Puncture Ultrasound Guidance: Decrease Access Site Complications. Peter A. Schneider, MD Kaiser Foundation Hospital Honolulu, Hawaii
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1 Puncture Ultrasound Guidance: Decrease Access Site Complications Peter A. Schneider, MD Kaiser Foundation Hospital Honolulu, Hawaii
2 Disclosure Speaker name: Peter A. Schneider... I have the following potential conflicts of interest to report: Chief Medical Officer for Intact Vascular Modest royalty from Cook
3 Usage of Ultrasound in Routine Vascular Practice All venous cases Evaluate for vein as conduit for bypass or dialysis access Plan incisions for arterial access; distal bypass, carotid endarterectomy, vein graft revisions Endovascular access-both arterial and venous
4 Longitudinal/In-plane Transverse/Out-of-plane Needle Tip Ultrasound Guidance of Optimal Puncture Site
5 Thresholds for Access Site Complications SIR: MAE threshold hematoma (requiring transfusion, surgery or increased LOS) <0.5% access site occlusion <0.2% pseudoaneurysm or AVF <0.2% ACC benchmark After diagnostic <1.0% After intervention <3.0% Singh et al. J Vasc Interv Radiol 2003;14:S Bashmore et al. J Am Coll Cardiol 2001;15:
6 Decrease Access Site Complications Complication Rate Femoral hematoma % Pseudoaneurysm % Arteriovenous fistula % Access site occlusion % Retroperitoneal hematoma % Hirano et al. J Cardiol 2004;43: Doyle et al. JACC 2008;1: Frank et al. J Interv Cardiol 2010;23: Farouque et al. JACC 2005;43: Stone et al. Vasc Endovasc Surg 2012;46:
7 Optimal Puncture Site Placement= Lower Rate of Complication Pitla et al. CCI. 2011;78:294.
8 Rationale Puncture Ultrasound Guidance Reduce access site complications Lower risk of hematoma, bleeding, AV fistula Single puncture, first pass, single wall Avoid-branches, calcification, lesions Optimal use of closure Avoid arterial access site disease Best choice of closure Safety of percutaneous EVAR-reduce open conversions
9 Optimal Puncture Site Placement Optimal Puncture Site Placement
10 Puncture Ultrasound Guidance Endovascular arterial access: Brachial artery access Antegrade common femoral Superficial femoral artery access Pedal or distal tibial artery access Percutaneous EVAR Retrograde common femoral Where we thought we least needed it!
11 Puncture Ultrasound Guidance Results for Retrograde Femoral Approach Gedikoglu, et al. Catheter Cardiovasc Intervent 2013 Jan, epub.
12 Seto, et al. JACC Intv. 2010;3:751.
13 Puncture Ultrasound Guidance Quality Improvement Project Retrograde Femoral Approach Protocol Standard Seldinger technique Ultrasound and micropuncture Time Period Complication Rate 2007: 206 consecutive cases 2011: 382 cases All: 6.0% Serious: 1.0% All: 1.8% Serious: 0.3% Closure Device Usage Notes 55% Retroperitoneal hematoma (1), surgical repair of hematoma (1) 86% Operation to evacuate hematoma (1) Schneider et al. Kaiser Hawaii Experience.
14 Lamperti et al. Intensive Care Med 2012;38:1105
15 Puncture Ultrasound Guidance Tips and Pitfalls Find profunda and place needle 1-2cm superior to the bifurcation. Inguinal ligament variable Not always clearly visible If too close, can interfere with closure Use image to avoid small common femoral artery branches and calcific patches More calcified or scarred artery, place needle at steeper angle
16 Ultrasound and Micropuncture for Endovascular Access Obtain a Spot Film with the Needle in Place Puncture site: must be inferior to the top of the femoral head Avoid retroperitoneal hematoma
17 Kopac et al. J Vasc Surg 2013; 58:735
18 Ultrasound Guidance and Micropuncture Conclusion Ultrasound guided access provides added safety and reduces our most common complications Readily available More more ideal needle puncture placement Enhances use of closure devices Opportunity for quality improvement
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