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 3. Internal Jugular Veins 4. Carotid cutdown 5. Subclavian Veins
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.
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
Problems Encountered Using Femoral Veins 1. Thrombosis 2. Interruption of the IVC 3. IVC Filters 4. Protection for future catheterization
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!
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
Transhepatic Access When other access sites are not available 1.Thrombosis 2. Interruption of the IVC 3. IVC Filters 4. Protection for future catheterization
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. 3. 0.018 guide wire 4. Coaxial dilator (4-5Fr) 5. MUOM sheath
End of Procedure 1. Remove sheath-no coiling 2. Coil closure of tract 3. Gel foam closure of tract
Coil closure of tract 3mmx4cm coil if sheath 6F or less Coils should be used after sheath was withdrawn and no blood comes back.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 may be required.
Gel Foam
Complications 1. Intraperitoneal hemorrhage 2. Cholangitis
Direct LV Puncture
Indications 1. Double mechanical valves 2. For closure of paravalvar mitral leaks
Technique 1. CT/TTE to localize the apex of the LV 2. Mark the chest wall 3. Use a 0.021 puncture needle (Micro puncture kit) 4. Place a short sheath 5. Perform study/intervention 6. At end, hold pressure
Complications 1. Pericardial effusion 2. Pleural effusion
$500 $400 $300 $200 $100 $0 2000 2001 2002 2003 2004 2005 2006 Closure Device Market Medtech Insight.
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
Categories of closure devices Anchored plugs Unanchored plugs Suture closure Clip/staple closure Topical patches No footprint devices Ultrasound/heat
Anchored Plugs Active Approximation Angio-Seal Collagen Thrombosing agent Advantages- High success rate, short learning curve, short deployment time Disadvantages-vascular occlusion, potential infection
Suture and Staple/Clip Devices Active Approximation Superstitch Perclose StarClose AngioLink
Unanchored Plugs Passive Approximation VasoSeal Duett Thrombosing agent
New Unanchored Plug Technology Passive Approximation Mynx Vascular Sealants ExoSeal
No footprint devices Passive approximation Boomerang Catalyst ClosureWire Advantages-No foreign body No thrombosing or sealing agents
Ultrasound/Heat Passive Approximation Therus Epiclose Plus
Closure Begins with Access Femoral Introducer Sheath and Hemostasis Arstasis device
Topical Hemostatic Patches Passive Approximation NON-INVASIVE Chito-Seal, Clo-Sur P.A.D., D-Stat, Neptune, Stasys, Syvek
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
10 The Importance of Operator Experience 8 % 6 4 2 0 25 75 150 250 350 450 550 650 750 850 930 Patients Balzer et al. CCI 2001; 53: 174
10 The Importance of Operator Experience 8 % 6 4 2 0 25 75 150 250 350 450 550 650 750 850 930 Patients Balzer et al. CCI 2001; 53: 174
Moral of the Learning Curve
Moral of the Learning Curve Learn one or two devices and learn them extremely well
Moral of the Learning Curve Learn one or two devices and learn them extremely well Consider an additional device for special circumstances
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
Complications Specific to VCDs Device-related: Embolization Infection Vessel obstruction Direct mechanical Injection into vessel Bleeding Mechanical secondary to device Secondary to early sheath pull
Retroperitoneal Hemorrhage Ellis et al., CCI 2006, 67:541
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
How to Decrease Complications Courtesy of Zoltan Turi
How to Decrease Risk of Complications Courtesy of Zoltan Turi
Conclusions/Take Home Message The interventional Cardiologist should know the advantages of trans-hepatic approach and how to perform it safely. VCDʼs are extremely useful in older patients. Knowledge of 1-2 VCD is important.
Pediatric & Adult Cardiac Interventional Therapies