how to manage access complications
TRANSCRIPT
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