Dr. Paul Lavigne describes access and groin management for large bore closure that is critical for transcatheter structural heart interventions and hemodynamic support.
So everyone feel free to chime in um some of this stuff or I should say all of this stuff is, is I think part and parcel of our training is interventional cardiologists, but um likely amplified when we're putting in sheets that are the size that we need for hemodynamic support or of our structural colleagues, some of these um giant sheets they use for um structural interventions. And so I think reasonable to review on occasion, some of the, you know, basics but important tenants. Um So I'll, I'll go through some things but uh you know, please everyone share some experience that they, you know, would have that would be pertinent to informing us all. So um we do most of our interventions these days radially. Um And so some of this stuff is lost uh maybe in, in our everyday practice, but no less important. Um And so maintaining good femoral access skills, particularly when we're dealing with larger she is uh vital to patient outcomes. The worst thing you can do is uh you know, a really um well thought out thought out and, and, and good intervention will need to be foiled by not taking your time up front to make sure that your access is um adequate. So, an atomic considerations, um We're all likely aware of these, but again, even more important when we're dealing with uh femoral access with large sheets. But calcification um either if at the site or above the access site with uh the likelihood to obstruct our our sheath from advancing, we need to consider whether there are alternative access points or access sites or whether that calcium can be treated effectively to facilitate large war access vessel size is important. Here, we have uh resources that have been largely developed um and curated by our structural colleagues, but are available to all of us and I use their expertise a great deal in terms of reconstructing CT scans, um and other imaging studies to really help plan excess so that that's done before you're in the lab. So assessing vessel size calcification can be done well before you're even in the procedure, plaque, identifying alternative sites. If you see that or identifying potential treatment options, often relying on some of our colleagues that do peripheral interventions. Like Doctor mckechnie, our, our, our vascular surgeons who are excellent here. Um Let me move this out of the way and then tortuosity, sometimes you can have pretty good vessels um but considerable tortuosity that makes things very challenging, particularly if there's even mild to moderate calcification. If you add to that, you know, considerable tortuosity that can be an issue. So assessing both sides and, and maybe um modifying your approach based on that key anatomical landmarks um under fluoroscopy, you know, I won't go through all of these in great detail to, to not belabor things, although I will say the crease is often used, uh you know, I'm guilty of this. Um but that's probably not the best landmark as it relates to um the ligament and the potential to um either stick low or high. The variance there is something on the order of something like 10 centimeters and, and about 75% of people, the uh adequate access site is uh above the, you know, uh crease. So, utilizing imaging access uh landmarks is probably um far superior. In this case, you're looking for, you know, middle to lower two thirds of the femoral head. What is this? So they can hear you better. I've got this one. Is this different? Oh, she's telling me to ignore you. I will ignore you. OK. Um uh So, of course, the, the femoral head is our, our biggest landmark. We're aiming for the middle floor, you know, two thirds. Um And it's important for compression, it's also uh likely where you're going to see the uh bifurcation, you know, let's take above the bifurcation. So why use ultrasound um particularly for larger um access sites? And this is true even if you can, you know, palpate a pulse good. Uh Well, and you have good uh fluoroscopic landmarks. But um ultrasound is far superior than to, to our, you know, clinical judgment here. As far as assessing vessel size and calcification, it might might modify your access point by a centimeter or so to identify an area um without significant calcification, you can see the bifurcation which in um some folks is a little bit um uh variant and so understanding if it's low or high can help modify your uh access uh technique accordingly. Yeah. What is anyone not aggressive? Radio is an amazing way to like the radio. I, I use radio. Always use it. I use it. Most of my guys. I do like a letter so it's there so I can see it. Iii I don't agree with you not wear it much really well or it's hard or something. And the ultrasound, um the one, the ones here um are nice for the leg, but the ones at the beach are better for why, why they have the small trousers and easier to hold that space. But the ones you guys have at the beach, I feel it, you know, the gel before, but something like that where it can go up a little bit higher than where you want. I, I do both. I do both. And this is where I do the same thing. I mark the lower from our head and we'll talk about this in a second. I use ultrasound and I think also important and what we don't necessarily realize when we don't use it is and this comes into play when you're going to close these things, but a single front wall stick is super important and you can easily get into the, you know, side the vessel, which you can probably get away with, with a six French sheath. But if you have a, you know, 15 French sheath in there, that can be a real challenge. So, ultrasound, super helpful. Thankfully here, I think um and this is not by my doing because I was probably one of the stalwarts that occasionally would say I don't really need it. Um But now every femoral access that I've been involved in in the last year or so has come with ultrasound before I'm even scrubbed and that's really, you have very little excuse to use it at that point. You taking credit for that on it. One important point is, you know, we are in Ceta, we see so many, none of our patients are straightforward, right? So one question always comes is what would, where would you think if you have a high back patient? Right? You in better case you go on the left side and the bifurcation is right there somewhere. Now you go on the left side like, ok, there are two groins