Complications of Vascular Access and Hemostasise Layout

Fadi Saab M.D. FASE, FACC, FSCAIMedical Director of Elective PCI Program

Medical Director of Pulmonary Embolism and Deep Venous Thrombosis ProgramCardiovascular Medicine- Interventional Cardiology

Clinical Assistant Professor- Michigan State UniversitySchool of Medicine

Metro Health-University of Michigan Health

Presentation Outline

• Common Femoral Artery in another way

• Antegrade vs Retrograde CFA access

• Conservative vs endovascular treatment

• Closure vs no closure

• Case example

Common Femoral Artery

Traditional Retrograde Access

Superior understanding with US?

Saab et al

Saab et al

Types of Alternative Access

• Antegrade CFA

• Retrograde Tibial Access

• CTO access, Schmidt Access

Saab et al. The AMP Group

Antegrade Access

• Ultrasound guided access

• Allows visualization of wire access

• Less radiation

The Challenge of Antegrade Access

SFA

Profunda

Angle of 30- 60 degrees

Fluoroscopic Access

Antegrade AccessThe wire is always biased toward the profunda artery

But its not that simple….!!!

Start with short access view

Switch to long access

Sheath Placement

Wire Manipulation

Saab et al. The AMP Group

20

PERIPHERAL VASCULAR DISEASE

VOL. 28, NO. 6, JUNE 2016 259

Peripheral artery disease (PAD) is of epidemic propor-

tions, currently affecting approximately 202 million

patients worldwide. Its prevalence has increased by

approximately 25% from 2000 to 2010 and its global mag-

nitude continues to rise.1 Simultaneously, the evolution of

technology has led to the use of endovascular revasculariza-

tion as a primary strategy for patients with PAD and critical

limb ischemia (CLI). One of the most vital components of

these procedures is arterial access, and unfortunately it also

represents the rate-limiting step, as it is the most commonly

associated with complications.2,3 Historically, arterial access

has been primarily achieved with the use of palpation, an-

atomic landmarks, fluoroscopic guidance, and combinations

of these maneuvers. However, in current practice, lack of

consensus exists regarding which method is the safest and

most effective.4

Retrograde common femoral artery (CFA) access is the

most frequently utilized approach for endovascular inter-

ventions.5 Careful assessment of the target site for retro-

grade puncture (below the inguinal ligament and above

the bifurcation) is essential to avoid anatomically “ high” or

“ low” arterial access, which accounts for up to 71% of vas-

cular access complications.6 Fluoroscopic guidance has been

recommended to improve accuracy and reduce complica-

tions.7,8 However, randomized trials failed to show superior-

ity of these strategies to palpation of anatomic landmarks.9,10

In an attempt to further improve the technique, the use

of ultrasound guidance (USG) has been attempted, as this

technique had been previously shown to be safe and effec-

tive to guide central venous access.11-13 Arterial access with

USG has now been studied in multiple trials comparing this

approach to palpation and fluoroscopic guidance.14,15 Use of

USG was found to reduce the number of access attempts,

time to access, and complication rates for CFA access when

compared with standard fluoroscopic guidance.14 However,

there was no benefit when compared with palpation, except

for patients with a weak arterial pulse and obesity.15 USG

has also been recommended for less commonly accessed ar-

terial segments, such as the superficial femoral (SFA), popli-

teal, and tibial arteries.16-19 Patients with advanced PAD and

CLI often require unconventional approaches, including the

use of antegrade CFA access and retrograde tibial accesses.

There is a paucity of data regarding the safety and efficacy

of USG access in these scenarios, and how these approach-

es compare with conventional retrograde CFA access. This

article examines the feasibility and immediate outcomes of

Ultrasound-Guided Arterial Access: Outcomes Among

Patients With Peripheral Artery Disease and Critical

Limb Ischemia Undergoing Peripheral Interventions

J.A. Mustapha, MD1; Larry J. Diaz-Sandoval, MD1; Michael R. Jaff, DO2; George Adams, MD3; Robert Beasley, MD4;

Sara Finton, BSN1; Theresa McGoff, BSN1; Larry E. Miller, PhD5; Mohammad Ansari, MD1; Fadi Saab, MD1

