A novel interventional method for treating femoral pseudoaneurysms Dresden / Washington 23/08/2017 PD Dr. med. Karim Ibrahim Technische Universität Dresden Heart Center Dresden University Hospital

Introduction Transradial approach is associated with fewer complications than the one via arteria femoralis. Due to the use of larger sheath sizes the transradial approach is not suitable for complex procedures like TAVI, Impella or Rotablation. The femoral artery is commonly used to gain access to the heart. A severe complication of the femoral approach is development of a pseudoaneurysm in up to 8% of the cases

Introduction Risk factors of development of a pseudoaneurysm are: Gender Age High BMI Anticoagulative Therapy (e.g. mechanical Valves, VKA) Antiplatelet Therapy (e.g. ACS)

Todays Treatment of Pseudoaneurysms Treatment options: Small pseudoaneurysms can spontaneously clot Manual compression (sonographically guided) Thrombin (collagen) injection Implantation of covered stent (emergency) Open surgical repair (painful, lymphocele etc.)

Todays Treatment of Pseudoaneurysms Complications of thrombin injection: (Anaphylactic reactions) intra-arterial thrombosis Depending of the anatomy of the pseudoaneurysm Especially short, wide „necks“ of the pseudoaneurysm

New methods Use of suture-based closure devices approach to treat pseudoaneurysms (PA): (Proglide) as novel Especially after failure of ultrasound-guided compression Especially in patients with oral anticoagulation/antiplatelet- therapy Especially in pseudoaneurysms with wide short „necks“

Baseline

Methods

Methods 1. Under local anesthesia / ultrasound-guided PA is punctured

Methods 2. Guidewire is positioned direction of neck in cavity to insert sheath (5F) in

Methods Advantages: with 4F catheter in 5F sheath– administration of contrast medium via sheath is possible 4F catheter will be guided with PTCA wires 3. Use a PTCA wire (e.g. Pilot 50) to pass the neck of the PA into the femoral artery, use a 4F diagnostic catheter (e.g. Multipurpose) to facilitate steering

Methods 4. Correct positon is confirmed by angiography - Change to a 0.035-inch guidewire

Methods 5. Closure System is used to occlude the neck of the PA (also Angioseal is possible) Total closure of neck, loss of flow and comlete thrombosis of cavity is confirmed 5-10min later by ultrasound

Results 5 of 8 patients were able to be discharged the following day. 3 of 8 patients suffered from Heart Failure and due to Heart Failure related treatment their stay extended – not because of PA closure. No complications occured in all cases. Patients with ongoing oral anticoagulation were succesfully treated. This novel technique is effective in 100% of cases.

Discussion Reduction of procedure time needed (mean time 69 min / fluoroscopy time 20 min) Direct placement of pyhsician´s hand in radiation (special gloves!) Two physicians recommended (due to instable sheath, usually only 2-3 cm inside the skin) Still use of about 70ml contrast medium needed

Conclusion Surgical interventions have to be avoided in PA Manual compression is the method of choice Thrombin injection might be possible in special anatomies Interventional closure technique is recomended in previously failed cases Take home message: Use different techniques depending on the anatomy of the pseudoaneurysm!

Thank you.