Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I. SCRIPPS CLINIC

Transcription

1 Avoiding and Managing Femoral Access Site Complications Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I. Director, Peripheral Interventions Program Director, Interventional Cardiology Fellowship Division of Cardiology Scripps Clinic La Jolla, CA

2 Radial Access: A Game Changer

3 Radial Myth vs. Radial Reality Radial catheterization is an important innovation in cardiology and works very well for the right patient and the right anatomical situation Skilled operators can probably perform around 80% of cases from the radial approach. but what about the other 20%? Peripheral interventions? Impella, ECMO? Complex cases? TAVR? Aberrant radial anatomy/tortuosity/spasm? Aberrant radial anatomy/tortuosity/spasm? Learning and maintaining proper femoral access and management skills is still of critical importance!

4 How do we teach new fellows to be proficient at femoral access when we do so many radial cases now??

5 Femoral Access: Considerations Many femoral access site complications can be avoided by proper access technique Always presume that the access site will be managed by manual compression alone DO NOT assume a closure device can/will be used and will always work Goal is to obtain access in a compressible site to maximize chances of success of a manual hold

6 Anatomy of the Femoral Region External Iliac Deep Circumflex Iliac Inferior Epigastric Common Femoral Inguinal Ligament Profunda Femoris Superficial Femoral

7 Anatomy of the Femoral Region Origin of IEA Inferior border of IEA

8 Lateral Diagram of the Femoral Region Inferior Epigastric Artery Common Femoral Skin Inguinal Ligament Superficial Femoral Artery External Iliac Artery Pubis Femoral Head Profunda Femoris Artery

9 The Common Femoral Artery Directly Overlies the Pubis and NOT The Femoral Head

10 The Pubis: A Key Structure in Femoral Artery Access and Closure PUBIS

11 How Does Manual Compression Really Work? Vessel is compressed to stop bleeding long enough to allow the stretched arteriotomy to recoil back down to original 18 Gauge hole and develop a small thrombus

12 External Compression of Appropriate Access Site External compression controls access site due to the presence of bony structure posteriorly (pubis)

13 Attempted External Compression of High Access Site External compression fails to control high access sites due to displacement of vessel inferiorly and lack of bony structure posteriorly to compress against

14 Attempted External Compression of Low Access Site External compression fails to control low access sites due to displacement of vessel inferiorly and lack of bony structure posteriorly to compress against

15 The Common Femoral Artery: A New Definition Functional Conventional

16 This is probably how you were taught to get femoral arterial access...

17 Hemostat Guidance Thin Patient Hemostat SKIN

18 Hemostat Guidance Obese Patient Hemostat SKIN

19 Hemostat fluoroscopic guidance followed by manual palpation in obese patient OOPS...

20 Retroperitoneal bleeding due to laceration of the inferior epigastric artery Using fluoroscopic guidance of the femoral head followed by manual palpation can lead to laceration of adjacent structures

21 LESSON: Using the femoral head as a marker followed by manual palpation is fraught with problems!

22 1004 patients randomized 1:1 to femoral access using fluroscopy alone vs. ultrasound guidance Ultrasound Use Associated with: Lower vascular complication rates Improved first pass success rate Reduced number of access attempts Reduced risk of inadvertent venopuncture Reduced time to access JACC INTERV., VOL. 3, NO. 7, 2010 JULY 2010:751 8

23 BUT... I Used Ultrasound! Entry site is within the conventional common femoral artery, but not within the functional CFA

24 Use fluoroscopy to position ultrasound probe over the pubis Then use ultrasound to visualize needle entering artery Insert needle into artery at 45 degree angle

25 Optimal Femoral Access: Ultrasound AND Fluoroscopy Ultrasound gets you into the vessel Assures single puncture of the center of the artery, avoids inadvertent injury of unwanted structures Fluoroscopy gets you into the vessel in the right place Assures entry into the artery over the pubis

26 Lets take an angiogram at the end of the case to see if we can use a closure device LESSON: Take angiogram BEFORE proceeding with case and giving anticoagulation

27 Wire Insertion Technique Correct Technique Incorrect Technique Needle bevel not fully inserted through vessel wall, but inserted enough to get flash Needle inserted fully into vessel (but NOT through posterior wall) at 45 degree angle Wire advanced into subintimal space leading to dissection

28 Glidewire used and advanced easily but guide wont advance LESSON: Use soft tip shapeable wire (ie: Wholey wire) if J wire wont advance

29 Complications Associated With Femoral Access Hematoma Pseudoaneurysm Arterial-Venous Fistula Retroperitoneal Hemorrhage Dissection Endarteritis Acute Closure/Vascular Compromise Distal Embolization Nerve Injury

30 Complications Associated With Femoral Access Hematoma Multiple punctures Back wall/through and through puncture Poor hemostasis with closure device or manual hold Laceration of femoral artery Laceration/puncture of adjacent vessels Kinked sheath at arteriotomy replace with braided sheath Access site not over bony structures cant adequately control bleeding with compression Any of the above with anticoagulation

31 78yo morbidly obese female PCI via left groin Manual hold in recovery area During hold process large hematoma forms and is expanding Multiple people pressing down on groin site Hypotensive responds to fluids Hypotensive again taken back to cath lab..

