Percutaneous Insertion Use and Contraindications

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Percutaneous InsertionUse and Contraindications
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Background

• Drive towards minimal invasive surgery
• Advancement of endovascular techniques
• Expanding indication
• Larger device profiles required
• More aggressive anticoagulation

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Vascular Access

• transfemoral most common
• small sheath sizes (lt9F) - manual compression
• larger sheath sizes - open groin dissection
• alternative routes brachial, radial, carotid and
  popliteal

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Haemostasisfactors

• 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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Percutaneous Access

• has been limited by sheath size
• can be achieved by
• smaller device profiles
• closure devices

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External compression

• external compression
• manual or mechanical
• disadvantages
• patient discomfort, mobility restricted
• labour intensive (time and effort)
• prolonged compression - anticoagulation and large
  sheath sizes (gt9F)
• less effective with high punctures

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Access Site Complications

• angiogram 0.5-1.5
• balloon angioplasty 1-3
• coronary stenting 5-17
• endoluminal(open groin) 13-14

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Closure Devices

• Developed over the last 10 years.
• Driven by objectives to
• reduce vascular complications
• reduce time to ambulation/discharge
• reduce patient discomfort

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Closure Devices Types

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

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Closure Devices

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

• Disadvantages
• high costs
• steep learning curve
• closure related complications
• delayed repuncture

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Device Related Complications

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

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Closure Devices

• emerging suggestions of new pattern of
  complications
• no decrease in the incidence of complications
• reduction in minor complications but no reduction
  in major complications
• complications tend to occur later

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Closure Devices

• Dangas, G. et al J Am Coll Cardiol 2001
• retrospective review of closure devices (n516))
  versus manual compression (n5892
• more frequent haematoma (9.3 vs 5.1 plt0.001)
• higher significant haematocrit drop (5.2 vs 2.5
  plt0.001)
• higher rate of surgery (2.5 vs 1.5, p0.03)
• similar rates of pseudoaneurysms and
  arteriovenous fistulae

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VasoSeal (Datascope)

• biodegradable purified bovine collagen sponge
• deployed through an applicator sheath into the
  soft tissue tract, directly over the arterial
  puncture site
• requires inflow compression during application
• followed by manual compression

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VasoSeal Trials
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VasoSeal Advantages

• extravascular
• does not enlarge arteriotomy
• seals diseased arteries
• early repuncture

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VasoSeal Disadvantages

• relies solely on thrombus plug
• limited to lt9F
• requires 2 operators
• high failure rate in obese patients
• ambulation delay (1-3hr)
• infection - antibiotics, pseudoaneurysms
• obstruction

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Angio-Seal (Sherwood)

• 3 bioabsorbable components - anchor, collagen
  plug and connecting suture
• contained in a delivery sheath
• deployed on wire at end of procedure
• anchor in lumen holds collagen plug in place

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Angio-Seal Trials
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Angio-Seal Advantages

• easy to learn
• one operator
• secure plug
• no external compression

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Angio-Seal Disadvantages

• intraluminal anchor - obstruction, infection
• limited to lt9F
• enlarges arteriotomy
• ambulation delay (1-3hr)
• repuncture delay (weeks)

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Duett (Vascular Solutions)

• temporary balloon occlusion and extravascular
  injection of collagen/thrombin through a sideport.

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Duett Advantages

• does not enlarge arteriotomy
• 1 operator
• immediate repuncture
• simple conversion to compression

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Duett disadvantages

• intravascular administration
• ambulation delay (1-3hr)
• diseased vessels

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Perclose Prostar and Closer

• percutaneous suturing of vessel wall
• closure of large sheath sizes (10F)
• requries one operator
• immediate repuncture possible
• immediate ambulation
• very steep learning curve

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Prostar Trial

• Sprouse, L.R. et al J Vasc Surg 2001
• retrospective review of patients requiring
  vascular surgery admission following use of
  Prostar (n11) and manual compression (n14)
• 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 abd require aggressive
  surgery

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Prostar Endoluminal Trials
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Perth Prostar Experience

• Aims
• evaluate results of our early experience
• Methods
• 82 percutaneous closures in 44 patients
• 10F Prostar XL PVS device
• 1 iliac, 1 thoracic and 42 abdominal aortic
  aneurysms
• product specialist present

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Perth Prostar Experience

• 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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Perth Prostar Experience

• Results
• 12 failures requiring surgical intervention
  (14.6)
• reasons for failure
• tortuous iliac artery (2)
• scarred groin (1)
• obesity (5)
• sutures catching (1)
• high CFA bifurcation (2)
• pseudoaneurysm (1)

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Perth Prostar Experience

• Pitfalls
• obesity
• calcified, turtuous iliofemoral vessels
• angled proximal necks

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Conclusion

• Open groin dissection remains the standard
• Patient selection is vital
• Tutorlage and experience vital
• Monitor for late complications
• Surgical skills to recognise and deal with
  complications