Optimal Techniques for Obtaining Large Caliber Arterial Access

Transcription

1 Optimal Techniques for Obtaining Large Caliber Arterial Access Gerald Yong MBBS (Hons) FRACP FSCAI Interventional Cardiologist Royal Perth Hospital Western Australia APCASH 11 October 2014

2 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial Interest /arrangement or affiliation with the organization(s) listed below Affiliation/Financial Relationship Grant/ Research Support: Consulting Fees/Honoraria: Company Edwards Lifesciences (consultant & proctor) Major Stock Shareholder/Equity Interest: Royalty Income: Ownership/Founder: Salary: Intellectual Property Rights: Other Financial Benefit:

3 Transfemoral access will always be the preferred access route for TAVR Vascular complications is common after TAVR Main contributors Large sheaths Bulky devices Risky patient cohort Assoc with catastrophic consequences

4 TAVR Outcomes - VARC Meta-Analysis - 16 studies published Jan 2011 Oct ,519 patients Endpoint Pooled Estimate (%) [95% CI] Vascular 30 days Major 11.9 [8.6, 16.4] Minor 9.7 [6.7, 14.0] All 18.8 [14.5, 24.3] Genereux, P., et al. J Am Coll Cardiol. 2012;59:

5 Vascular Complications associated with Increased Mortality

6 TAVI Vascular Complications: Contemporary Results VARC metaanalysis ADVANCE CoreValve SOURCE-XT Euro-Sentinel Registry N & Valve type 3,619 SAPIEN / XT & CoreValve 1,015 CoreValve 2,700 SAPIEN XT 4,571 SAPIEN XT & CoreValve Time Period Major Vascular Cx Publications Jan 2011-Oct 2011 Mar 2010 Jul 2011 Jun Oct % 6.3% 3.1% Jan Jun 2012

7 Optimal Technique for Obtaining Large Calibre Vascular Access No Optimal technique Rigorous screening Careful procedure Able to deal with emergency

8 Screening, screening, screening Careful puncture Careful preclosure Careful sheath insertion Careful sheath removal Be prepared for emergency Be friends with vascular surgeon

9 Screening, screening, screening Careful puncture Careful preclosure Careful sheath insertion Careful sheath removal Be prepared for emergency Be friends with vascular surgeon

10 Basic Screening Guidelines Determine size and calcification for femoral, external iliac, common iliac and aorta. Vessel size/sheath OD Ratio Evaluate extreme tortuosity Utilize stiff wire during diagnostic cath Observe for significant lesions Minor discrete lesions are generally crossed with dilator/sheath Strategy of pre-stenting iliac generally not successful. Focus on calcification at bifurcations. Aortic and iliac

11 Predictors of Major Vascular Complications Hayashida Van Mieghem Genereux Toggweiller Female Gender Peripheral vascular disease High Sheath:Femoral Artery Ratio; Minimal artery diameter < sheath OD Femoral Calcification on CT Early experience Genereux, P., et al. J Am Coll Cardiol. 2012;60: Hayashida, K., et al. JACC Cardiovasc Interv. 2011;4:851-8 Toggweiler, S., et al. J Am Coll Cardiol. 2012;59:113-8 Van Mieghem, N. M., et al. Am J Cardiol. 2012;110:1361-7

12 Sheath Outer Diameters 16Fr 18Fr 19Fr 20Fr 22Fr 24Fr RF3 Sheath NF Sheath E-Sheath - Unexpanded - Expanded Cook St Jude Gore Terumo Solopath Adpated from Toggweiler, S., et al. JACC Cardiovasc Interv. 2013;6:643-53

13 Vascular Screening Modalities Invasive aortogram bifemoral angiogram CT angiogram Ideally with contrast Non-contrast also useful for assessing calcification Intravascular ultrasound

14 Aortibifemoral Angiography Marker pigtail for calibration ADVANTAGES Good spacial resolution Done same time as coronary angiography Lower contrast load than CT Assess tortuous vessel response to stiff wire for straightening DISADVANTAGES Limited in identification of calcification and atherosclerotic burden Can t identify full 3D feature of tortuosity Can t identify eccentric severe stenoses in one view

