Vascular Access (Femoral) Ramesh Daggubati, MD FACC FSCAI Clinical Professor of Medicine Director of Interventional Cardiology East Carolina University, Greenville, NC USA Ramesh Daggubati, MD FACC FSCAI Clinical Professor of Medicine Director of Interventional Cardiology East Carolina University, Greenville, NC USA

Disclosures Speaker’s Bureau: Abbott, Abiomed, Astra Zeneca, Gilead, Janssen, Medtronic, Volcano Speaker’s Bureau: Abbott, Abiomed, Astra Zeneca, Gilead, Janssen, Medtronic, Volcano

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Avoiding Complications Patient history. Patient history. Physical examination. Physical examination. Technical performance. Technical performance.  Front wall stick.  Pulsatile flashback.  Reliable landmarks.  Special considerations in PVD. Patient history. Patient history. Physical examination. Physical examination. Technical performance. Technical performance.  Front wall stick.  Pulsatile flashback.  Reliable landmarks.  Special considerations in PVD.

Patient History Signs or symptoms of PVD. Signs or symptoms of PVD. Prior access problems. Prior access problems. Inability to lie flat. Inability to lie flat. Signs or symptoms of PVD. Signs or symptoms of PVD. Prior access problems. Prior access problems. Inability to lie flat. Inability to lie flat.

Physical Examination Examine all pulses. Examine all pulses. Listen for bruits. Listen for bruits. Allen’s test for radial access. Allen’s test for radial access. Examine all pulses. Examine all pulses. Listen for bruits. Listen for bruits. Allen’s test for radial access. Allen’s test for radial access.

Technical Elements Front wall stick. Front wall stick. Pulsatile blood flow before wire advancement. Pulsatile blood flow before wire advancement. Wire exits needle without resistance. Wire exits needle without resistance. Use of fluoroscopic guidance. Use of fluoroscopic guidance. Front wall stick. Front wall stick. Pulsatile blood flow before wire advancement. Pulsatile blood flow before wire advancement. Wire exits needle without resistance. Wire exits needle without resistance. Use of fluoroscopic guidance. Use of fluoroscopic guidance.

Landmarks Goal is access in common femoral art. Goal is access in common femoral art. Medial inferior aspect of femoral head. Medial inferior aspect of femoral head. Confirm with fluoroscopy and or ultrasound. Confirm with fluoroscopy and or ultrasound. Use Micropuncture needle always. Use Micropuncture needle always. Goal is access in common femoral art. Goal is access in common femoral art. Medial inferior aspect of femoral head. Medial inferior aspect of femoral head. Confirm with fluoroscopy and or ultrasound. Confirm with fluoroscopy and or ultrasound. Use Micropuncture needle always. Use Micropuncture needle always.

Considerations in PVD Known aorto-iliac disease or prior AFB. Known aorto-iliac disease or prior AFB. Consider brachial or radial access. Consider brachial or radial access. Review any previous angiography. Review any previous angiography. Aorto-femoral graft may be used for access, avoid retrograde access into blind limb of iliac artery. Aorto-femoral graft may be used for access, avoid retrograde access into blind limb of iliac artery. Known aorto-iliac disease or prior AFB. Known aorto-iliac disease or prior AFB. Consider brachial or radial access. Consider brachial or radial access. Review any previous angiography. Review any previous angiography. Aorto-femoral graft may be used for access, avoid retrograde access into blind limb of iliac artery. Aorto-femoral graft may be used for access, avoid retrograde access into blind limb of iliac artery.

Considerations in PVD Distal SFA occlusive disease is not a contraindication. Enter CFA !! Distal SFA occlusive disease is not a contraindication. Enter CFA !! Take care NOT to compromise the patent profunda femoris artery (only remaining circulation to the leg). Take care NOT to compromise the patent profunda femoris artery (only remaining circulation to the leg). Distal SFA occlusive disease is not a contraindication. Enter CFA !! Distal SFA occlusive disease is not a contraindication. Enter CFA !! Take care NOT to compromise the patent profunda femoris artery (only remaining circulation to the leg). Take care NOT to compromise the patent profunda femoris artery (only remaining circulation to the leg).

Considerations in PVD Beware of brachiocephalic disease in patients with occlusive aorto-iliac disease. Beware of brachiocephalic disease in patients with occlusive aorto-iliac disease. Increased risk of stroke with catheter manipulation in tortuous subclavian vessels. Increased risk of stroke with catheter manipulation in tortuous subclavian vessels. Beware of brachiocephalic disease in patients with occlusive aorto-iliac disease. Beware of brachiocephalic disease in patients with occlusive aorto-iliac disease. Increased risk of stroke with catheter manipulation in tortuous subclavian vessels. Increased risk of stroke with catheter manipulation in tortuous subclavian vessels.

