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