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Vascular Access and Vascular Closure Devices PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Vascular Access and Vascular Closure Devices" by Nelson Lim Bernardo, MD.

This medical PowerPoint presentation talks about Vascular access and vascular closure devices. Vascular access and vascular closure devices are two important medical devices used in interventional cardiology and other medical procedures.

Vascular access devices, such as catheters and sheaths, are used to gain access to the bloodstream for diagnostic or therapeutic purposes. They are typically inserted into an artery or vein in the arm, leg, or groin area. These devices are essential for procedures such as angiography, angioplasty, and stenting, as they allow doctors to deliver medical equipment and drugs to the site of the problem.

Vascular closure devices, on the other hand, are used to close the puncture site in the artery or vein after the procedure is complete, reducing the risk of bleeding and complications. There are several types of vascular closure devices, including suture-based devices, collagen plugs, and vascular clips. These devices offer several advantages over traditional manual compression techniques, including faster hemostasis, shorter recovery time, and reduced patient discomfort.

Both vascular access and vascular closure devices are important tools in interventional cardiology and other medical procedures, allowing doctors to perform minimally invasive procedures that can often replace more invasive surgical techniques. However, these devices must be used with caution, as they carry certain risks, such as bleeding, infection, and vessel damage. It is important for healthcare providers to carefully consider the benefits and risks of these devices for each individual patient and procedure.

Tags : Vascular access devices, vascular closure devices, interventional cardiology, cardiology

Published on : Mar 17, 2023 | Views : 1545 | Downloads : 0

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Slide 1-

Nelson Lim Bernardo, MDWashington Hospital Center Vascular Access and Vascular Closure Devices
Slide 2-

Faculty Disclosure No conflict of interest related to this presentation
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Vascular Access for Catheterization Successful vascular access is paramount in the performance of invasive catheterization procedures (Dxtic or Interventional) Uncomplicated hemostasis of the vascular access site is key to the success of any invasive procedure
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Vascular Access Sites: Femoral artery Brachial artery Axillary artery Radial artery Ulnar artery
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Vascular Access Sites: Femoral artery Most commonly used in the U.S. (Coronary) Brachial artery Axillary artery Radial artery Europe and the rest of the world (Coronary) Ulnar artery
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Vascular Access for Catheterization Successful vascular access is paramount in the performance of invasive catheterization procedures (Dxtic or Interventional) Uncomplicated hemostasis of the vascular access site is key to the success of any invasive procedure GOAL: “0” groin complication Uncomplicated 1-stick during access Good Hemostasis ASAP
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Vascular Access for Catheterization Vascular access complications will happen Diagnostic caths: 0.8 - 1.8% Therapeutic/PCI : 1.5 - 9% Factors: Patient, Anti-coagulation Tx, anti-platelet Tx, bigger sheath size, delayed sheath removal, etc. Complications lead to: Morbidity/Mortality Increased length of stay Adds to health care cost
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Chandrasekar B, et. al. Cath & Cardiovasc Interventions. 2000; 52(3):289-295.Cardiac Cath: Complication Rates % Complications Diagnostic (n = 7,953) Therapeutic/Intervention (n = 3,868) Complications 2-year period (April 1996 to March 1998) – 11,821 procedures
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Kiemeneij et. al. JACC. 1997; 29:1269-1275.ACCESS: PTCA using Femoral, Brachial or Radial A. 6F Femoral Brachial Radial (n=900) (n=300) (n=300) (n=300) Major entry site complications (%) 2.0 2.3 0 Successful coronary cannulation (%) 99.7 95.7 93.0 Primary PTCA success (%) 90.7 90.7 91.7 Asymptomatic occlusion (%) 3
Slide 10-

Complications: Femoral Artery Access Femoral artery complications: 2-10% Complications: Groin Hematoma (1-10%) Pseudoaneurysm (1-6%) AV fistula (<1%) Retroperitoneal bleed (0.1-0.9%) Acute closure (<1%) Dissection (intimal) Vessel Laceration Neural injury Infection Venous thrombosis (+/- right heart cath) Sheath/catheter clot
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Complications: Femoral Artery Access Factors increasing risk: Advanced age - >70 years Female Percutaneous coronary intervention (PCI) Chronic kidney disease (CKD) + venous sheath Operator driven/dependent Vascular access Sheath removal - Hemostasis
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Vascular Access: Seldinger technique Acta Radiologica. 1953. 38: 368-376.
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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
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Vascular Access: Femoral Artery U.S. – Use of the common femoral artery (CFA) as the primary access site is still the most common Puncture site (of CFA) is key “Not too-high” (RPH) & “Not too-low” (PSA) Pulsation Skin/inguinal crease Bony landmark – Fluoroscopy Guidance – doppler needle, ‘road-map’ Ultrasound ‘direct’ visualization
Slide 15-

CFA: Use of Skin Crease for Vascular Access Inguinal skin crease (non-obese male) Micropuncture needle
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CFA: Bony Landmarks for Vascular Access
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CFA: Bony Landmarks for Vascular Access Ideal Needle Entry Site
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CFA: Bony Landmarks for Vascular Access Ideal Needle Entry Site Too high – Retroperitoneal bleed Too low – PSA, etc.
Slide 19-

