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VASCULAR ACCESS AND COMPLICATIONS

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Small fistula may spontaneously close or remain stable for many years. Larger fistula may cause significant AV shunts, swelling and tenderness ... – PowerPoint PPT presentation

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Title: VASCULAR ACCESS AND COMPLICATIONS


1
VASCULAR ACCESS AND COMPLICATIONS
BARRY F URETSKY CORE CURRICULUM PORTO ALEGRE,
BRAZIL JULY 18, 2006
2
AVOIDING VASCULAR COMPLICATIONS
  • PATIENT HISTORY
  • Prior access problems
  • Signs or symptoms of PVD
  • Inability to lie flat
  • PHYSICAL EXAMINATION
  • Examine all pulses
  • Listen for bruits
  • Allens test for radial access
  • TECHNICAL PERFORMANCE
  • Front wall stick
  • Pulsatile flashback
  • Wire exits needle without resistance
  • Angle of needle maximize guide wire
    entry, minimize subQ tract
  • parallel to vascular structures
  • Nick and tunnel approach

3
OPERATIONAL ANATOMY FOR FEMORAL ACCESS
  • GOALCFA
  • LANDMARK INF-MED QUAD FEM HEAD
  • POINT OF MAXIMAL IMPULSE gt90

4
VASCULAR ACCESS
Low vascular access
Low vascular access
5
THE FRONT-WALL STICK
6
CONSIDERATIONS IN PVD
  • With known aorto-iliac disease or prior AFB
    consider brachial or radial access
  • Remember that there is often brachiocephalic
    disease in patients with occlusive aorto-iliac
    disease and that there is an increased risk of
    stroke with catheter manipulation in tortuous
    subclavian vessels
  • Review any previous angiography
  • AFB graft may be used for access avoid
    retrograde access into blind limb of iliac artery
  • Distal SFA occlusion is not a contraindication.
    Enter CFA !!
  • Take care NOT to compromise the patent profunda
    femoris artery (only remaining circulation to the
    leg)

7
Femoral Access Complications
  • Hematoma, bleeding, transfusion
  • Pseudoaneurysm
  • AV fistula
  • Thrombosis
  • Dissection
  • Perforation
  • Infection

8
RISK FACTORS FOR VASCULAR COMPLICATIONS
  • Larger arterial sheath.
  • Prolonged sheath time.
  • Older age.
  • Low platelet count.
  • IABP.
  • Concomitant venous sheath.
  • Need for repeat intervention.
  • Female gender
  • Obesity
  • Low body weight
  • Hypertension
  • OveranticoagulationGp IIb/IIIa
  • Elevated serum creatinine

9
Access Bleeding/Hematoma
  • Incidence 6 (transfusion 3.0)
  • Discontinue heparin after procedure
  • Reduce heparin dose with IIb/IIIa (60-70 U/Kg)
  • Sheath removal with ACT lt 170 sec
  • Minimize sheath size

10
RETROPERITONEAL HEMATOMA
  • Incidence 3.0
  • Avoid high CFA punctureFront-wall stick only
    preferred
  • Suspect when unexplained blood loss, hypovolemia,
    hypotension, supra-inguinal fullness or
    tenderness or flank pain
  • If suspicion is high, and blood loss significant,
    treat before a definitive diagnosis is made.
  • Discontinue/reverse anticoagulation
  • -Reverse heparin with protamine (10
    mg/1000 U heparin)
  • -Platelet transfusion with abciximab
    time with tirofiban/eptifibatide
  • Treat with contralateral access and balloon
    tamponade or surgery

11
HYPOTENSION POST-CATH/PCI
  • DIFFERENTIAL DIAGNOSIS

Bleeding Bleeding Bleeding
OTHER CARDIAC TAMPONADE, DRUG EFFECT,
HYPOVOLEMIA WITHOUT BLEEDING
12
PSEUDOANEURYSM
  • Duplex 6 Clinical detection 1 - 3
  • Risk factors female gt 70 yrs, DM, obesity, low
    (SFA) stick
  • TREATMENT
  • Small ( 2 cm) may be observed and are
    likely to close spontaneously.
  • Larger aneurysms may be closed with
  • Ultrasound guided compression
  • Thrombin injection (not FDA approved)
  • Surgical repair

