Ziyad M. Hijazi, M.D., MPH, FSCAI, FACC Professor of Pediatrics - - PowerPoint PPT Presentation

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Ziyad M. Hijazi, M.D., MPH, FSCAI, FACC Professor of Pediatrics - - PowerPoint PPT Presentation

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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

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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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

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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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

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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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

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Gel Foam

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Complications

  • 1. Intraperitoneal hemorrhage
  • 2. Cholangitis

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Direct LV Puncture

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Indications

  • 1. Double mechanical valves
  • 2. For closure of paravalvar mitral leaks

Monday, December 21, 2009

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Complications 1. Pericardial effusion 2. Pleural effusion

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Closure Device Market

Medtech Insight.

$500 2000 2001 2002 2003 2004 2005 2006 $400 $300 $200 $100 $0

Monday, December 21, 2009

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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

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices Anchored Plugs

Active Approximation Collagen Thrombosing agent Angio-Seal Advantages- High success rate, short learning curve, short deployment time Disadvantages-vascular occlusion, potential infection

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Suture and Staple/Clip Devices

AngioLink Superstitch StarClose Perclose Active Approximation

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Thrombosing agent

Unanchored Plugs

Passive Approximation

VasoSeal Duett

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices New Unanchored Plug Technology

Mynx ExoSeal

Passive Approximation Vascular Sealants

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices No footprint devices

Boomerang Catalyst ClosureWire

Passive approximation

Advantages-No foreign body No thrombosing or sealing agents

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Ultrasound/Heat

Therus

Passive Approximation

Epiclose Plus

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Femoral Introducer Sheath and Hemostasis

Closure Begins with Access

Arstasis device

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Topical Hemostatic Patches

Chito-Seal, Clo-Sur P.A.D., D-Stat, Neptune, Stasys, Syvek

NON-INVASIVE

Passive Approximation

Monday, December 21, 2009

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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

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Vascular Access-Trans-hepatic & Vascular Closure Devices The Importance of Operator Experience

Balzer et al. CCI 2001; 53: 174

10 8 6 4 2 25 75 150 250 350 450 550 650 750 850 930 % Patients

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices The Importance of Operator Experience

Balzer et al. CCI 2001; 53: 174

10 8 6 4 2 25 75 150 250 350 450 550 650 750 850 930 % Patients

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Moral of the Learning Curve

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Moral of the Learning Curve

Learn one or two devices and learn them extremely well

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Moral of the Learning Curve

Learn one or two devices and learn them extremely well

Consider an additional device for special circumstances

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Moral of the Learning Curve

Learn one or two devices and learn them extremely well

Consider an additional device for special circumstances Remember that manual compression is always an option

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Complications Specific to VCDs

  • Device-related:

– Embolization – Infection – Vessel obstruction

  • Direct mechanical
  • Injection into vessel

– Bleeding

  • Mechanical secondary to device
  • Secondary to early sheath pull

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Retroperitoneal Hemorrhage

Ellis et al., CCI 2006, 67:541

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices How to Decrease Risk of Complications

  • 1. Use fluoroscopy and/or ultrasound to ensure needle entry below centerline of

femoral artery

  • 2. Femoral angiogram regardless of closure device use. Allow ACT to normalize
  • 3. Proceed to PCI (and anticoagulate) only if puncture in safe zone

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices How to Decrease Complications

Courtesy of Zoltan Turi

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices How to Decrease Risk of Complications

Courtesy of Zoltan Turi

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices Conclusions/Take Home Message The interventional Cardiologist should know the advantages of trans-hepatic approach and how to perform it safely. VCDʼs are extremely useful in older patients. Knowledge of 1-2 VCD is important.

Monday, December 21, 2009

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Vascular Access-Trans-hepatic & Vascular Closure Devices

Pediatric & Adult Cardiac Interventional Therapies

Monday, December 21, 2009