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IRTB - Arterial Access and Angioplasty

IRTB - Arterial Access and Angioplasty. Dr Hilary White Nottingham. 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

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IRTB - Arterial Access and Angioplasty

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  1. IRTB - Arterial Access and Angioplasty Dr Hilary White Nottingham

  2. Outline • Vascular access • Anatomy • Equipment • complications • Angioplasty • Closure • Cases

  3. 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?

  4. Pre-op • What does the request card say? • Intermittent claudication vs critical limb ischaemia • side? • Previous imaging • Check bloods • Consider equipment • Approach

  5. The Kit • The WHO • 035 vs 018 • Access • Bail out kit – covered stents/ aspiration catheters/ angiojet – Call For Help

  6. Access • Antegrade vs retrograde • Anatomy • Hostile groin? • Time • Equipment • Experience

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 A round-tipped guidewire is then advanced through the lumen of the trocar, and the trocar is withdrawn.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

  8. 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

  9. 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

  10. 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

  11. Think about the steps • Access • Angiogram IS THIS A STRAIGHT FORWARD ANGIOGRAM? • Heparin • Closure • Do no harm

  12. 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

  13. Why Not? • Subclavian occlusion • Infection • Easier to reach from femoral approach • Risk of stroke • Small vessels (particularly women)

  14. 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

  15. Complications of Brachial Artery Puncture • Median nerve damage • Haematoma • False Aneurysm • Embolisation to Fingers • Dissection (with lower arm ischemia) • Stroke (especially posterior circulation)

  16. 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

  17. 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.

  18. Complications (most common) • Dissection • Haematoma • False Aneurysm (Femoral or Inferior Epigastric) • Retroperitoneal Haemorrhage (patients can die from this) • Infection

  19. Questions?

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