how to manage access complications

Dr. S. Noble, CC

Médecin adjoint agrégé

Stephane.noble@hcuge.ch

How to manage access complications ?

This is what we want to avoid

Prevention is essential

Prevention is essential

Femoral puncture site site

• In the common femoral artery

• A puncture below or above the femoral head can increase the difficulty to obtain hemostasis by device closure and manual compression (lack of bone structures)

Do not take the skin crease as a landmark

Femoral puncture site

What we want is a puncture between the

femoral bifurcation and the epigastric artery

In general you can target the center or

the right superior portion of the femoral

head

Femoral Vascular Complications

• Retroperitoneal hematoma

• Arterio venous fistula

• Pseudoaneurysm

• Perforation

Fistule artério-veineuse

• Results of a simultaneous puncture of the artery and vein with a communication between both

• Doppler or arteriography allow the diagnosis

• Can be treated by echo-guidedcompression, covered stent or surgerywhen of large caliber

Arterio venous fistula

Long cross over 7Fsheath 5 mm x 50 mm self-expanding Viabahn (Gore)

covered stent over a 0.35 wire with post dilatation

• if < 3 cm and asymptomatic = observation and check (q 1-2 weeks)

• If > 3 cm or symptomatic

-echo-guided compression -thrombin (long and narrow neck)

-covered stent

-surgery

Pseudo-aneurysm

Cross over 9F Arrow sheath

0.35 Advantage wire (Terumo)

8 mm x 60 mm Fluency vascular graft stent

Post dilatation

Device closure complications

6F introducer sheath close to the

bifurcation and in a stenosis

Starclose (Abott Vasc)

According to the IFU: CFA > 5 mm

Ischemia of the leg at 48hBefore Starclose deployment

From radial approach using a 6F introducer, balloon inflation using a Saber

OTW 6 mm x 60 mm at the level of the device closure

Vascular perforation

When dealing with large bore introducer sheath cross over

access (with or without balloon inflation) is wise when closing

the access site

Especially in difficult anatomies in which cross over is difficult

and may require snaring

Why transradial approach in PCI ?

To decrease vascular and bleeding complications

in ACS patients

Technical challenge

Radial Loop and Recurrent Artery

Never push fast or with force

Radial loop and recurrent artery

Anatomic VariationsAnatomic variations

Mother-and-child technique

5-F 125-cm long diagnostic catheter into a standard GC

C. Frangos, S. Noble. Cardiovascular Medicine 2011;14(11):315-324

Hematoma

Compartment syndrome

Courtesy of O Bertrand , Quebec

Leeches to avoid compartment syndrome

Radial occlusion

Asymptomatic

1-8 %

Conclusions

• Prevention is essential

• Meticulous puncture

• Radial access in ACS

• Most of the femoral complications can be treated by

stenting (covered stent or BMS) or balloon angioplasty

• Pseudoaneurysm could be treated by echo-guided thrombin

injection or by covered stents

• Compartment syndrome in TRA is exceptional and is related

to the absence of adequate care in case of bleeding in the

forearm

Thank you for your attention

Decrease the sheath to radial artery ratio

Perforation

Femoral artery punctured above the inguinal

ligament → resulting hematoma extend into the

retroperitoneal space.

Not evident from surface, suspect when:

Unexplained hypotension

Ipsilateral flank pain

Fall in hematocrit.

CT scan or abdominal ultrasound.

Retroperitoneal hematoma

Complexes cases 7F…

Reducing the equipment sizewithin the RA lumen by ≈ 2-F sizes

Cardiovascular medicine 2012

Complex procedures using large GC ?

Vein puncture for structural intervention

Large sheath

If any resistance do not

push

Here puncture of a small

branch too small to

accomodate a large

introducer sheath