Femoral Access Complications Hematoma, bleeding, & transfusion. Hematoma, bleeding, & transfusion. Pseudoaneurysm. Pseudoaneurysm. AV fistula. AV fistula. Thrombosis. Thrombosis. Infection. Infection. Hematoma, bleeding, & transfusion. Hematoma, bleeding, & transfusion. Pseudoaneurysm. Pseudoaneurysm. AV fistula. AV fistula. Thrombosis. Thrombosis. Infection. Infection.

Risk Factors Femoral Complications Female gender. Female gender. Obesity. Obesity. Low body weight. Low body weight. Hypertension. Hypertension. Over anticoagulation ± GP IIb/IIIa. Over anticoagulation ± GP IIb/IIIa. Thrombolytic agents. Thrombolytic agents. Elevated creatinine. Elevated creatinine. Female gender. Female gender. Obesity. Obesity. Low body weight. Low body weight. Hypertension. Hypertension. Over anticoagulation ± GP IIb/IIIa. Over anticoagulation ± GP IIb/IIIa. Thrombolytic agents. Thrombolytic agents. Elevated creatinine. Elevated creatinine.

Larger arterial sheath. Larger arterial sheath. Prolonged sheath time. Prolonged sheath time. Older age. Older age. Low platelet count. Low platelet count. Intra-aortic counterpulsation balloon. Intra-aortic counterpulsation balloon. Concomitant venous sheath. Concomitant venous sheath. Need for repeat intervention. Need for repeat intervention. Larger arterial sheath. Larger arterial sheath. Prolonged sheath time. Prolonged sheath time. Older age. Older age. Low platelet count. Low platelet count. Intra-aortic counterpulsation balloon. Intra-aortic counterpulsation balloon. Concomitant venous sheath. Concomitant venous sheath. Need for repeat intervention. Need for repeat intervention. Risk Factors Femoral Complications

Femoral Access Bleeding Incidence ≤ 6% (transfusion ≤ 3.0%). Incidence ≤ 6% (transfusion ≤ 3.0%). Discontinue heparin after procedure. Discontinue heparin after procedure. Reduce heparin with GP IIb/IIIa (70 U/KG). Reduce heparin with GP IIb/IIIa (70 U/KG). Sheath removal with ACT < 170 sec. Sheath removal with ACT < 170 sec. Minimize sheath size. Minimize sheath size. ADP inhibitors instead of coumadin. ADP inhibitors instead of coumadin. Incidence ≤ 6% (transfusion ≤ 3.0%). Incidence ≤ 6% (transfusion ≤ 3.0%). Discontinue heparin after procedure. Discontinue heparin after procedure. Reduce heparin with GP IIb/IIIa (70 U/KG). Reduce heparin with GP IIb/IIIa (70 U/KG). Sheath removal with ACT < 170 sec. Sheath removal with ACT < 170 sec. Minimize sheath size. Minimize sheath size. ADP inhibitors instead of coumadin. ADP inhibitors instead of coumadin.

Retroperitoneal Hematoma Incidence ≤ 1.0%. Incidence ≤ 1.0%. Avoid “high” CFA arterial puncture. Avoid “high” CFA arterial puncture. Front-wall puncture desirable. Front-wall puncture desirable. Suspect when: Suspect when:  Blood loss, hypovolemia, hypotension.  Supra-inguinal fullness, tenderness.  Flank pain. Incidence ≤ 1.0%. Incidence ≤ 1.0%. Avoid “high” CFA arterial puncture. Avoid “high” CFA arterial puncture. Front-wall puncture desirable. Front-wall puncture desirable. Suspect when: Suspect when:  Blood loss, hypovolemia, hypotension.  Supra-inguinal fullness, tenderness.  Flank pain.

Retroperitoneal Hematoma If suspicion is high, and blood loss significant, treat before a definitive diagnosis is made. If suspicion is high, and blood loss significant, treat before a definitive diagnosis is made. Discontinue/reverse anticoagulation. Discontinue/reverse anticoagulation. If suspicion is high, and blood loss significant, treat before a definitive diagnosis is made. If suspicion is high, and blood loss significant, treat before a definitive diagnosis is made. Discontinue/reverse anticoagulation. Discontinue/reverse anticoagulation. CT Scan Surgical Repair CT Scan Surgical Repair Contralateral Access Balloon Tamponade Contralateral Access Balloon Tamponade

HYPOTENSION POST-CATH Differential Diagnosis

Retroperitoneal Bleeding 6 Fr IMA Coils

PSEUDOANEURYSM Incidence Incidence  Duplex ultrasound ≤ 6.0 %.  Clinical detection %. Risk factors Risk factors  Female > 70 yrs.  Diabetes.  Obesity.  Low (SFA) stick. Incidence Incidence  Duplex ultrasound ≤ 6.0 %.  Clinical detection %. Risk factors Risk factors  Female > 70 yrs.  Diabetes.  Obesity.  Low (SFA) stick.

