CARDIOLOGY GRAND ROUNDS

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1 Presentation: Speakers: Presentation: Speakers: Presentation: Speakers: CARDIOLOGY GRAND ROUNDS Date: Case Review: Open thoracoabdominal aortic aneurysm repair Timothy M. Sullivan, MD, Minneapolis Heart Institute at Abbott Northwestern Hospital OBJECTIVES At the completion of this activity, the participants should be able to: 1. Identify the indications for aneurysm repair. 2. Identify risk factors for spinal cord ischemia during open repair. 3. Review operative techniques to reduce visceral ischemia during open repair. Case Review: Endovascular repair of thoracoabdominal aortic aneurysm using fenestrated stent graft Jesse M. Manunga, Jr., MD, Minneapolis Heart Institute at Abbott Northwestern Hospital OBJECTIVES At the completion of this activity, the participants should be able to: 1. The indication for repair of thoracoabdominal aneurysm. 2. Available options for repair of thoracoabdominal aneurysm. 3. Limitations of the currently available treatment options. Data Review: Closure device complications following percutaneous femoral arterial catheterization Jason Q. Alexander, MD, Minneapolis Heart Institute at Abbott Northwestern Hospital OBJECTIVES At the completion of this activity, the participants should be able to: 1. Identify the pertinent anatomic landmarks for percutaneous femoral access 2. Identify the characteristics which increase the risk of closure device complications 3. Recognize the long term patient implications of closure device complications. Monday, November 30, 2015, 7:00 8:00 AM Location: ANW Education Building, Watson Room ACCREDITATION Physician: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Allina Health and Minneapolis Heart Institute Foundation. Allina Health is accredited by the ACCME to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Nurse: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.2 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. DISCLOSURE STATEMENTS Speaker: Dr. Manunga declared the following relationship; Consultant: Cook Medical, Inc. Dr. Alexander declared the following relations; Consultant: Lake Region Medical. None of their devices will be discussed nor are germane to the presentation. Dr. Sullivan has declared he does not have any conflicts of interest. Planning Committee: Dr. Michael Miedema, and Jolene Bell Makowesky have declared that they do not have any conflicts of interest associated with the planning of this activity. Dr. Robert Schwartz declared the following relationships stockholder: PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE

2 Cardiomind, Interface Biologics, Aritech, DSI/Transoma, InstyMeds, Intervalve, Medtronic, Osprey Medical, Stout Medical, Tricardia LLC, CoAptus Inc, Augustine Biomedical; scientific advisory board: Abbott Laboratories, Boston Scientific, MEDRAD Inc, Thomas, McNerney & Partners, Cardiomind, Interface Biologics; options: BackBeat Medical, BioHeart, CHF Solutions; speakers bureau: Vital Images; consultant: Edwards LifeSciences. PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE

3 UPDATE ON CLOSURE DEVICE COMPLICATIONS JASON Q. ALEXANDER MD ERICA BAUMANN PA-C NOVEMBER 30 TH,

4 WHERE TO PUNCTURE IN THE COMMON FEMORAL ARTERY? GOLDILOCKS PRINCIPLE 2

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6 INFERIOR EPIGASTRIC ARTERY DEMONSTRATION OF INFERIOR EPIGASTRIC ARTERY LEADING TO RETROPERITONEAL POSITION 4

7 IDEAL STICK LEVEL 33 FEMORAL ACCESS SITE COMPLICATIONS EVALUATED FOR PUNCTURE LOCATION ANGIOGRAPHICALLY TOO HIGH 100% OF PATIENTS WITH RETROPERITONEAL BLEEDS HAD PUNCTURE ABOVE THE INFERIOR BORDER OF INFERIOR EPIGASTRIC ARTERY Inferior epigastric artery ANGIOGRAPHIC PREDICTORS OF FEMORAL ACCESS SITE COMPLICATIONS: IMPLICATION FOR PLANNED PERCUTANEOUS CORONARY INTERVENTION SHEREV DA ET AL. CATHETER CARDIOVASC INTERV

