Complications of Vascular Access and Hemostasis
George L. Adams MD, MHS, FACC, FSCAI
Clinical Associate Professor University of North Carolina Health System Raleigh, North Carolina, USA Director of Cardiovascular and Peripheral Vascular Research REX Health Care Raleigh, North Carolina, USA
Disclosures
• Consultant • Cook Medical • Daiichi Sankyo • Lake Region Medical • Volcano • Asahi • Abbott Vascular • CSI • Medtronic • Terumo
• Research • Boston Scientific • CloSys • Daiichi Sankyo • Flexible Stenting Solutions • Medtronic • Volcano • Mercator
• Speaker • Abbott Vascular • CSI • Cook Medical • Spectranetics • Medtronic
Background • At least 8 million Americans have PAD • In 2010, 2.8 - 3.5 million people in the US had CLI [1].
• 80% of CLI occurs in 65 y/o and older. • 60% of more CLI patients are diabetic.
• Between 1996 to 2006 Endovascular treatment of lower extremity lesions increased [2]:
• The use of balloon angioplasty increased from 135 to 337 procedures per 100,000
• The use of atherectomy increased from 3 to 118 per 100,000
• Access site complications occur in approximately 4.2% of all Peripheral Vascular Interventions. [3]
1. SAGE Report 2010 2. Journal of Vascular Surgery 2009 50, 54-‐60DOI: (10.1016/j.jvs.2009.01.035) 3. OrAz, D., Jahangir, A., Singh, M., Allaqaband, S., Bajwa, T. K., & Mewissen, M. W. (2014). CirculaAon: Cardiovascular IntervenAons, 7(6), 821-‐828.
Trends in Endovascular and Vascular Surgery
Journal of Vascular Surgery 2009 50, 54-‐60DOI: (10.1016/j.jvs.2009.01.035)
Vascular Access Sites
Brachial
Radial
Common Femoral Direct SGck of Superficial Femoral Artery
Tibial-‐Pedal
Popliteal
Hemostasis
Thrombosis Bleeding
Tipping the Scale
Thrombosis
Bleeding
An#thrombo#c Therapy
An#platelet and An#coagulants
Vascular Access Complications • Hematoma • Compartment Syndrome • Retroperitoneal Bleeding • Pseudoaneurysms • AV-Fistula • Arterial occlusion (Thrombosis) • Femoral Neuropathy • Infection
Vascular Access Site Complications
Retroperitoneal Bleed Pseudoaneurysm
Vascular Access Site Complications
Femoral Artery DissecGon Compartments of the Lower Leg
[1] American Academy of Orthopaedic Surgeons, 2003.
[1]
Access Site Occlusion
Femoral Artery Occlusion
Dorsalis Pedis Occlusion
Predictors of Access Site Complications
Ortiz, D., Jahangir, A., Singh, M., Allaqaband, S., Bajwa, T. K., & Mewissen, M. W. (2014). Circulation: Cardiovascular Interventions, 7(6), 821-828.
Sheath Size and Complications • Larger Sheath sizes leads to increased risk bleeding
complications.
Doyle BJ, Ting HH, Bell MR, et al. J Am Coll Cardiol Intv. 2008;1(2):202-209. doi:10.1016/j.jcin.2007.12.006.
Complication Rates in Older Patients
Dick, P., Barth, B. Journal of Endovascular Therapy, 15(4), 383-389.
Discharge Rates • Access Site complications lead to increased
hospitalization rates.
Discharge Status by access site complication
Ortiz, D., Jahangir, A., Singh, M., Allaqaband, S., Bajwa, T. K., & Mewissen, M. W. (2014). Circulation: Cardiovascular Interventions, 7(6), 821-828.
Outcomes after Complications
Doyle BJ, Ting HH, Bell MR, et al. J Am Coll Cardiol Intv. 2008;1(2):202-209. doi:10.1016/j.jcin.2007.12.006.
Kaplan-‐Meier Curves Depic#ng Long-‐Term Survival of Pa#ents With or Without Major Bleeding Complica#ons
Preventing Bleeding • Accurate Stick • Judicial use of Anticoagulation and Antiplatelet
therapy. • Maintain ACT between 200-250
• Maintain INR<1.5 • Use smaller sheaths and micropuncture for access. • Tamponade with a balloon to prevent compartment
syndrome.
Vascular Closure • Holding Pressure
• Manual • TR Band – Radial Compression Device • BOA device – Tibial Closure Device. • FemStop – Pneumatic Compression Device
• Specialized Closure Devices: • Closys • Angioseal • Starclose • Perclose
Patient History
• 58 y/o male • IDDM, HTN, Hyperlipid, ESRD (Dialysis) • Non-healing ulcer on 4th toe of left foot
Selective Angiography of the Left Lower Extremity
Antegrade Peroneal approach – Unsuccessful Now What?
Popliteal
AT
TP trunk
AT
Peroneal
PT
Access Peroneal Artery (LAO 40 degrees)
Crossing Peroneal CTO into Popliteal
TP trunk
Peroneal
Taking out the 3rd Dimension
“Flossing”
Perforation at Access Site
Perforation
Antegrade PTA/Stent
Post-Intervention
Peroneal Perforation
Thank You
Complications of Vascular Access and Hemostasis
George L. Adams MD, MHS, FACC, FSCAI
Clinical Associate Professor University of North Carolina Health System Raleigh, North Carolina, USA Director of Cardiovascular and Peripheral Vascular Research REX Health Care Raleigh, North Carolina, USA