PSEUDOANEURYSM Small (≤ 2 cm) may be observed and are likely to close spontaneously. Small (≤ 2 cm) may be observed and are likely to close spontaneously. Larger aneurysms may be closed with: Larger aneurysms may be closed with:  Ultrasound guided compression.  Thrombin injection.  Surgical repair. Small (≤ 2 cm) may be observed and are likely to close spontaneously. Small (≤ 2 cm) may be observed and are likely to close spontaneously. Larger aneurysms may be closed with: Larger aneurysms may be closed with:  Ultrasound guided compression.  Thrombin injection.  Surgical repair.

A-V FISTULA Incidence ≤ 0.4%. Incidence ≤ 0.4%. Associated with low (SFA/Profunda) access and a venous branch. Associated with low (SFA/Profunda) access and a venous branch. Small fistula may be observed and many will spontaneously close or remain stable. Small fistula may be observed and many will spontaneously close or remain stable. Larger fistula may cause signifcant AV shunts, swelling and tenderness. Larger fistula may cause signifcant AV shunts, swelling and tenderness. Incidence ≤ 0.4%. Incidence ≤ 0.4%. Associated with low (SFA/Profunda) access and a venous branch. Associated with low (SFA/Profunda) access and a venous branch. Small fistula may be observed and many will spontaneously close or remain stable. Small fistula may be observed and many will spontaneously close or remain stable. Larger fistula may cause signifcant AV shunts, swelling and tenderness. Larger fistula may cause signifcant AV shunts, swelling and tenderness.

A-V FISTULA Surgical repair. Surgical repair. Ultrasound guided compression. Ultrasound guided compression. Balloon tamponade. Balloon tamponade. Stent graft. Stent graft. Surgical repair. Surgical repair. Ultrasound guided compression. Ultrasound guided compression. Balloon tamponade. Balloon tamponade. Stent graft. Stent graft.

Ischemia/Thrombosis/Emboli Incidence ≤ 1.0 %. Incidence ≤ 1.0 %. Risk factors: Risk factors:  Large access catheter/small artery.  Presence of peripheral arterial disease.  Iatrogenic dissection.  Thrombus within sheath. Incidence ≤ 1.0 %. Incidence ≤ 1.0 %. Risk factors: Risk factors:  Large access catheter/small artery.  Presence of peripheral arterial disease.  Iatrogenic dissection.  Thrombus within sheath.

Ischemia/Thrombosis/Emboli Signs and symptoms: Signs and symptoms:  Pain  Pallor  Paresthesia  Pulseless  Polar (cold). Signs and symptoms: Signs and symptoms:  Pain  Pallor  Paresthesia  Pulseless  Polar (cold).

Ischemia/Thrombosis/Emboli Contralateral access and angiography. Contralateral access and angiography. Selective lysis below access site. Selective lysis below access site. Mechanical thrombectomy. Mechanical thrombectomy. Suction thrombectomy. Suction thrombectomy. Contralateral access and angiography. Contralateral access and angiography. Selective lysis below access site. Selective lysis below access site. Mechanical thrombectomy. Mechanical thrombectomy. Suction thrombectomy. Suction thrombectomy.

SHEATH EMBOLISM POPLITEAL UK LACING FINAL

Surgical Repair Dependent on facility with catheter- based repair techniques. Dependent on facility with catheter- based repair techniques.  Bleeding.  Thrombosis.  Pseudoaneurysm. Incidence ranges from 1% to 3%. Incidence ranges from 1% to 3%. Dependent on facility with catheter- based repair techniques. Dependent on facility with catheter- based repair techniques.  Bleeding.  Thrombosis.  Pseudoaneurysm. Incidence ranges from 1% to 3%. Incidence ranges from 1% to 3%.

Groin Infection Incidence ≤ 0.2%. Incidence ≤ 0.2%. Risk factors: Risk factors:  Reintervention at same site.  Hematoma formation.  Prolonged sheath placement. Incidence ≤ 0.2%. Incidence ≤ 0.2%. Risk factors: Risk factors:  Reintervention at same site.  Hematoma formation.  Prolonged sheath placement. N.B. Future series will include infections secondary to closure devices such as angioseal and perclose.

NEUROPATHY Rare complication. Rare complication. Due to nerve injury: Due to nerve injury:  Retroperitoneal hematoma with compression of lumbar plexus.  Femoral hematoma with nerve compression.  Femoral nerve injury during access. Rare complication. Rare complication. Due to nerve injury: Due to nerve injury:  Retroperitoneal hematoma with compression of lumbar plexus.  Femoral hematoma with nerve compression.  Femoral nerve injury during access.

