Zoltan G. Turi, M.D. Professor of Medicine University of Medicine and Dentistry of New Jersey A Bad Vascular Access and Closure Outcome

Disclosure Information Zoltan G. Turi MD, FSCAI Grant/Research Support: Abbott, Arstasis, Cordis, Marine Polymer Technologies, St. Jude Medical

History 48 year old hypertensive diabetic ♀ Anterior ischemia Routine PCI  Heparin – ACT 240  Eptifibatide  Aspirin and clopidogrel loading Bifurcation stenting – sheath ↑ 7 F DES placed LAD with good result Agitated during much of case – difficult to sedate  BP ↑

Systolic BP during procedure mm Hg 10:48 am12:08 pm

Post procedure femoral angio

Angio-Seal deployed by fellow ~ 12:10  Attending with little VCD experience Patient sent to step down No special warnings or other communication with staff Initial BP in step down = 120 mm Hg Regular staff went on break ~ 12:30 pm

BP now 100 Patient became agitated Fellow sees patient and calls attending Attending – in office - ordered antihistamines and steroids Repeat BP ~ 100 mm Hg Fellow still worried CT scan ordered Staff worried Ask another attending to take a look Other attending worried

Patient rushed to lab

mm Hg intra- procedure Step- down 10:48 am12:08 am

Post mortem Large retroperitoneal bleed Closure device in place – some space between plug and arterial wall

Insertion IEA

A D C F E B CCI 2011 Freilich

What went wrong here 1. High stick 2. Failure to recognize high stick prior to sheath placement/upsizing sheath 3. Failure to recognize high stick prior to anticoagulation 4. Use of closure device after PCI with high stick 5. Failure to recognize “bladder sign”

6. Sending patient to recovery 7. Failure to communicate with nursing staff implications of high stick/bladder compression 8. Shift change 9. Failure to recognize importance of lower BP and agitation 10. Failure to intervene early

11. Failure to transfuse 12. Wrong groin used for access 13. Too little, too late

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Preflight

Checklist – 1 Preflight History of prior access Examine potential access sites  Palpate, auscultate, distal pulses, ABIs - record Review prior femoral angiograms

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Consider alternatives

2 - Consider Radial

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Micropuncture

3 - Micropuncture

Some simple math ~ 7 th grade Flow =  Pressure/Resistance Resistance = viscosity * length radius 4 If  Pressure, viscosity and length fixed Then  Flow ~  radius 4

5.9 fold  in blood loss  In size = 56% Std needle (18g) = 1.27 mm Micropuncture (21g) =.813 mm

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Ultrasound and/or iterative fluoroscopy

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy Optimize access Ultrasound and/or iterative fluoroscopy

  BIF IEA Cumulative Target Zone FH Centerline

Smallest sheath possible Trimarchi JACC CI 2010

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients No VCD or VCD appropriate to situation Femoral angiogram every case

Femoral Angio Everyone Age Gender Diabetes ↓ Body surface area Sheath size Vessel size* Anticoagulation Puncture location* Prior instrumentation Vascular disease at puncture site* ? IIb/IIIa * = requires femoral angio Know anatomy for next time

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients No VCD or VCD appropriate to situation 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients No VCD or VCD appropriate to situation 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg/needle mgmt/groin mgmt

Bleeding Complications Blankenship. CCI Dauerman JACC 2007

Strategies Minimizing Bleeding Weight-adjusted heparin Lower heparin dose No postprocedure heparin No venous sheath Smaller guiding catheter Fixed dose heparin should largely disappear

Consider bivalirudin Trimarchi JACC CI 2010

Needle management Avoid multiple sticks, posterior wall sticks  Stop and compress if failed puncture Anterior wall only, good blood flow, no resistance to wire

1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients, VCD appropriate to situation or no VCD 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD

Suspicion of RPH Stable CT Scan

Suspicion of RPH ShockStable Cath lab* Contralateral Access Tamponade Leak CT Scan Transfuse ! Reverse Anticoagulation !