13
A-V FISTULA
  • Incidence 0.4
  • Associated with low (SFA/Profunda) access and a
    venous branch
  • Small fistula may spontaneously close or remain
    stable for many years
  • Larger fistula may cause significant AV shunts,
    swelling and tenderness
  • TREATMENT 1) surgery, 2)US-guided compression,
  • 3)balloon tamponade, 4) covered stent,
    5)observation

14
ACCESS VASCULAR INJURY ISCHEMIA/THROMBOSIS/EMBOLI
  • Incidence lt1
  • Injury can be caused by needle, guide wire,
    and/or sheath.
  • May caused leg ischemia or be asymptomatic.
  • Some iatrogenic dissections are self-limited,
    may be followed without intervention if blood
    flow is maintained and may heal over time.
  • Risk factors 1) relatively large sheath, small
    artery
  • 2) PVD 3) Thrombus
    within sheath
  • Most complications can be treated by the
    interventional cardiologist.
  • Contralateral access and angiography lysis,
    PTA, stent
  • Surgery1-3 (pseudoaneurysm, bleeding,
    thrombosis)

15
SHEATH EMBOLISM
POPLITEAL
UK LACING
FINAL
16
IATROGENIC DISSECTION
Immediate angiogram
17
IATROGENIC DISSECTION
End of procedure
18
IATROGENIC DISSECTION
Two weeks later
19
VASCULAR SITE PERFORATION
  • Very rare
  • Life-threatening
  • Must be treated immediate interventional
  • approach should be considered first
  • Surgery if interventional approach unsuccessful
    or not feasible
  • Primary therapeutic approach is hemostasis
  • CFAmanual hemostasis
  • CIA, EIA PTA, covered stent

20
VASCULAR SITE PERFORATION
21
VASCULAR SITE PERFORATION
22
VASCULAR SITE PERFORATION
23
Groin Infection
  • Incidence 0.2
  • Risk factors
  • Reintervention at same site
  • Hematoma formation
  • Prolonged sheath placement

N.B. Future series will include infections
secondary to closure devices.
24
NEUROPATHY
  • Rare complication
  • Due to nerve injury
  • Retroperitoneal hematoma with compression of
    lumbar plexus
  • Femoral hematoma with nerve compression
  • Femoral nerve injury during access

25
BRACHIAL ACCESS
  • Cutdown or percutaneous
  • May use specificifically for LIMA PCI
  • Heparin is recommended
  • Frequency of complications similar to femoral
    access.
  • Ischemia, thrombosis, embolization
  • -Conservative therapy heparinization
  • -Surgical therapyembolectomy
  • -Percutaneous lysis, mechanical thrombectomy,
    or balloon inflation to tack-up a dissection flap
  • Median nerve injury
  • -Brachial fossa hematoma (median n.
    compression)
  • -Nerve injury during access
  • -Ischemic nerve injury

26
BRACHIAL COMPLICATION
PTA
27
RADIAL ACCESS
  • Successful access 90.
  • Normal Allen test required.
  • Most common failure is inability to cannulate
    artery.
  • Occlusion post-PCI approx 3 - 5.
  • Associated with fewest major complications of any
    access site.

28
RANDOMIZED TRIAL OF RADIAL, BRACHIAL, VS FEMORAL
ACCESS
P 0.035
Kiemeneij F. JACC 1997291269.
29
METHODS OF HEMOSTASIS
  • Manual compression.
  • Mechanical compression device
  • . Equal or superior to manual compression
    for safety
  • Pressure dressings do not decrease
    complications and may obscure bleeding
  • Require constant attention, patient cannot be
    left unattended
  • Patient at bedrest 4 to 6 hrs
  • Closure devices.
  • Angioseal, Vasoseal, Perclose, Starclose, and
    many others.
  • Closure devices
  • Have not demonstrated reduction in major
    complications
  • Do allow earlier ambulation
  • Offer less intensive monitoring post-procedure
  • Significant cost
  • New set of complications!

30
(No Transcript)
31
MAUAL HEMOSTASIS
CORRECT TECHNIQUE
INCORRECT TECHNIQUE
32
VASCULAR ACCESS
  • SPECIFIC TECHNICAL ASPECTS AND COMPLICATIONS FOR
    EACH SITE
  • MOST COMPLICATIONS CAN BE TREATED BY THE INVASIVE
    CARDIOLOGIST.

33
  • MUITO OBRIGADO!
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