Groin Complication from Access Closure Failures Aravinda Nanjundappa, MD, FSCAI,FACC West Virginia University Charleston. WV

Access site complications Most common complication for endovascular procedures 90% of on table and 24 hour mortality after endovascular case is from access problems Learn how to safely access and close is the key to a successful case Know the access puncture site location before patient leaves the lab

Access closure Manual compression is the best However hematoma can occur Prolongs turn over Closure devices: Choose what is comfortable “Devil made MOST of the closure devices” Famous words of my vascular surgeon

More tips and tricks Femoral angiogram at start of the case Use micro puncture plus ultrasound for carotid stenting, AAA, TAA with preclose and thrombolysis cases If the stick is unsuccessful hold pressure for 5 mins for large bore needle and 2 to 3 mins for micro puncture before the next stick Heparin only after intervention sheath is placed unless brachial or pedal or radial

Femoral artery access Locate medial and lower femoral head All cases need fluroscopy Locate medial and lower femoral head Puncture at least one inch below the lower femoral head Single front wall puncture If on anticoagulation use micropuncture needle

Tips and Tricks for acess management Fluoroscopic needle location Micro puncture : multiple attempts less forgiving, useful in severely calcified arteries Mirco puncture will not reduce RP bleed Doppler assisted “SMART” needle can be of help especially obese patients Use of ultrasound guided puncture probably safe approach: learning curve

Management of access site Use manual compression for diagnostic cases Interventional case with good femoral puncture use the closure device u r comfortable with and have experience Small hematoma: manual compression followed by femstop Large hematoma with with nerve compromise or skin necrosis : needs evacuation

Case 72 yr old female with HTN uncontrolled on 3 meds underwent renal angiogram Bilateral renal artery <60% stenosis Right femoral artery failed perclose: Angioseal used 3 hours later severe right leg pain, mottled Patient bought to the lab for angiogram

Post closure device

Still not a good flow Failed Snare : Covered stent Balloon expandable

Femo stop Case: 76 yr old lady underwent cardiac cath and PCI plus stent sent to floor with fem-stop 30 mins after fem stop removal patient has pain in the groin and discomfort Hemodynamically stable Exam shows ABI 0,71 right leg, cool to touch feeble right femoral pulse ALI Stage 1

Cross over femoral angiogram and PTA and stent of the right EIA

Femoral- popletal angiogram Now patient is hypotensive and in pain Where is the bleed? What happened?

Covered Stent across the profunda femoris artery

Case of manual compression 69 yr old underwent catheterization and stent 2 hours after the manual compression on left side patient is hypotensive and left flank pain What is the next test? CT scan? CT scan is as good as sending patient to get a hair cut

Cross over and left femoral angiogram

Bleed from EIA Rx Covered stent

Case of failed Prostar 82 yr old female underwent attempted transcutaneous aortic valve replacement attempt from right femoral artery 2 days later presents with right leg acute limb ischemia stage IIa Right leg ABI 0.22

Balloon PTA via SFA puncture

Image of star close

What about new closure devices 29 yr old history of CAD, CABG, presents with angina Post cath minx device placed in right femoral artery Right leg ABI 0.2 Emergent angiogram planned

Right leg Angiogram

One more closure device Patient underwent diagnostic cathetrization of carotid artery Right femoral angio was not performed at end of the case due to S. creat 1.8 Angioseal deployed One hour later patient has severe right leg pain Angiogram planned

Right leg angiogram and snare?

Management of collagen plug

Conclusions Access complications are serious Angiogram all femoral punctures Use closure device cautiously and learn one device very well Know how to use covered stents and embolisation