8 TOO LOW 116 PATIENTS EVALUATED FOR PUNCTURE SITE EIA 2.7% CFA 77.7% SFA/PFA 19.8% 273 PSEUDOANEURYSMS EIA 7.6% CFA 54.3% SFA/PFA 38.1% HIGH BIFURCATIONS 45% OF BIFURCATIONS ARE AT OR ABOVE THE LOWER BORDER OF THE FEMORAL HEAD 5.5% BIFURCATION IS AT OR ABOVE THE CENTER OF THE FEMORAL HEAD 6

9 INCIDENCE OF COMMON FEMORAL ARTERY DISEASE 21/85 PATIENTS WITH CALCIFICATION IDENTIFIED IN THE COMMON FEMORAL ARTERY ON ULTRASOUND EXAM 13/85 WITH ANTERIORLY LOCATED CALCIFICATION ULTRASOUND GUIDED PUNCTURE OF THE FEMORAL ARTERY FOR TOTAL PERCUTANEOUS AORTIC ANEURYSM REPAIR OGUZKURT ET AL. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY

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11 CLOSURE DEVICES FOR PERCUTANEOUS FEMORAL ACCESS LONGER, MORE COMPLICATED PROCEDURES IN BIGGER, OLDER, MORE COMPLICATED PATIENTS, REQUIRING GREATER DEGREES OF ANTICOAGULATION PATIENTS LOVE THEM CLOSURE DEVICES FOR PERCUTANEOUS FEMORAL ACCESS LONGER, MORE COMPLICATED PROCEDURES IN BIGGER, OLDER, MORE COMPLICATED PATIENTS, REQUIRING GREATER DEGREES OF ANTICOAGULATION PATIENTS LOVE THEM WHEN THEY WORK 9

12 DO CLOSURE DEVICES STOP BLEEDING? DATA SURGICAL COMPLICATIONS WITH CLOSURE DEVICES 29/5576: 0.5% 26/5538: 0.5% HIGH RISK PCI? ABSOLUTELY 10

13 Common Femoral Artery Superficial femoral artery Profunda femoral artery Common Femoral Artery Superficial femoral artery Profunda femoral artery 11

14 Raised dissection flap 12

15 TREATMENT FOR COLD LEG 13

16 GAPS IN THE DATA SET: PERCENTAGE OF PATIENTS UNDERGOING PERCUTANEOUS PROCEDURES THAT HAVE A CLOSURE DEVICE PLACED (PREVIOUSLY 50%) WHICH OPERATOR PLACES THE CLOSURE DEVICE IS NOT ALWAYS CLEARLY DELINEATED WE DID NOT LOOK INTO FACTORS THAT MAY HAVE CHANGED SINCE THE LAST INVESTIGATIVE PERIOD: LENGTH OF PROCEDURE, HIGH RISK BLEED PCI, SHEATH SIZE CHANGES, NEW DEVICE USE ETC. DID NOT LOOK AT COMPLICATIONS IN PATIENTS THAT DID NOT HAVE CLOSURE DEVICES QUALITY IMPROVEMENT JAN 2009-JUNE 2011 (30 MONTHS) 11,114 PERCUTANEOUS FEMORAL ARTERIAL PROCEDURES 29/11,114 CLOSURE DEVICE COMPLICATIONS REQUIRING SURGERY 0.26% 29/5576 PERCUTANEOUS FEMORAL ARTERIAL PROCEDURES WITH CLOSURE DEVICES 0.52% JAN 2015-OCTOBER 2015 (10 MONTHS) 3,166 PERCUTANEOUS FEMORAL ARTERIAL PROCEDURES 21/3, % P=0.002 (FISHER S EXACT) 14