32 Alternate access rapidly obtained Balloon inserted and inflated Hemostasis achieved Blood pressure immediately improves Taken to OR: left femoral artery repaired, large left thigh hematoma evacuated

33 Small hematomas can be stabilized and resolved with good manual pressure Large hematomas are nearly impossible to manage with external compression alone- impossible to get point pressure on the artery just above the puncture site Often pressure is distributed too widely and can lead to injury of adjacent femoral nerve or compression of vessel distal to bleeding site accentuates bleeding These are best managed by rapid internal tamponade technique, +/- surgery or covered stent placement along with supportive measures

34 Complications Associated With Femoral Access Pseudoaneurysm Site of access below pubis cant compress adequately Use of Femostop for primary hemostasis Poor manual hold technique/weak hands Multiple punctures in close proximity Late/delayed failure of closure device

35 Mechanism of Pseudoaneurysm Formation

36 Pseudoaneurysm from low access and poor hold technique

37 Management of Pseudoaneurysm If less than 2cm in size and assymptomatic, may not require intervention If 2cm or greater in size and with narrow neck, ultrasound guided compression or thrombin injection is very effective Wide neck pseudoaneurysms are not ideal for thrombin injection, and may require surgical intervention

38 Complications Associated With Femoral Access Arterial-Venous Fistula Low access site Improper technique: see dark red flash, but instead of removing needle, needle is advanced further and see bright red flash sheath inserted Multiple punctures: more likely to hit vein and artery simultaneously Needle inserted medial to artery and at lateral angle

39 AV Fistula Large AV fistula from previous low access Typically not treated unless large shunt leads to symptoms or CHF

40 Complications Associated With Femoral Access Retroperitoneal Hemorrhage High access site/non-compressible access site Use of Femostop or poor manual hold in obese patients large pannus leads to pressure being applied DISTAL to arteriotomy blood then tracks upwards through femoral canal into abdomen instead of into thigh because Femostop or manual pressure is creating a physical barrier Laceration of adjacent vessels Wire perforation of small branches in pelvis use of Glidewire/non J-tipped wires

41 Not just from a high stick!! Obese patient: Femostop slipped down

42 Retroperitoneal bleeding with Bladder Sign

43 Complications Associated With Femoral Access Dissection Most often due to poor access technique- partial needle insertion or simply forcing J wire to go if resistance felt Use of Glidewire or other hydrophillic and/or stiff wires Advancing wire without fluoro imaging

44 Most dissections are retrograde, and simply removing wires/equipment will allow them to heal over time Antegrade dissections can occur upon withdrawl of shaped catheters or bulky devices (ie: valvuloplasty balloons, large diameter sheaths, etc.) and should be treated to prevent propagation and subsequent flow limitation Antegrade dissections typically can be managed with a combination of balloon angioplasty and stent placement

45 Complications Associated With Femoral Access Endarteritis Can occur with closure devices, especially in very thin or very obese Don t discharge patients with tegaderm-type dressings in place! Don t use closure devices in immunocompromised patients

46 Complications Associated With Femoral Access Acute Vessel Closure DO NOT hold fully occlusive pressure on a severely diseased artery for more than 10 minutes Do not deploy closure devices in a significantly diseased or dissected femoral artery Assess distal pulses before and immediately after hemostasis is complete to assure no new compromise has occurred If patient complains of foot/leg pain or numbness consider acute vascular compromise this is an EMERGENCY

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48 Complications Associated With Femoral Access Distal Embolization Can occur due to disruption of plaque by catheters/wires, or thrombus formation around sheath, catheters. Critically important to assess distal pulses before and after procedure to assess for any change.

49 Aspirate 2-4 cc of blood from indwelling sheath before removing it DON T flush sheath by flushing saline into patient may embolize a clot DON T aspirate 2-3 cc and then flush it right back into the patient! DON T leave a sheath in a patient for longer than really necessary

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51 Complications Associated With Femoral Access Femoral Nerve Injury Be sure you are placing point pressure on the artery or vein and NOT on the femoral nerve! Prolonged holds or holds that use a wide hand technique are more likely to injure the femoral nerve Hematomas and pseudoaneurysms can also locally compress the femoral nerve

52 Stinis Rule First episode: Could be vaso-vagal (if getting manual pressure) Fluids, Atropine Second episode: Retroperitoneal bleeding until proven otherwise! Fluids, call for blood, vasopressors, Trandelenberg, consider immediate return to cath lab for further investigation and internal tamponade and/or covered stent placement DO NOT send a suspected retroperitoneal bleeding patient to the CT scanner! CT is not an actual therapy for hypotension or retroperitoneal bleeding!!

53 It s July at a teaching institution... What to do? Call surgeons Pull and hold (and pray) Closure device?

54 Contralateral femoral access obtained Be sure second access is not too high!

55 Cross over into external iliac with Rim catheter and glidewire and obtain angiogram

56 Remove sheath, close high access site with Perclose device and reinsert guidewire to maintain vessel access Angiogram taken to assess for extravasation

57 Wire removed Sutures secured in place Completion angiogram performed to assure no evidence of bleeding

58 Important to take angiograms in multiple views Mild vessel spasm noted, but no extravasation

59 Management of Inadvertent High Access Site DO NOT send the patient for a manual hold! DO NOT blindly close the access site and assume the patient is OK because you don t see any bleeding and they seem stable... You wont see the bleeding- its going into the retroperitoneal space! DO obtain alternative access and close the high access with a Perclose device and directly visualize by angiography that it is indeed closed- DO NOT use any other closure device! DO have an appropriately sized balloon ready to go in case internal tamponade is needed

60 Most femoral access site complications can be avoided by obtaining proper access of the vessel Access should be iin the functional CFA over the pubis Use ultrasound AND fluoroscopy: neither by itself Avoid high and low sticks Single anterior wall puncture at 45 degrees Perform femoral angiogram at the BEGINNING of the case Don t attempt to perform a manual hold on any site of access in the vicinity of or above the inguinal ligament Large or expanding hematomas are best managed by urgent internal tamponade, followed by surgical intervention or covered stent placement