1. IRTB - Arterial Access and Angioplasty Dr Hilary White Nottingham

2. Outline  Vascular access  Anatomy  Equipment  complications  Angioplasty  Closure  Cases

3. Patient selection  Warfarin and Clopidogrel should be stopped 1 week before (at least 3 days before). INR <1.5  Stop Heparin 3 hours before  Aspirin omitted on the day  Metformin – stop 48 hours after procedure  Hypertension >180/110 mmHg  Smoking  Diabetes – check blood sugar  Renal failure – contrast induced nephropathy  CAN THEY LIE FLAT?

5. Pre-op  What does the request card say?  Intermittent claudication vs critical limb ischaemia  side?  Previous imaging  Check bloods  Consider equipment  Approach

6. The Kit  The WHO  035 vs 018  Access  Bail out kit – covered stents/ aspiration catheters/ angiojet – Call For Help

7. Access  Antegrade vs retrograde  Anatomy  Hostile groin?  Time  Equipment  Experience

8. Seldinger Technique  The desired vessel or cavity is punctured with a sharp hollow needle called a trocar, with ultrasound guidance if necessary. A round- tipped guidewire is then advanced through the lumen of the trocar, and the trocar is withdrawn. (introduced in 1953) Wikipedia

11. Vascular sheaths  Colour coded – red 4 Fr, grey 5 Fr, Green 6 Fr, Orange 7 Fr, Blue 8 Fr etc  Different lenghts – standard 11 cm, 23 cm, 45 cm, 60 cm, 90 cm  Some are bright tipped  Different to guide catheters

16. Heparin  After access  Therapeutic anticoagulation for 30mins with 3000 IU IA, 45 mins with 5000 IU IA  Effect after 10-15 mins  After 1 hour consider additional bolus  For flushing – 1000-5000IU heparin/1 L of normal saline

17. Other Drugs  During:  GTN – 100mcg – 200mcg IA – consider in intervention in the infrapopliteal region  Papaverine 20mg IA – good for pressure measurements (smooth muscle relaxant – vasodilatation)  After:  Clopidogrel  Aspirin  Warfarin

18. Think about the steps  Access  Angiogram IS THIS A STRAIGHT FORWARD ANGIOGRAM?  Heparin  Closure  Do no harm

22. Brachial artery access  Easy to compress if bleeding risk  Easy to find with U/S  Anatomy ie easier to catheterise mesenteric vessels, close to subclavians  Antegrade approach to radial fistula  Bilateral Femoral occlusions  Previous femoral surgery or on going infection

23. Why Not?  Subclavian occlusion  Infection  Easier to reach from femoral approach  Risk of stroke  Small vessels (particularly women)

26. Brachial Puncture Technique  Try to always use U/S  Map out anatomy with U/S (beware high take off radial artery)  Sterile prep  Infiltrate local under U/S guidance  Micro puncture kit helps reduce the trauma

27. Complications of Brachial Artery Puncture  Median nerve damage  Haematoma  False Aneurysm  Embolisation to Fingers  Dissection (with lower arm ischemia)  Stroke (especially posterior circulation)

28. Arterial Access Alternatives  Radial Artery (useful for fistulas and coronary angios)  Axiliary Artery (risk of brachial plexus injury but good calibre vessel)  Direct Carotid Puncture  Direct Aortic Puncture (historical)  Popliteal artery  Dorsalis pedis

33. Closure  Vascular closure devices:  Angio-Seal (St Jude Medical)  StarClose (Abbott)  Perclose/{erclose Proglide (Abbott)  Mynx (AccessClosure)  Exo-Seal (Cordis) Complication rate 2 % - incorrect deployment, infection, stenosis, embolus, local dissection.

34. Complications (most common)  Dissection  Haematoma  False Aneurysm (Femoral or Inferior Epigastric)  Retroperitoneal Haemorrhage (patients can die from this)  Infection

37. Questions?