15 Tortuosity Tortuous right femoral artery With Lunderquist wire

16 Eccentric lesion AP VIEW LAO VIEW

17 CT Aortogram Better appreciation of calcium and atherosclerotic burden Appreciate tortuosity in 3D Centre-line multiplanar reformat allows measurement of true orthogonal dimensions and CA of vessel Uses more contrast generally than invasive angiography Lower spacial resolution than invasive angiography

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19 Intravascular U/S Vessel size over 7.5 mm throughout except 10 mm segment in external where diameter ~6 x 6 mm

20 Screening, screening, screening Careful puncture Careful preclosure Careful sheath insertion Careful sheath removal Be prepared for emergency Be friends with vascular surgeon

21 Common Femoral Artery Puncture Puncture the anterior wall of the common femoral artery Ideally avoid calcified plaques Options Bony landmark Angiographic guidance from contralateral side Antegrade angiography Cross-over pigtail Ultrasound guidance

22 Common Femoral Artery Puncture Contralateral antegrade AG Cross-over pigtail marking CFA

23 Screening, screening, screening Careful puncture Careful preclosure Careful sheath insertion Careful sheath removal Be prepared for emergency Be friends with vascular surgeon

24 Preclosure for large vascular access KNOW THE DEVICE WELL

25 Perclose ProGlide Insertion and Pre-deployment Needle Plunger Handle Collar Lever Marker Lumen Foot Body QuickCut Link Foot (Deployed) Proximal Guide Guide Wire Exit Port Distal Guide Marker Port Sheath Posterior side of device

26 Simple Pre-tied knot Single operator procedure Secure Perclose ProGlide Insertion and Pre-deployment Polypropylene monofilament suture No reaccess restrictions Control Ability to maintain wire access 1. Foot deployment 2. Needles deployment 3. Connection with pre-tied knot 4. Suture brings the tissues together

27 ProStar XL Insertion and Pre-deployment

28 ProStar XL Insertion and Pre-deployment Four Nitinol Needles Two sutures.038 guidewire compatible Integrated Pre-dilator Knot Pusher

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30 Screening, screening, screening Careful puncture Careful preclosure Careful sheath insertion Careful sheath removal Be prepared for emergency Be friends with vascular surgeon

31 Large Sheath Insertion Over stiff wire Amplatz Extra-stiff or Lunderquist Apply traction to wire Know position of final sheath tip Do not force sheath

32 Large Sheath Insertion Issues Do not force sheath Watch movement of vessel calcium on fluroscopy

33 Large Sheath Insertion Issues Watch BP Occlusion balloon If vascular complications or rupture Occlusion balloon Insert dilator +/- sheath to tamponade

34 Screening, screening, screening Careful puncture Careful preclosure Careful sheath insertion Careful sheath removal Be prepared for emergency Be friends with vascular surgeon

35 Removal Of Large Sheath Contrast injection during sheath removal Contralateral catheter or large sheath Leave guidewire in-place until haemostasis secured if preclosure Final check angiogram from contralateral pigtail Watch BP during sheath removal Ready large dilator or occlusion balloon to tamponade any perforation

36 Crossover Balloon Occlusion Technique (CBOT) Genereux, P., et al. JACC Cardiovasc Interv. 2011;4:861-7

37 Iliac Rupture Hypotension upon sheath removal post CoreValve

38 Screening, screening, screening Careful puncture Careful preclosure Careful sheath insertion Careful sheath removal Be prepared for emergency Be friends with vascular surgeon

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40 Occlusive Dissection Post TAVR with SAPIEN XT 23mm valve (18Fr sheath) Primary failure of preclosure Successful primary closure with Prostar

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42 Gentle balloon dilatation

43 Conclusion Careful pre-procedural screening and meticulous procedural technique are the OPTIMAL technique for vascular access to maintain low vascular complications Prepared to handle complications Well-planned techniques Bail-out equipments Vascular surgical back-up Understand limits Alternatives available TA, TAo, Transubclavian Prepared to take consequences if pushing limit