BRACHIAL ACCESS Cutdown or percutaneous. Cutdown or percutaneous. Heparin is recommended. Heparin is recommended. Complications similar to femoral access. Complications similar to femoral access.  Ischemia, thrombosis, embolization.  Brachial fossa hematoma (median n.) Cutdown or percutaneous. Cutdown or percutaneous. Heparin is recommended. Heparin is recommended. Complications similar to femoral access. Complications similar to femoral access.  Ischemia, thrombosis, embolization.  Brachial fossa hematoma (median n.)

BRACHIAL ACCESS Ischemia, thrombosis, embolisation. Ischemia, thrombosis, embolisation.  Conservative therapy, heparization.  Surgical repair, embolectomy.  Percutaneous lysis, mechanical thrombectomy, or balloon inflation to tack- up a dissection flap. Ischemia, thrombosis, embolisation. Ischemia, thrombosis, embolisation.  Conservative therapy, heparization.  Surgical repair, embolectomy.  Percutaneous lysis, mechanical thrombectomy, or balloon inflation to tack- up a dissection flap.

BRACHIAL COMPLICATION PTAPTA

BRACHIAL ACCESS Median nerve injury (≤ 1.0 %). Median nerve injury (≤ 1.0 %).  Brachial fossa hematoma compression.  Nerve injury during access.  Ischemic nerve injury. Median nerve injury (≤ 1.0 %). Median nerve injury (≤ 1.0 %).  Brachial fossa hematoma compression.  Nerve injury during access.  Ischemic nerve injury.

BRACHIAL ACCESS Selective LIMA access from left arm. Selective LIMA access from left arm.

RADIAL ACCESS Successful access ≥ 90%. Successful access ≥ 90%. Normal “Allens” test required. Normal “Allens” test required. Most common failure is inability to cannulate artery. Most common failure is inability to cannulate artery. Occlusion post-PCI approx 5%. Occlusion post-PCI approx 5%. Associated with fewest major complications of any access site. Associated with fewest major complications of any access site. Successful access ≥ 90%. Successful access ≥ 90%. Normal “Allens” test required. Normal “Allens” test required. Most common failure is inability to cannulate artery. Most common failure is inability to cannulate artery. Occlusion post-PCI approx 5%. Occlusion post-PCI approx 5%. Associated with fewest major complications of any access site. Associated with fewest major complications of any access site.

Randomized Trial Attempted PTCA (n = 900) Attempted PTCA (n = 900) % % After successful cannulation, there was no difference in successful PCI. Kiemeneij F. et al. JACC 1997;29:1269.

Randomized Trial Kiemeneij F. et al. JACC 1997;29:1269. P = Asymptomatic radial artery occlusion in 3%. NB

HEMOSTASIS Manual compression. Manual compression. Mechanical compression device. Mechanical compression device. Closure devices. Closure devices.  Angioseal.  Vasoseal.  Perclose. Manual compression. Manual compression. Mechanical compression device. Mechanical compression device. Closure devices. Closure devices.  Angioseal.  Vasoseal.  Perclose.

DEVICES Mechanical compression. Mechanical compression.  Equal or superior to manual compression for safety.  Pressure dressings do not decrease complications and may obscure bleeding.  Require constant attention, patient cannot be left unattended.  Patient at bedrest 4 to 6 hrs. Mechanical compression. Mechanical compression.  Equal or superior to manual compression for safety.  Pressure dressings do not decrease complications and may obscure bleeding.  Require constant attention, patient cannot be left unattended.  Patient at bedrest 4 to 6 hrs.

DEVICES Closure devices: Closure devices:  Have not demonstrated any reduction in major complications.  Offer less intensive needs for monitoring and personnel post-procedure.  Significant disposable cost.  Offer early ambulation. Closure devices: Closure devices:  Have not demonstrated any reduction in major complications.  Offer less intensive needs for monitoring and personnel post-procedure.  Significant disposable cost.  Offer early ambulation.

HEMOSTASIS Reverse heparin with protamine (10 mg / 1000 U of heparin). N.B. protamine excess can also cause anticoagulation. Reverse heparin with protamine (10 mg / 1000 U of heparin). N.B. protamine excess can also cause anticoagulation. IIb/IIIa platelet inhibitors. IIb/IIIa platelet inhibitors.  Abciximab - platelet transfusion.  Eptifibatide/tirofiban - renal clearance. Reverse heparin with protamine (10 mg / 1000 U of heparin). N.B. protamine excess can also cause anticoagulation. Reverse heparin with protamine (10 mg / 1000 U of heparin). N.B. protamine excess can also cause anticoagulation. IIb/IIIa platelet inhibitors. IIb/IIIa platelet inhibitors.  Abciximab - platelet transfusion.  Eptifibatide/tirofiban - renal clearance.

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