair Exclude thrombosis/thrombotic occlusion Major Minor

Slide 4 :

Diagnostic Cardiac Catheterisation 1992-1997 Surgical vascular complication 5 (0.25%) Non-surgical vascular complication 10 (0.5%) Large Haematoma 4 False Aneurysm 4 Re-bleed 1 Entry site infection 1 Papaconstantinou H, Marshall A, Burrell C. Heart 1999;81:465-9 Femoral Brachial Radial n=2000 n=1966 n=27 n=7

Slide 5 :

Coronary Angiography with Peripheral Vascular Disease Major vascular complications 6 0 <0.01 Success Rate (%) 79 91 <0.01 Procedure Duration (%) 42+/-22 51+/-19 <0.01 Radiation Dose (CGy) 41+/-25 47+/-26 0.03 Hilldick-Smith DJR et al Cathet Cardiovasc Intervent 2000;49:32-7 Femoral Brachial/Radial n=297 n=154 n=143 p Value

Slide 6 :

ACCESS: A Randomised Comparison of PTCA by the Femoral, Brachial and Radial Approaches Major entry site complications (%) 2.0 2.3 0 Successful coronary cannulation (%) 99.7 95.7 93.0 Primary PTCA success (%) 90.7 90.7 91.7 Asymptomatic occlusion - - 3.0 Kiemeneij et al JACC 1997;29:1269-75 6F Femoral Brachial Radial n=900 n=300 n=300 n=300

Slide 7 :

Major Vascular Complications for PCI Femoral Compression 2 - 4% Device Closure 1.2 - 2.8% Brachial 2 - 3% Radial 0.1% 3 – 5% Access Site Major Vascular Thrombotic Complication Occlusion Cremanasi J Invas Cardiol 1994;10:464 Kussmaul JACC 1995;25:1685 Sanbourn JACC 1993;22:1272 Ernst JACC 1993;21:851 Ellis Circ 1999;100:I-313 Benit et al CCD 1997;41:124-30 Kiemeneij et al JACC 1997;29:1269 Shrake et al Am J Cardiol; 2000;85:1024 Mann T et al JACC 1998;32:572 Catheter Cardiovasc Intervent 1997;40:156

Slide 8 :

Vascular Complications: Mechanisms Spasm Dissection Stenosis Thrombosis/Occlusion Rupture AV Fistula Bleeding/Haematoma False Aneurysm Intravascular Extravascular

Slide 9 :

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Slide 11 :

Avoiding Radial Spasm Keep patient warm and hydrated Use anxiolytics Minimise manipulation and trauma Use hydrophilic sheaths Use vasodilators (Apply warm saline bag) Use coronary (014”) guidewire Be prepared to use femoral approach

Slide 12 :

Diabetes Mellitus + Sheath size > Vessel size + Gender * Female 80% Male 18% Heparin 3-5000 units * Eur Heart J 1995;16:293 Cath Cardiovasc Intervent; 1999;46:173 + Nagai et al Am J Cardiol 1999;83:180 Avoiding Radial Occlusion

Slide 13 :

Treating Radial Occlusion Conservative Local Thrombolysis Percutaneous Intervention Surgery

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Slide 18 :

Vascular Complications: Mechanisms Spasm Dissection Stenosis Thrombosis/Occlusion Rupture AV Fistula Haematoma/Bleeding False Aneurysm Intravascular Extravascular

Slide 19 :

Femoral Approach Puncture Common Femoral Artery Train Manual or Device (e.g. Femostop) Compression Avoid Use Closure Devices Obesity Systemic anticoagulation GP IIb/IIIa inhibitors* * EPIC NEJM 1994;330:956 EPILOG NEJM 1997;336:1689 Pursuit NEJM 1998;339:436

Slide 20 :

Femoral Angiography Prior to Angioseal Deployment Talwar S et al Int J Cardiovasc Intervent 2001;4:22 n=81 300 RAO 200 Caudal

Slide 21 :

1. Low Puncture 5 (8%) SFA 3 PF 2 – Not deployed successfully 2. Bifurcation Puncture 17 (19%) 3. PVD 21 (32%) All deployed successfully Outside Manufacturer’s Recommendations

Slide 22 :

Femoral Artery False Aneurysm Sac

Slide 23 :

Spontaneous Closure of Selected Iatrogenic Pseudoaneurysms and Arteriovenous Fistulae Toursarkissian et al J Vasc Surg 1997;25:803 n=286 (196 pseudoaneurysms, 81 arteriovenous fistulae, 9 mixed lesions) : diagnosed by Duplex scan 147 managed without surgery 86% resolved without limb threatening complication 14% eventually required surgical closure

Slide 24 :

Ultrasound Compression of Iatrogenic False Aneurysms Introduced 1991* Treatment of choice Painful and time-consuming, especially if anticoagulants *Fellmeth B et al. Radiology 1991;178:671.

Slide 25 :

Ultrasound Guided Percutaneous Thrombin Injection Treatment of Iatrogenic False Aneurysms Elford J, Burrell C, Roobottom C Heart 1999;82:526. n=1 (axillary false aneurysm) Loose HW, Haslam PJ. Br J Radiol 1998;71:1255. Kang SS, Labropoulos N et al J Vasc Surg 1998;27:1032. Liau CS, Ho FM, Chen MF J Vasc Surg 1997;26:18

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Slide 27 :

Femoral Artery False Aneurysm Sac xxxxxxxxxxx

Slide 28 :

Human Thrombin Injection for Iatrogenic Pseudoaneurysms Elford J, Burrell C, Freeman S, Roobottom C. Clin Rad 2001; n=14: (10 CFA, 3 SFA, 1 Ax ) Size 2.5-7.5 cm 1000 IU Human Thrombin under ultrasound guidance Repeat colour Doppler at 24h 14/14 occluded at 24h 2 additional balloon inflation across neck 2 required 2nd injection

Slide 29 :

Conservative (2-4/52 if small & asymptomatic)* Ultrasound-Guided Compression* Human (or Recombinant) Thrombin Injection Coil Embolisation Stent Graft Surgical Repair Managing Pseudoaneurysms (and Arterio-venous Fistulae*)

Slide 30 :

Transradial Transfemoral Positive Allens Obesity Anticoagulants Thrombolysis+IIb/IIIa Peripheral Vasc Dis Dilated Aortic Root Use Heparin (3-5000 units) Negative Allens Diabetes Mellitus Small Vessel/Large Sheath Anxious/Young/Female Tortuous Anatomy Grafts (LIMA) Use Closure Device (Femoral angiogram?)

Slide 31 :

Conclusions Radial approach offers advantages but not in all patients nor in all circumstances Straightforward technique but learning curve Best way to manage complications is to avoid them Involves familiarity with both techniques combined with flexibility Next generation will use radial approach

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