Diagnosis and Management of Femoral Access Site Complications IV: Novel Techniques for Endovascular Rescue
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1 Diagnosis and Management of Femoral Access Site Complications IV: Novel Techniques for Endovascular Rescue Robert M. Bersin, M.D. Director, Endovascular Services Seattle Cardiology and the Cardiovascular Consultants of Washington Seattle, Washington Cardiovascular Consultants of Washington
2 Conflict of Interest Statement Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Robert M. Bersin, M.D Name of Company: Abbott Vascular P Name of Company: Boston Scientific AB, C, GS, P, SB Name of Company: Bristol-Myers Squibb C, SB Name of Company: Cordis Endovascular AB,C, EI, P, SB Name of Company: E.I Lilly C, SB Name of Company: ev3 P Name of Company: Guidant Corporation C, P Name of Company: The Medicines Company SB Name of Company: Medtronic Vascular P Name of Company: Sanofi-Aventis C, SB Name of Company: Vascular Solutions AB, C, SO AB: Advisory Board C: Consulting Relationship EI: Equity Interest GS: Grant Support P: Proctor or Training Course Sponsorships SB: Speakers Bureau SE: Spouse Employee SO: Stock Options or Positions Off label use of products will be discussed in this presentation: Off label use of nitinol stents for iliac and femoral artery stenting
3 Access Site Complications Hypotension, hematoma, bleeding Pseudoaneurysm Neuropathy AV fistula Dissection, thrombosis, acute occlusion Infection
4 Percutaneous Treatment Options Balloon tamponade Endoluminal grafts Coils Thrombin injection
5 Endoluminal Graft for Retroperitoneal Hemorrhage
6 What is the diagnosis? Silva et al, CCI 64: , 2005
7 Inferior epigastric artery engaged with 6Fr guiding catheter Silva et al, CCI 64: , 2005
8 Balloon inflated across perforation x 3 No change in rapid bleeding Silva et al, CCI 64: , 2005
9 Thrombin 200 IU injected distally Bleeding reduced but still present Silva et al, CCI 64: , 2005
10 Final angiogram No flow after 300 IU thrombin Silva et al, CCI 64: , 2005
11 Pseudoaneurysms
12 Pseudoaneurysms Incidence Duplex ultrasound 6.0 % Clinical detection % Risk factors Female > 70 yrs Diabetes Obesity High or low (SFA) stick
13 Treatment Options Surgical repair Manual compression Ultrasound guided compression Thrombin injection Ultrasound guided Flouroscopic Samal et al, Cathet Cardiovasc Intervent 2001;53:
14 Pseudoaneurysms Small ( 2 cm) may be observed and are likely to close spontaneously Larger aneurysms may be closed with: Ultrasound guided compression Ultrasound guided thrombin injection Surgical correction Catheter-based therapy
15 Ischemia/Thrombosis/Emboli Incidence 1.0 % Causes: Large access catheter/small artery Presence of peripheral arterial disease Iatrogenic dissection Thrombus within sheath Closure device complication
16 Ischemia/Thrombosis/Emboli Signs and symptoms: Pain Pallor Paresthesia Pulselessness Polar (cold).
17 Ischemia/Thrombosis/Emboli Management Contralateral access and angiography. Cross with hydrophilic wire. Mechanical thrombectomy. AND/OR PTA with provisional stenting.
18 Ischemia/Thrombosis/Emboli
19 Thrombectomy and PTA
20 Access site closure The right tool for the job! Manual compression External mechanical compression (FemoStop, Hold) External plug (Vasoseal, Quickseal) Internal fixation of external collagen (Angioseal) Surgical closure (Perclose, Sutura) Thrombin/collagen closure (Duett) Vascular Sealing Gel
21 With new technology comes new problems
22 New complications Closure device related: Device failure Access site abscess Septic emboli Collagen embolization syndrome Vessel rupture Acute limb ischemia
23 Perclose Complication
24 Angioseal Complication
25 Meta-Analysis of Closure Device Trials 33,125 Patients - 21 Independent Trials AngioSeal Diag Inter VasoSeal Diag Inter Duett Diag Inter Perclose Diag Inter Manual Diag Inter Major Complications 2.3% 2.3% 1.8% 11.2% 2.4% 4.1% 2.0% 2.8% 0.5% 2.9% Minor Complications 3.8% 3.9% 1.7% 16.1% 5.6% 4.9% 3.2% 7.8% 1.2% 7.7% n= E. K. Hoffer, et. al. JVIR, July 2003 Versus
26 Meta-Analysis of Closure Device Trials 37,066 Patients - 30 Independent Trials JACC 2004;44:1200-9
27 Limitations of the trials Excluded high risk patients! Obese Uremia CFA calcification CFA or external iliac stenosis Coagulopathy Low platelet count Uncontrolled hypertension Oral anticoagulants Lumbar radiculopathy So extrapolation of these results to the general patient population is hazardous!
28 Access Site Complications Conclusions Bleeding is life threatening and needs rapid diagnosis and treatment. CT scans document the obvious but don t tell you if the patient is still bleeding. Diagnosis requires CFD or Angiography Treatment options include: Manual compression Percutaneous tamponade, thrombin, ELG and coils Surgery AVF only require treatment if symptomatic. Pseudoaneurysms, acute ischemia, and other access complications can be managed percutaneously or surgically. Baseline angiogram after obtaining access can permit safe intervention without bleeding from collateral bleeding and unusual access configurations.
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