Vascular Access-Trans-hepatic & Vascular Closure Devices Ziyad M. Hijazi, M.D., MPH, FSCAI, FACC Professor of Pediatrics & Internal Medicine Rush University Medical Center Chicago Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Traditional Venous & arterial Access � 1. Umbilical vein/artery 2. Femoral Veins/arteries 3. Internal Jugular Veins 4. Carotid cutdown 5. Subclavian Veins Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Umbilical vein/Artery Access � 1. Neonatal period-may be up to a week of life 2. Efforts should be made to use this route-spare other access routes for future caths 3. most interventional procedures in neonates can be done using this access. Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Femoral Vein & Artery � 1. Preferred site for cardiac caths beyond neonatal period 2. Straight access to the right and left heart 3. Femoral veins can accommodate large sheaths Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Problems Encountered Using Femoral Veins 1. Thrombosis 2. Interruption of the IVC 3. IVC Filters 4. Protection for future catheterization Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Internal Jugular Vein/Subclavian Vein 1. Suitable alternatives 2. Cumbersome to manipulate catheters/devices from such routes, but are important access sites that catheterizers need to know anatomy well! Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Carotid Artery 1. cut-down is the preferred method! 2. Usually limit this route to neonatal period-Risk of stroke 3. Neonatal critical AS: this approach has been used for balloon valvuloplasty Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Transhepatic Access When other access sites are not available 1.Thrombosis 2. Interruption of the IVC 3. IVC Filters 4. Protection for future catheterization Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Technique 1. Mid axillary line 2. Chiba needle with a stylet � Puncture 1/2 way between diaphragm and liver edge � Orientate the needle horizontal/posterior to 1/2 way from midline � Withdraw stylet; aspirate until blood comes back; inject contrast. 3. 0.018” guide wire 4. Coaxial dilator (4-5Fr) 5. MUOM sheath Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices End of Procedure 1. Remove sheath-no coiling 2. Coil closure of tract 3. Gel foam closure of tract Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Coil closure of tract 3mmx4cm coil if sheath 6F or less Coils should be used after sheath was withdrawn and no blood comes back. Multiple coils may be required. Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Gel Foam Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Complications 1. Intraperitoneal hemorrhage 2. Cholangitis Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Direct LV Puncture Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Indications 1. Double mechanical valves 2. For closure of paravalvar mitral leaks Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Technique 1. CT/TTE to localize the apex of the LV 2. Mark the chest wall 3. Use a 0.021 puncture needle (Micro puncture kit) 4. Place a short sheath 5. Perform study/intervention 6. At end, hold pressure Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Complications 1. Pericardial effusion 2. Pleural effusion Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices $500 $400 $300 $200 $100 $0 2000 2001 2002 2003 2004 2005 2006 Closure Device Market Medtech Insight. Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices The Promise of Vascular closure Devices Patient comfort and convenience Decreased Time to hemostasis Early ambulation Shorter hospital stay Decreased overall procedure-related hospital costs Decreased complication rates Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Categories of closure devices • Anchored plugs • Unanchored plugs • Suture closure • Clip/staple closure • Topical patches • “No footprint” devices • Ultrasound/heat Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Anchored Plugs Active Approximation Angio-Seal Collagen Thrombosing agent Advantages- High success rate, short learning curve, short deployment time Disadvantages-vascular occlusion, potential infection Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Suture and Staple/Clip Devices Active Approximation StarClose Superstitch Perclose AngioLink Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Unanchored Plugs Passive Approximation VasoSeal Duett Thrombosing agent Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices New Unanchored Plug Technology Passive Approximation Mynx ExoSeal Vascular Sealants Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices No footprint devices Passive approximation Boomerang Catalyst ClosureWire Advantages-No foreign body No thrombosing or sealing agents Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Ultrasound/Heat Passive Approximation Therus Epiclose Plus Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Closure Begins with Access Femoral Introducer Sheath and Hemostasis Arstasis device Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Topical Hemostatic Patches Passive Approximation NON-INVASIVE Chito-Seal, Clo-Sur P.A.D., D-Stat, Neptune, Stasys, Syvek Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Which Device to Use? Patient and Vessel specific Heavily anti-coagulated- invasive active approximation Diseased vessel- passive approximation Residual oozing- thrombosing sealing agent or topical hemostatic patch Operator experience/competence Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices The Importance of Operator Experience 10 8 6 % 4 2 0 25 75 150 250 350 450 550 650 750 850 930 Patients Balzer et al. CCI 2001; 53: 174 Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices The Importance of Operator Experience 10 8 6 % 4 2 0 25 75 150 250 350 450 550 650 750 850 930 Patients Balzer et al. CCI 2001; 53: 174 Monday, December 21, 2009
Vascular Access-Trans-hepatic & Vascular Closure Devices Moral of the Learning Curve Monday, December 21, 2009
Recommend
More recommend
