Ziyad M. Hijazi, MD, FSCAI, FACC
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1 Ziyad M. Hijazi, MD, FSCAI, FACC The James A. Hunter, MD, University Chair Professor of Pediatrics & Internal Medicine Rush Center for Congenital & Structural Heart Disease Rush University Medical Center Chicago, IL
2 Topics 1. Traditional Vascular Access 2. Untraditional Vascular Access (Transhepatic & Direct LV access) 3. Vessel Closure Device (VCD)
3 Traditional Venous & arterial Access! 1. Umbilical vein/artery 2. Femoral Veins/arteries 3. Internal Jugular Veins 4. Carotid cutdown 5. Subclavian Veins
4 Umbilical vein/artery Access! 1. Neonatal period-may be up to a week of life 2. Efforts should be made to use this route-spare other access routes for future caths 3. most interventional procedures in neonates can be done using this access.
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6 Femoral Vein & Artery! 1. Preferred site for cardiac caths beyond neonatal period 2. Straight access to the right and left heart 3. Femoral veins can accommodate large sheaths
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8 Problems Encountered Using Femoral Veins 1. Thrombosis 2. Interruption of the IVC 3. IVC Filters 4. Protection for future catheterization
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10 Internal Jugular Vein/Subclavian Vein 1. Suitable alternatives 2. Cumbersome to manipulate catheters/devices from such routes, but are important access sites that catheterizers need to know anatomy well!
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12 Carotid Artery 1. cut-down is the preferred method! 2. Usually limit this route to neonatal period-risk of stroke 3. Neonatal critical AS: this approach has been used for balloon valvuloplasty
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14 Topics 1. Traditional Vascular Access 2. Untraditional Vascular Access (Transhepatic & Direct LV access) 3. Vessel Closure Device (VCD)
15 Transhepatic Access When other access sites are not available 1. Thrombosis 2. Interruption of the IVC 3. IVC Filters 4. Protection for future catheterization
16 Technique 1. Mid axillary line 2. Chiba needle with a stylet! Puncture 1/2 way between diaphragm and liver edge! Orientate the needle horizontal/posterior to 1/2 way from midline! Withdraw stylet; aspirate until blood comes back; inject contrast guide wire 4. Coaxial dilator (4-5Fr) 5. MUOM sheath
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23 End of Procedure 1. Remove sheath-no coiling 2. Coil/plug closure of tract 3. Gel foam closure of tract
24 Coil closure of tract 3mmx4cm coil if sheath 6F or less Coils should be used after sheath was withdrawn and no blood comes back. Multiple coils/plug may be required.
25 Gel Foam Vascular Access-Trans-hepatic & Vascular
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29 Complications 1. Intraperitoneal hemorrhage 2. Cholangitis
30 Direct LV Puncture
31 Indications 1. Double mechanical valves 2. For closure of paravalvar mitral leaks
32 Technique 1. CT/TTE/coronary angiography to localize the apex of the LV & localize LAD 2. Mark the chest wall 3. Use a puncture needle (Micro puncture kit) 4. Place a short sheath 5. Perform study/intervention 6. At end, hold pressure
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34 Complications 1. Hemo pericardium 2. Hemo thorax
35 Topics 1. Traditional Vascular Access 2. Untraditional Vascular Access (Transhepatic & Direct LV access) 3. Vessel Closure Device (VCD)
36 $500 $400 $300 $200 $100 $ Closure Device Market Medtech Insight.
37 The Promise of Vascular closure Devices Patient comfort and convenience Decreased Time to hemostasis Early ambulation Shorter hospital stay Decreased overall procedure-related hospital costs Decreased complication rates
38 Categories of closure devices Anchored plugs Unanchored plugs Suture closure Clip/staple closure Topical patches No footprint devices Ultrasound/heat
39 Anchored Plugs Active Approximation Angio-Seal Collagen Thrombosing agent Advantages- High success rate, short learning curve, short deployment time Disadvantages-vascular occlusion, potential infection
40 Suture and Staple/Clip Devices Active Approximation Superstitch Perclose StarClose AngioLink
41 Unanchored Plugs Passive Approximation VasoSeal Duett Thrombosing agent
42 New Unanchored Plug Technology Passive Approximation Mynx Vascular Sealants ExoSeal
43 No footprint devices Passive approximation Boomerang Catalyst ClosureWire Advantages-No foreign body No thrombosing or sealing agents
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45 Ultrasound/Heat Therus Passive Approximation Epiclose Plus
46 Closure Begins with Access Femoral Introducer Sheath and Hemostasis Arstasis device
47 Topical Hemostatic Patches Passive Approximation NON-INVASIVE Chito-Seal, Clo-Sur P.A.D., D-Stat, Neptune, Stasys, Syvek, HemCon
48 Active Approximation for Venous Puncture Figure of 8
49 Which Device to Use? Patient and Vessel specific Heavily anti-coagulated- invasive active approximation Diseased vessel- passive approximation Residual oozing- thrombosing sealing agent or topical hemostatic patch Operator experience/competence
50 10 Vascular Access-Trans-hepatic & Vascular The Importance of Operator Experience 8 % Patients Balzer et al. CCI 2001; 53: 174
51 Moral of the Learning Curve Learn one or two devices and learn them extremely well Consider an additional device for special circumstances Remember that manual compression is always an option
52 Device-related: Embolization Infection Vessel obstruction Direct mechanical Injection into vessel Bleeding Mechanical secondary to device Secondary to early sheath pull Complications Specific to VCDs
53 Ellis et al., CCI 2006, 67:541 Vascular Access-Trans-hepatic & Vascular Retroperitoneal Hemorrhage
54 How to Decrease Risk of Complications 1. Use fluoroscopy and/or ultrasound to ensure needle entry below centerline of femoral artery 2. Femoral angiogram regardless of closure device use. Allow ACT to normalize 3. Proceed to PCI (and anticoagulate) only if puncture in safe zone
55 How to Decrease Complications Courtesy of Zoltan Turi
56 Courtesy of Zoltan Turi Vascular Access-Trans-hepatic & Vascular How to Decrease Risk of Complications
57 Conclusions/Take Home Message The interventional Cardiologist should know the advantages of trans-hepatic approach and how to perform it safely. VCD s are extremely useful in older patients. Knowledge of 1-2 VCD is important.
58 PICS-AICS SAVE THE DATE APRIL Marriott CHICAGO Downtown 2O12 CHICAGO
Ziyad M. Hijazi, M.D., MPH, FSCAI, FACC
Ziyad M. Hijazi, M.D., MPH, FSCAI, FACC Professor of Pediatrics & Internal Medicine Rush University Medical Center Chicago Traditional Venous & arterial Access! 1. Umbilical vein/artery 2. Femoral Veins/arteries
Vascular Closure Techniques
Vascular Closure Techniques Femoral Approach Clifford J Kavinsky, MD, PHD Professor of Medicine and pediatrics Associate Director, Center for Congenital and Structural Heart Disease Rush University Medical
Vascular Closure Techniques
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Femoral Closure Devices: Good, Bad and Ugly. Zoltan G. Turi, M.D. Rutgers Robert Wood Johnson Medical School New Brunswick, NJ
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Vascular Closure Techniques
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Closure Devices. Peter F Ludman Advanced Angioplasty 2003
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