Transcript 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
 early studies indicate less blood loss, shorter
lengths of stay in ICU and in hospital
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
Percutaneous Access


limited by sheath size
 endoluminal stenting 14-24F
 carotid/subclavian stenting 7-10F
can be achieved by
 smaller device profiles
 closure devices
Percutaneous Access: Haemostasis

Affected by
 1) Patient factors
 age
 weight
 comorbid

conditions - hypertension, coagulopathies
2) Procedural factors
 use
of anticoagulation
 sheath sizes
 puncture site
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
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)
Closure Devices
Perclose Prostar XL

Perclose Australia
Perclose Prostar XL

Perclose Australia
Perclose Prostar XL

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
Device Related Complications







persistent bleeding
pseudoaneurysm
infection
arterial/venous occlusion
arterial dissection
arteriovenous fistula
distal embolism
Closure Devices

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
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

Prostar Endoluminal Trials
Traul, D. et al. 2000
AneuRx stentgraft
12 main body insertions
(22-24F)
14 contralateral limb
insertions (16-22F)
75% main body success
71% contralateral limb
success
bleeding (6)
dissection (1)
device failure (1)
embolisation (1)
Howell, M. et al. 2001
AneuRx stentgraft
144 insertions (16F)
94% success
obesity (2)
calcification (6)
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
Perth Prostar Experience
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)
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
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
Developments


X-Site PFC (Blue Pell, PA)
 lower cost alternative to Perclose
SuperStitch (Sutura, Inc)
 suture mediated device for up to 24F
Conclusion




Open groin dissection remains the standard
Careful patient selection
Tutorlage and experience
Surgical skills to recognise and deal with
complications