percutaneous insertion: use and contraindications
DESCRIPTION
Percutaneous Insertion: Use and Contraindications. Background. Drive towards minimal invasive surgery Advancement in endovascular techniques and technology Expanding indications Development of endoluminal stenting - PowerPoint PPT PresentationTRANSCRIPT
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)
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 stentgraft12 main body insertions(22-24F)14 contralateral limbinsertions (16-22F)
75% main body success71% contralateral limbsuccessbleeding (6)dissection (1)device failure (1)embolisation (1)
Howell, M. et al. 2001 AneuRx stentgraft144 insertions (16F)
94% successobesity (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 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