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Percutaneous Insertion: Use and Contraindications

Percutaneous Insertion: Use and Contraindications. Background. Drive towards minimal invasive surgery Advancement in endovascular techniques and technology Expanding indications Development of endoluminal stenting

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Percutaneous Insertion: Use and Contraindications

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  1. Percutaneous Insertion: Use and Contraindications

  2. Background • Drive towards minimal invasive surgery • Advancement in endovascular techniques and technology • Expanding indications • Development of endoluminal stenting • early studies indicate less blood loss, shorter lengths of stay in ICU and in hospital

  3. Percutaneous Access • 1) reduce patient discomfort • 2) reduce time to ambulation • 3) reduce time to discharge • 4) allow earlier return to normal activities • 5) reduce local complications

  4. Percutaneous Access • limited by sheath size • endoluminal stenting 14-24F • carotid/subclavian stenting 7-10F • can be achieved by • smaller device profiles • closure devices

  5. Percutaneous Access: Haemostasis • Affected by • 1) Patient factors • age • weight • comorbid conditions - hypertension, coagulopathies • 2) Procedural factors • use of anticoagulation • sheath sizes • puncture site

  6. Access site Complications • Coronary catheterisation • diagnostic angiogram 0.5-1.5% • balloon angioplasty 1-3% • coronary stenting 5-17% • open incision endoluminal stenting 13-14% • wound seroma and infection • bleeding • dissection and distal emboli

  7. Closure Devices: Types • Extravascular • implantable collagen plug (Vasoseal) • collagen/thrombin injection (Duett) • Intravascular • bio-absorbable haemostatic anchor (Angio-Seal) • percutaneous suture device (Prostar XL and Closer)

  8. Closure Devices

  9. Perclose Prostar XL • Perclose Australia

  10. Perclose Prostar XL • Perclose Australia

  11. Advantages secure haemostasis large bore/ anticoagulation, high punctures minimal compression patient comfort and mobility Disadvantages high costs steep learning curve (Loubeyre C, et al J Am Coll Cardiol 1997) 9% complication 2.1% surgical rate >250 cases/user closure related complications Perclose Prostar XL

  12. Device Related Complications • persistent bleeding • pseudoaneurysm • infection • arterial/venous occlusion • arterial dissection • arteriovenous fistula • distal embolism

  13. Sprouse, L.R. et al J Vasc Surg 2001 retrospective review of patients requiring vascular surgery admission with (n=11) and without (n=14) use of closure devices pseudoaneurysm are larger and do not respond to ultrasound compression complications result in more blood loss and increased need for transfusions infections are more common and require aggressive surgery Closure Devices

  14. Prostar for endoluminal stenting • Preclose method (Haas, P. Et al. 1999) • limited (1cm) incision • subcutaneous tract dilatation • needles deployed prior to endoluminal stent • sutures tied at end of procedure

  15. Prostar Endoluminal Trials

  16. Perth Prostar Experience • Methods • 82 percutaneous closures in 44 patients • 10F Prostar XL PVS device • 1 iliac, 1 thoracic and 42 abdominal aortic aneurysms • 2 devices for main body and 1 for contralateral limb • product specialist present

  17. Perth Prostar Experience

  18. Perth Prostar Experience • Results • 85% success rate, 12 failures requiring surgery • 1 death related to a myocardial infarction precipitated by a retroperitoneal bleed • device introduction - unable to advance device • needle deployment - needle deflection • closure of arteriotomy - bleeding(7), obstruction(1) • late complication - psuedoaneurysm (1)

  19. Lessons • patient selection • obesity (5) • scarred groin (1) • preoperative ilio-femoral assessment • tortuous iliac artery (2) • high CFA bifurcation (2) • calcified artery • CT scanning/on-table ultrasound

  20. Lessons • high puncture • 1 mortality - unrecognised bleeding • suture management • suture catching (1) • keep sutures wet, ensure free running • guide wire • not a true over the wire system • angulated proximal neck

  21. X-Site PFC (Blue Pell, PA) lower cost alternative to Perclose SuperStitch (Sutura, Inc) suture mediated device for up to 24F Developments

  22. Conclusion • Open groin dissection remains the standard • Careful patient selection • Tutorlage and experience • Surgical skills to recognise and deal with complications

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