17 VARIATION IN CLOSURE DEVICE COMPLICATIONS BETWEEN SERVICES NEURO-INTERVENTIONAL RADIOLOGY (2/252) 0.79% INTERVENTIONAL CARDIOLOGY (19/2581) 0.73% INTERVENTIONAL RADIOLOGY (0/135) 0.0% VASCULAR SURGERY (0/198) 0.0% VARIATION IN CLOSURE DEVICE COMPLICATIONS BETWEEN SERVICES VASCULAR SURGERY (0/198) 0.0% INTERVENTIONAL CARDIOLOGY (19/2581) 0.73% INTERVENTIONAL RADIOLOGY (0/135) 0.0% NEURO-INTERVENTIONAL RADIOLOGY (2/252) 0.79% 15

18 VARIATION: INDIVIDUAL PRACTITIONERS (MINIMUM OF 250 ACCESSES) HIGHEST: (7/287) 2.4% LOWEST: (1/391) 0.25% P=0.007% BUT WITH BLAST SHIELD DOWN I CAN T SEE ANYTHING -LUKE SKYWALKER, A LONG TIME AGO IN A GALAXY FAR, FAR AWAY 16

19 MOST CONSECUTIVE (BLINDFOLDED) 88 (FRED NEUMAN) 1 MINUTE (BLINDFOLDED) 17 (ED PALBINSKAS) FREE THROW RECORDS MOST CONSECUTIVE 5221 (TED ST. MARTIN) 24 HOURS 20,371/22,043 (FRED NEUMAN) 1 MINUTE 50/59 (BOB J. FISHER) 17

20 VARIATION: ULTRASOUND USE (MINIMUM 250 ACCESSES) NO ULTRASOUND GUIDED PUNCTURE (13/1170) 1.1% ULTRASOUND GUIDED PUNCTURE (5/1058) 0.47% P= 0.09% 18

21 DEVICE COMPLICATIONS FROM DEVICE WAS NOT STATISTICALLY SIGNIFICANT BETWEEN ANGIOSEAL AND PERCLOSE IN ANALYSIS COMPARISON OF TYPES OF CLOSURE DEVICES PERCLOSE HAD A 0.8% FAILURE RATE REQUIRING SURGICAL INTERVENTION (22/2507) ANGIOSEAL HAD A 0.73% FAILURE RATE REQUIRING SURGICAL INTERVENTION (6/826) STARCLOSE HAD A 0.045% FAILURE RATE REQUIRING SURGICAL INTERVENTION (1/2243)- STATISTICALLY SIGNIFICANT WITH A P VALUE OF <

22 CLOSURE DEVICE BREAKDOWN 2015 ANGIOSEAL: 12 PERCLOSE: 8 UNKNOWN: 1 BREAKDOWN OF THE 21 CLOSURE DEVICE COMPLICATIONS ANGIOGRAM PERFORMED: 9 NO ANGIOGRAM RECORDED: 11 UNABLE TO OBTAIN INFORMATION: 1 20

23 21

24 ADEQUACY OF ANGIOGRAM 9 ANGIOGRAMS 5 ADEQUATE ANGIOGRAMS 3 OF THE ADEQUATE COMPLETION ANGIOGRAMS HAD FINDINGS THAT MAY HAVE BEEN PROHIBITIVE OF CLOSURE DEVICE PLACEMENT 22

25 WHO PLACES THE CLOSURE DEVICE? NON PRIMARY PRACTITIONER: 8 NOT DOCUMENTED: 1 CONCLUSIONS THE CLOSURE DEVICE COMPLICATION RATE IN MHI/ABBOTT HAS INCREASED IN THE LAST YEAR ULTRASOUND APPEARS TO BE A FORMIDABLE WEAPON IN DECREASING THE CLOSURE DEVICE COMPLICATION RATE AN ADEQUATE ANGIOGRAM OF THE FEMORAL ARTERY MAY HELP WITH DECISION MAKING REGARDING PLACEMENT OF A CLOSURE DEVICE AS WITH ANY TECHNOLOGY, TRAINING IS IMPORTANT IS APPROPRIATE DEPLOYMENT AND USE 23

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