1. Access Site Complications Nick Cheshire MD FRCS, Professor of Vascular Surgery Imperial College Healthcare St Mary’s Hospital Campus

2. St Mary’s Hospital Regional Vascular Unit Surgeons & Cardiologists ‘Eye of a Hawk, Heart of a Lion & the Hand of a Lady’ Interventional Cardiology 2008

3. St Mary’s Hospital Regional Vascular Unit Annual Coronary Intervention 215,575 diagnostic angiograms in the UK in 2006 1 73,692 percutaneous coronary interventions in the UK in 2006 1 Over 1,000,000 coronary interventions in the United States 2,3 Probably greater than 2,000,000 worldwide 2,3 1.Ludman on behalf of the British Cardiac Intervention Society Audit Returns for Adult Interventional Procedures January 2006 to December 2006 2.American Heart Association. 2004 Heart and Stroke Statistical Update 3.Smith, S.C., Jr., et al., ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol, 2006. 47(1): p. e1-121

4. St Mary’s Hospital Regional Vascular Unit Groin Haematoma, False aneurysm, Skin Necrosis

5. St Mary’s Hospital Regional Vascular Unit Lower Limb Ischaemia

6. St Mary’s Hospital Regional Vascular Unit Predictors of Vascular Site Complications Advanced age Female gender Renal failure Lower extremity vascular disease Shock Longer time to sheath removal PCI within 24 hours of thrombolytic therapy Stent implantation Concomitant placement of venous sheath Higher heparin doses Use of thienopyridines and glycoprotein IIb/IIIa inhibitor therapy 1.Mandak, J.S., et al., Modifiable risk factors for vascular access site complications in the IMPACT II Trial of angioplasty with versus without eptifibatide. Integrilin to Minimize Platelet Aggregation and Coronary Thrombosis. J Am Coll Cardiol, 1998. 31(7): p. 1518-24. 2.Piper, W.D., et al., Predicting vascular complications in percutaneous coronary interventions. Am Heart J, 2003. 145(6): p. 1022-9.

7. St Mary’s Hospital Regional Vascular Unit Types & Incidence of Complications Boston Experience Arora et al (Am Heart J 2007): Propensity Analysis

8. St Mary’s Hospital Regional Vascular Unit Does the use of a closure device reduce complications? ClosureDeviceTypePuncture SizeManufacturer AngioLink EVSStaple6-8FMedtronic AngioSealCollagen Plug6-8FSt. Jude Medical DuettCollagen Plug5-9FVascular Solutions EliteCollagen Plug5-8FVascular Solutions PercloseSuture5-10FAbbott Vascular QuickSealGelatin Plug6-8FSub-Q StarcloseStaple6FAbbott Vascular Prostar XLSuture8&10FAbbott Vascular VasosealCollagen Plug4-8FDatascope X-siteSuture6FDatascope

9. St Mary’s Hospital Regional Vascular Unit American College of Cardiology National Cardiovascular Data Registry Tavris et al. J Invasive Cardiol 2004;16:459-464 Largest series reported to date 166,200 patients with 53,655 devices Lower incidence of vascular complications with ACDs in diagnostic angiograms but NOT PCI cases Lower vascular complication rate with collagen-based and suture-based products than manual compression in all patients

10. St Mary’s Hospital Regional Vascular Unit Nikolsky et al: Systematic Review 30 Studies, 37,0766 Patients Identified Primary endpoint was cumulative vascular complications No difference in complication incidence between Angio-Seal and mechanical compression Diagnostic setting (odds ratio [OR] 1.08, 95% confidence interval [CI] 0.11 to 10.0) PCI (OR 0.86, 95% CI 0.65 to 1.12) A trend toward less complications using Angio-Seal in a PCI setting (OR 0.46, 95% CI 0.20 to 1.04; p=0.062)

11. St Mary’s Hospital Regional Vascular Unit Arora et al (Am Heart J 2007): Propensity Analysis

12. St Mary’s Hospital Regional Vascular Unit Arora et al (Am Heart J 2007) Propensity Analysis Results

13. St Mary’s Hospital Regional Vascular Unit Types & Incidence of Complications Boston Experience Arora et al (Am Heart J 2007): Propensity Analysis

14. St Mary’s Hospital Regional Vascular Unit Arora et al (Am Heart J 2007): Propensity Analysis

15. St Mary’s Hospital Regional Vascular Unit Arora et al (Am Heart J 2007): Propensity Analysis

16. St Mary’s Hospital Regional Vascular Unit Managing Complications Duplex Guided Thrombin Injection 1.Lennox, A.F., et al., Treatment of an iatrogenic femoral artery pseudoaneurysm with percutaneous duplex-guided injection of thrombin. Circulation, 1999. 100(6): p. e39-41. 2.Lennox, A.F., et al., Duplex-guided thrombin injection for iatrogenic femoral artery pseudoaneurysm is effective even in anticoagulated patients. Br J Surg, 2000. 87(6): p. 796-801 >300 Cases Imperial 1 in-situ thrombosis 2-3% failure/repeat rate

17. St Mary’s Hospital Regional Vascular Unit Managing Complications Surgery for leg ischaemia Embolisation; ensure macro disease corrected

18. St Mary’s Hospital Regional Vascular Unit Summary & Conclusions Latest data: ACDs seem to be associated with a reduction in vascular complications Earlier data possibly reflected new devices, less experience etc Likely highest impact in PCI on bleeding Consider closure in higher risk interventions Multi-disciplinary approach and early referral