1. Nelson Lim Bernardo, MD Washington Hospital Center
Aortic Graft Workshop
February 5, 2012
Prostar or Proglide
for Percutaneous
Access Closure
Nelson Lim Bernardo, MD Washington Hospital Center

2. Faculty Disclosure
Abbott Vascular – Training Site
Cook Medical – Training Site
Cordis Endovascular – Training Site
Covidien/eV3 – Training Site
Medtronic – Training Site
Terumo Medical – Speaker
No conflict of interest related to this presentation

3. Percutaneous Vascular Closure
Totally percutaneous vascular access (with no cutdown) for insertion of large-bore sheaths (up to 26 French) under local anesthesia +/- conscious sedation
Preclose technique via common femoral artery
Utility in EVAR, TEVAR and TAVI
High success rate ≈ 94%

4. Percutaneous Vascular Closure
Impetus for growth:
Avoid complications of femoral artery repair
Avoid need for general anesthesia
‘High-risk’ patients
Preclose technique via common femoral artery
Deployment of closure device with a “smaller” arteriotomy size (6 - 8 French hole) prior to insertion of large-bore sheath/device

5. Percutaneous Vascular Closure
Vascular Closure Device for percutaneous common femoral artery repair
Preclose technique – deployment prior to insertion of large-bore sheath/device
Suture-mediated devices
Prostar XL - Approved for 10F
“Cumbersome” suture-management
Perclose ProGlide - Approved for 8F
Pretied suture/knot, short learning curve
‘Need’ to use 2 devices

6. Keys to Success
Evaluation of access site common femoral Artery – Pre-procedure imaging study

7. Preclose: Imaging Study
The common femoral artery access site should be imaged and evaluated:
Utility of CT-scan/angio
Inspect for calcification
Depth of artery
Size of the vessel = diameter
??allow entry of large-bore sheath/device

8. Preclose: Imaging Study
The common femoral artery access site should be imaged and evaluated:
Utility of CT-scan/angio
Inspect for calcification
Depth of artery
Size of the vessel = diameter
??allow entry of large-bore sheath/device

9. Keys to Success
Evaluation of access site common femoral Artery – Pre-procedure imaging study
A one (1)-stick to a ‘disease-free’ anterior wall of the common femoral artery is of foremost importance

10. Vascular Access: Simple Rules to Follow
1-stick – anterior wall only with good blood return
“NO-NO” – multiple sticks, ‘through & through’
else: Don’t rush – compress until hemostasis is
achieved
Needle to access artery
Use of micropuncture 21-gauge access needle
21-gauge ‘hole’ is more ‘forgiving’ if puncture fails
For ultrasound guidance – Echogenic tip

11. Femoral Artery Access: Ultrasound Guided
Real time ultrasound (US)-guided vascular access
Allows real time visualization of vessel anatomy and advancement of needle into the lumen
Real time/Dynamic imaging:
Vascular probe in sterile sleeve + US machine
Approaches for needle ‘entry’:
Transverse
Longitudinal

12. Real Time US-guided Vascular Access
Longitudinal view
Right CFA - SFA/DFA bifurcation
 Introduce needle above bifurcation

13. Real Time US-guided Vascular Access
Longitudinal view
Transverse view
Transverse view of right CFA

14. Real Time US-guided Vascular Access
Longitudinal view
Longitudinal view
Transverse view
Right CFA and CFV
Center the vessel (CFA) in center of screen
Center of imaging probe overlies center of vessel and serves as landmark for needle entry

15. Real Time US-guided Vascular Access
Advance needle to artery  “tenting” of vessel wall and entry of needle into vessel lumen followed by blood return
Common Femoral Artery
Watch as guidewire is ‘freely’ advanced into lumen of artery

16. Vascular Access: Simple Rules to Follow
After accessing the artery using the micropuncture needle, insert the 4F micropunture sheath.
Before upsizing from the micropuncture sheath, perform angiography of the access site for location of arteriotomy
Take angio of CFA - Ipsilateral 30-40O
Note vessel morphology