Common Femoral Artery: Bifurcation Using body landmarks would mean ≈ 5% CFA access ‘error’
Slide 20-

Common Femoral Artery: Bifurcation
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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
Slide 22-

Real Time US-guided Vascular Access Right CFA - SFA/DFA bifurcation  Introduce needle above bifurcation Longitudinal view
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Real Time US-guided Vascular Access Longitudinal view Transverse view of right CFA Transverse view
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Real Time US-guided Vascular Access Longitudinal view Right CFA and CFV Longitudinal view Center the vessel (CFA) in center of screen Center of imaging probe overlies center of vessel and serves as landmark for needle entry Transverse view
Slide 25-

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
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Ultrasound Guided Vascular Access Ultrasound guidance allows access to any vascular bed.
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Femoral Artery Access: Ultrasound Guided Advantage: Direct visualization of artery Anatomy Vessel wall Anterior stick Cons: Capital expenditure - Dedicated US in the lab Adds procedure time to patient with ‘easy’ access Operator’s preference “Comfort zone” Proficiency with ultrasound
Slide 28-

US Guided Access: ??recommendations When to use real time ultrasound-guided vascular access ? Difficult access – no discernable pulse in the CFA Insertion of large-bore sheath in the CFA – EVAR, TEVAR, Percutaneous TAVI (Especially with planned suture-mediated closure) Cannulation of infrequently accessed vessel – Popliteal artery, axillary artery, etc. Patients with bleeding diathesis Application of technique in vascular beds not usually accessed – safety vs Fluoro guidance
Slide 29-

Hemostasis of Vascular Access Site Manual compression – ‘standard of care’ With anticoagulation, i.e., Heparin – need to check ACT before pulling Delayed sheath removal ~ increased complication Adjunctive mechanical compression devices Pressure dressings – ??evidence base Compression devices – concern about compression necrosis
Slide 30-

Hemostasis: Vascular Closure Device (VCD) Rationale for Use of VCD: Earlier sheath removal – hemostasis Patient comfort – earlier ambulation, less pain Reduced Length of stay – healthcare cost Improve use of staff time Patient preference ??compelling evidence for lower complication rates. [Koreny 2004, Nikolsky 2004, Applegate 2006]
Slide 31-

Arora N, et. al. Am Heart J. 2007; 153:606-611.Vascular Complication Rates % Complications Diagnostic (n = 6,024) Therapeutic/Intervention (n = 6,913) Manual VCD Manual VCD
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Access Site Major Vascular Thrombotic Complications Occlusion Femoral Compression 2 - 4% Device Closure 1.2 - 2.8% Brachial 2 - 3% Radial 0.1% 3 - 5% Major Vascular Complications for PCI Benit et. al. CCD. 1997;41:124-130. Kiemeneij et. al. JACC. 1997;29:1269-1275. Shrake et. al. Am J Cardiol. 2000;85:1024. Mann et. al. JACC. 1998;32:572. Cremanasi. J Invas Cardiol. 1994;10:464. Kussmaul. JACC. 1995;25:1685. Sanbourn. JACC. 1993;22:1272. Ernst. JACC. 1993;21:851. Ellis. Circ. 1999;100:I-313.
Slide 33-

Vascular Closure Device (VCD) Primary Closure Clips and Sutures Angioseal Duett Vasoseal Angiolink Onyx Perclose Prostar Starclose X-site Sutura Mynx Quick seal Sub Q (gel foam) BioIntervention Clo-sure PAD Syvek Flo seal Biodisc Therus (Ultrasound) Collagen / Thrombin / Sealant No Foreign Body Boomerang Arstasis
Slide 34-

Vascular Closure Device (VCD) Device Types – NO “ideal” device Device selection ~ Operator “comfort zone” Anatomy
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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
Slide 36-

VCD Deployment: Simple Rules Access site – Single stick Location of arteriotomy Take angio of CFA - Ipsilateral 30-40O Note vessel morphology Re-prep groin + Change gloves Know the device
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VCD Use Use of vascular closure devices for hemostasis is not devoid of access site complications but is associated with device related/device deployment complications. Complications: Acute vessel closure Subacute occlusion Infection Device malfunction
Slide 38-

Marso, et. al. JAMA. 2010; 303:2156-2164.NCDR: Estimated Bleeding Reductions 2004-2008: 1,759,408 records (N = 1,522,935) Bleeding avoidance strategy: Bivalirudin, VCD or Both
Slide 39-

Vascular Closure Device: WHC Experience Single center: 2008 - 2010 period VCD use is Operator driven/discretion
Slide 40-

VCD Use: WHC Experience Single center: 2008 - 2010 period
Slide 41-

Conclusions: Vascular Access & VCD Successful vascular access with uncomplicated hemostasis of the vascular access site is key to the success of any invasive procedure. Adjunctive use of ‘new’ devices and imaging modalities improves success in vascular access and outcome of hemostasis management. Proper training and appropriate case selection are critical to optimize outcomes in device usage & minimize complications.