Percutaneous Insertion: Use and Contraindications

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Percutaneous Insertion Use and Contraindications
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Background

• Drive towards minimal invasive surgery
• Advancement in endovascular techniques and
  technology
• Expanding indications
• Development of endoluminal stenting
• early studies indicate less blood loss, shorter
  lengths of stay in ICU and in hospital

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Percutaneous Access

• 1) reduce patient discomfort
• 2) reduce time to ambulation
• 3) reduce time to discharge
• 4) allow earlier return to normal activities
• 5) reduce local complications

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Percutaneous Access

• limited by sheath size
• endoluminal stenting 14-24F
• carotid/subclavian stenting 7-10F
• can be achieved by
• smaller device profiles
• closure devices

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Percutaneous Access Haemostasis

• Affected by
• 1) Patient factors
• age
• weight
• comorbid conditions - hypertension,
  coagulopathies
• 2) Procedural factors
• use of anticoagulation
• sheath sizes
• puncture site

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Access site Complications

• Coronary catheterisation
• diagnostic angiogram 0.5-1.5
• balloon angioplasty 1-3
• coronary stenting 5-17
• open incision endoluminal stenting 13-14
• wound seroma and infection
• bleeding
• dissection and distal emboli

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Closure Devices Types

• Extravascular
• implantable collagen plug (Vasoseal)
• collagen/thrombin injection (Duett)
• Intravascular
• bio-absorbable haemostatic anchor (Angio-Seal)
• percutaneous suture device (Prostar XL and Closer)

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Closure Devices
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Perclose Prostar XL

• Perclose Australia

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Perclose Prostar XL

• Perclose Australia

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Perclose Prostar XL

• Advantages
• secure haemostasis
• large bore/ anticoagulation, high punctures
• minimal compression
• patient comfort and mobility

• Disadvantages
• high costs
• steep learning curve (Loubeyre C, et al J Am Coll
  Cardiol 1997)
• 9 complication
• 2.1 surgical rate
• gt250 cases/user
• closure related complications

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Device Related Complications

• persistent bleeding
• pseudoaneurysm
• infection
• arterial/venous occlusion
• arterial dissection
• arteriovenous fistula
• distal embolism

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Closure Devices

• Sprouse, L.R. et al J Vasc Surg 2001
• retrospective review of patients requiring
  vascular surgery admission with (n11) and
  without (n14) use of closure devices
• pseudoaneurysm are larger and do not respond to
  ultrasound compression
• complications result in more blood loss and
  increased need for transfusions
• infections are more common and require aggressive
  surgery

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Prostar for endoluminal stenting

• Preclose method (Haas, P. Et al. 1999)
• limited (1cm) incision
• subcutaneous tract dilatation
• needles deployed prior to endoluminal stent
• sutures tied at end of procedure

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Prostar Endoluminal Trials
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Perth Prostar Experience

• Methods
• 82 percutaneous closures in 44 patients
• 10F Prostar XL PVS device
• 1 iliac, 1 thoracic and 42 abdominal aortic
  aneurysms
• 2 devices for main body and 1 for contralateral
  limb
• product specialist present

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Perth Prostar Experience
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Perth Prostar Experience

• Results
• 85 success rate, 12 failures requiring surgery
• 1 death related to a myocardial infarction
  precipitated by a retroperitoneal bleed
• device introduction - unable to advance device
• needle deployment - needle deflection
• closure of arteriotomy - bleeding(7),
  obstruction(1)
• late complication - psuedoaneurysm (1)

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Lessons

• patient selection
• obesity (5)
• scarred groin (1)
• preoperative ilio-femoral assessment
• tortuous iliac artery (2)
• high CFA bifurcation (2)
• calcified artery
• CT scanning/on-table ultrasound

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Lessons

• high puncture
• 1 mortality - unrecognised bleeding
• suture management
• suture catching (1)
• keep sutures wet, ensure free running
• guide wire
• not a true over the wire system
• angulated proximal neck

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Developments

• X-Site PFC (Blue Pell, PA)
• lower cost alternative to Perclose
• SuperStitch (Sutura, Inc)
• suture mediated device for up to 24F

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Conclusion

• Open groin dissection remains the standard
• Careful patient selection
• Tutorlage and experience
• Surgical skills to recognise and deal with
  complications