ABSTRACT: Object ive. Arterial cannulation is a vital component of endovascular interventions and o en unconventional access

approaches are required due to disease complexity. Historically, varying maneuvers have been utilized to obtain arterial access. Lack

of consensus exists regarding the safest and most e ective method. This study examined the feasibility and immediate outcomes

of ultrasound-guided access in traditional and advanced access approaches. Methods. Data were analyzed from a cohort of 407

patients enrolled in the Peripheral RegIstry of Endovascular Clinical OutcoMEs (PRIME). The 407 patients underwent 649 procedures

with 896 access sites utilized. Access success, immediate outcomes, complications, and length of hospital stay were analyzed. Re-

sults. Mean age was 70 years, and 67% were male. The majority of patients had crit ical limb ischemia (58%), 39% were Rutherford

classification III. Most commonly utilized access sites were common femoral retrograde, common femoral antegrade, posterior tibial,

and anterior tibial arteries (34.6%, 33.0%, 12.1%, and 12.1%, respectively). Mean number of attempts was 1.2, 1.2, 1.5, and 1.4, respec-

tively; median time to access was 39, 45, 41, and 59 seconds, respectively; and access success rate was 99.4%, 97.3%, 90.7%, and

92.6%; respectively. Access-site combinations utilized were femoral antegrade (n = 188), femoral retrograde (n = 185), dual femoral/

t ibio-pedal (n = 130), dual femoral retrograde (n = 44), retrograde tibio-pedal (n = 73), and other (n = 29). Access-related complications

were low overall: hematoma (1.2%), bleeding requiring transfusion/ intervention (1.7%), pseudoaneurysm (1.7%), arteriovenous fistula

(0.3%), aneurysm (0%), compartment syndrome (0%), and death (0%). Conclusion. Utilization of ultrasound-guided arterial access

in this complex cohort was shown to be safe and e ective regardless of arterial bed and approach.

J INVASIVE CARDIOL 2016;28(6):259-264

KEY WORDS: peripheral intervent ions, peripheral vascular disease, crit ical limb ischemia, access-site management

Antegrade Access

• 72 year old female that presented with a non healing ulcer of the R great toe

• ADT corresponds to the R AT

• History of CAD with 5 vessel CABG and an EF of 35%

• Risk factors include HTN,DM and hyperlipidemia

Diagnostic Angiogram

Diagnostic Angiogram

1. Proceed with revascularization

2. Abort and use a closure device

3. Remove the sheath and obtain another access

4. Obtain contra lateral access

5. Obtain upper body access

6. Consider other modalities- TAMI?

• Wire access is lost

• The patient is hypotensive

• Unable to navigate brachio-cephalic junction

• Bilateral Common iliac stents prohibits contra lateral access

The patient is Hypotensive

Balloon Tamponade

Treatment Course

• Patient Stabilized

• Required 4 units of blood transfusion

• Required ICU and pressers support for 24 hours

• Underwent R Fem/Pop bypass

Access Landmarks

• 67 year old male with life limiting claudication, RF class III of the R lower extr

• ABI: R 0.7, L 0.9

• Risk factors include HTN, Smoking

Diagnostic Angiogram

Saab et al. The AMP Group

Distal Cap

Saab et al. The AMP Group

Access?

Saab et al. The AMP Group

On Discharge

• Next day, the patient walks to the bathroom. Severe pain

• Hypotension, Bradycardia

• Evaluated and decided that was a vasovagal episode

• Hb of 14.

• Third episode of Hypotension.

• Emergently taken to the cath lab……

What would you do?

Conclusion

• Evaluation of CFA is a brief but critical stage of any procedure

• Antegrade and retrograde access is essential in establishing successful revascularization

• Recognizing potential complications allows the operator to become ready

• Complications will HAPPEN , you need to be ready for them

Email: fadisaab17@hotmail.com

Twitter: @fadisaab17

Phone: 313-590-5902

Complications of Vascular Access and Hemostasise Layout

Fadi Saab M.D. FASE, FACC, FSCAIMedical Director of Elective PCI Program

Medical Director of Pulmonary Embolism and Deep Venous Thrombosis ProgramCardiovascular Medicine- Interventional Cardiology

Clinical Assistant Professor- Michigan State UniversitySchool of Medicine

Metro Health-University of Michigan Health