IRTB - Arterial Access and Angioplasty

Dr Hilary WhiteNottingham

Outline

Vascular access Anatomy Equipment complications

Angioplasty

Closure

Cases

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?

Pre-op

What does the request card say? Intermittent claudication vs critical limb

ischaemia side?

Previous imaging

Check bloods

Consider equipment

Approach

The Kit

The WHO

035 vs 018

Access

Bail out kit – covered stents/ aspiration catheters/ angiojet – Call For Help

Access

Antegrade vs retrograde

Anatomy

Hostile groin?

Time

Equipment

Experience

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 A round-tipped guidewire is then advanced through the lumen of the trocar, and the trocar is withdrawn.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

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

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

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

Think about the steps

Access

Angiogram

IS THIS A STRAIGHT FORWARD ANGIOGRAM?

Heparin

Closure

Do no harm

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

Why Not?

Subclavian occlusion Infection Easier to reach from femoral

approach Risk of stroke Small vessels (particularly women)

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

Complications of Brachial Artery Puncture

Median nerve damage

Haematoma

False Aneurysm

Embolisation to Fingers

Dissection (with lower arm ischemia)

Stroke (especially posterior circulation)

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

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.

Complications (most common)

Dissection

Haematoma

False Aneurysm (Femoral or Inferior Epigastric)

Retroperitoneal Haemorrhage (patients can die from this)

Infection

Questions?