17. Vascular Access: Simple Rules to Follow
After accessing the artery using the micropuncture needle, insert the 4F micropunture sheath.
Before upsizing from the micropuncture sheath, perform angiography of the access site for location of arteriotomy
Take angio of CFA - Ipsilateral 30-40O
Note vessel morphology
If location not ‘ideal,’ pull out and re-access

18. Vascular Access: Simple Rules to Follow
After accessing the artery using the micropuncture needle, insert the 4F micropunture sheath.
Before upsizing from the micropuncture sheath, perform angiography of the access site for location of arteriotomy
Take angio of CFA - Ipsilateral 30-40O
Note vessel morphology
If location not ‘ideal,’ pull out and re-access

19. VCD: When Not to Use Contraindications to Deployment
Multiple sticks, posterior sticks
‘Low’ sticks
PAD - Calcified tortuous vessel
Arteriotomy through ‘plaque’
‘Gut feeling’ – Trust instinct, if there is any doubt, do not deploy
Inexperience/unfamiliarity with particular device

20. Keys to Success
Evaluation of access site common femoral Artery – Pre-procedure imaging study
A one (1)-stick to a ‘disease-free’ anterior wall of the common femoral artery is of foremost importance
Know the closure devices by heart – deployment and trouble shooting

21. VCD: Prostar XL
Deployment of two (2) sutures to approximate arteriotomy

22. Right CFA – Post Prostar
Closure using Prostar XL
Right CFA – Baseline
Right CFA – Post Prostar

23. VCD: Perclose ProGlide
Prostar XL suture
To emulate the 2 sutures of
Prostar to close arteriotomy
Deployment of two (2) sutures to approximate arteriotomy - ??orthogonal

24. VCD: Perclose ProGlide
Prostar XL suture
To emulate the 2 sutures of
Prostar to close arteriotomy
Deployment of two (2) sutures to approximate arteriotomy - ??orthogonal

25. Left CFA – Post 2 Perclose
Closure using Perclose
Left CFA – Post 2 Perclose

26. Left CFA – Post 2 Perclose
Closure using Perclose
Left CFA – Post 2 Perclose

27. Percutaneous EVAR: Advantages
Avoids post-anesthesia complications
Local anesthesia
Less ‘trauma’ - ‘scarring’ of common femoral artery
Easier ‘access’ in the future
Patient comfort
Shorter hospital stay – no ICU stay
$$Cost effective

28. WHC Experience: Percutaneous EVAR
Single center experience, 89 patients for EVAR.
2 patients excluded:
Patient #2 – needed right iliac bypass conduit; contralateral limb closed with Prostar.
Patient #16 – “calcified” femoral artery, elective cutdown; contralateral limb closed with Prostar.
Technique:
Access obtained via both common femoral arteries using the Micropuncture technique.
Pre-deployment of Prostar closure device.
Local anesthesia +/- conscious sedation
Successful hemostasis obtained = 87/87
100%

29. WHC Experience: Percutaneous EVAR
Only drawback is “no bragging rights of having had an aneurysm repair” CB

30. Keys to Success
Evaluation of access site common femoral Artery – Pre-procedure imaging study
A one (1)-stick to a ‘disease-free’ anterior wall of the common femoral artery is of foremost importance
Know the closure devices by heart – deployment and trouble shooting
No device is better, learning curve and what you are comfortable with

31. Keys to Success
Evaluation of access site common femoral Artery – Pre-procedure imaging study
A one (1)-stick to a ‘disease-free’ anterior wall of the common femoral artery is of foremost importance
Know the closure devices by heart – deployment and trouble shooting
No device is better, learning curve and what you are comfortable with
Readily available surgical colleagues

32. Percutaneous Closure of Large-Bore Sheath
The primary benefit is the reduction in surgical wound complications and its associated morbidity.
Provides an alternative treatment option for patients with co-morbidities that are risks for surgery and general anesthesia.
Proper training and appropriate case selection are critical to optimize outcomes & minimize complications.

33. Thank you. Have a Good Day!
On the road to Mount Everest
Yamdro Yumtso Lake