and then same thing on the left side as well. Where would you stick? Would you take the S fa or not? Yeah, I I'd be inclined against sticking in the S fa, for the most part if I'm doing a 14 French or bigger shea. Um, I guess that that is uh a challenge. Uh, if I don't, I, I, I'd ask everyone to speak up. I'm confident enough in our closure techniques at this point that I'd rather stick healthy vessel. I mean, now, if it's above the inferior epigastric or something, I would not be comfortable with that. But um even if it's high on the femoral head, I'd, I would aim to do the new textbook and, and stick there. Yeah. And if there's, I, I thankfully and I, I don't know if it's like this everywhere because I haven't, you know, I've been lucky through training and then into my career to have really great colleagues. Um Phoning a friend is probably not a bad idea. I've definitely run things with Dexter and with Thor, if I think that there's gonna be some access problem and had them kind of on board, it doesn't happen often. But with CT imaging, sometimes you, you see that before it's even becomes apparent in the lab. So angle of entry is also important, particularly if you're using some of our closure devices that are kind of built for uh you know, a 40 degree angle of entry or so. So the ultrasound can help with that. Um This is just a depiction of, of what we're seeing all the time for most of us who are using this but not a bad reminder. Um We're using the ultrasound probe. It marked to the femoral head locating the artery and vein. You can see where that femoral artery bifurcates and you can then choose accordingly. It really takes a lot of the guess work out of it. Um And then, you know, try to stick somewhere where there's not AAA great deal of calcium and sometimes that can just be a couple of millimeters that you wouldn't be able to palpate. But ultrasound really gives us that um we're going to a 35 to 40 degree angle, seeing the needle enter the vessel is really helpful with ultrasound because you can see that you get a single front wall stick and that's um uh not something you'll notice at the beginning of the case, but something you'll be greatly appreciative for when you try to get that bad boy out key anatomical landmarks in our ultrasound. You can see the bifurcation, we're also using our fluoroscopy. So you have, you know, both uh you know, uh imaging modalities helping guide your access uh site. Um identification of calcification. Sometimes this is a little bit difficult. And in some of our patients who've had surgeries in their groin before or something with some of the reflections off of that. But in most folks, you can pretty readily uh identify calcification in the femoral artery and avoid it, um which will help with both uh minimizing risk of bleeding and uh closure with our um uh closure devices. I I'm gonna skip this. Uh There's calcium that is it? Ok. Um That's a nice stick. Uh OK. Um best practices for obtaining federal access um performing an angiogram through the micropuncture catheter is, is something that I think a lot of us do and I find super helpful. Um It's a lot easier to realize that you're not in a place that you wanna be after you've put in a micro sheet and after you've put in a large one, even if it's like a six French, you really can't modify too much beyond that. And again, it's something in the order of confirming um access site placement. So you should probably be in a good place if you've already used ultrasound in your fluoroscopic landmarks. I like to confirm it like this in patients that have a K I or some bad kidney disease. You can probably escape this if you're confident with your ultrasound skills and whatnot. But I, I generally do it without any contraindication um in place and have found it very helpful, dilating. The vessel is dependent upon the size of the sheep that you're using. And I can tell you that with the newer um in the last few years, uh um WM sheaths for impala, the tapered tip really for most people negates the need to use sequential dilators. So the long tapered sheath is, is really helpful there I don't know how many times you dilate to put in a, what are you using in taverns these days? What are you using in Tas in 1820? You, you, uh, how are those sheets? You, you put in a bunch of sequential dilator or are you going just straight in with the sheet? Yeah. Yeah. Yeah. So, II, I felt bad the first time I didn't use it. I thought I was kind of cheating or, or being lazy, but frankly, I think the less steps sometimes the better. And so I, I think some of these tapered sheaths are, are really well designed and nice to avoid the sequential dilation. But if you need it, um you need it, making sure that the patient's anticoagulated before you put it in and particularly before you take out the dilator and open up that, you know, giant sheath. Um And then I had for me a femoral and to evaluate distal flow. I don't know if anyone does that. Uh before the end of the case, I'm guilty of not, I don't know. Um At that point, I'm, I'm fairly committed to completing the case, so I don't give extra die. Um So for most of us, uh in myself included, this comes mostly into play for human dynamic support devices and impellers. Um Certainly the one that we utilize the most, this is uh exchange of the peel away sheath. Um It's uh it's pretty straightforward, make sure that the femoral artery access sheath is all the way out of the vessel. When you peel it away, that's a mistake that's easy to make. And you can leave yourself into huge trouble. But after that, it's really just sliding it forward. Don't hold pressure over the arteriotomy. Um, with the foot with the big sheath in place, it's a little bit tempting to do so because we all know how big it is and how much you can bleed, but you're not gonna lose that much with the impala place and you're gonna advance the sheath over it. Um And really focus on just making sure that things all the way out and, and peeling away after that, you can hold pressure until you get the peel away uh in or until you get the repositioning sheep in. Um This is uh something that I think most of us do even for smaller sheaths if we wind up suturing them in, but becomes particularly important in this tapered sheath when we're putting a patient in the IC U to prevent bleeding. But making sure that we're suturing with forward tension on the uh on the sheath to prevent it from moving back with the uh with the repositioning sheath, moving it back isn't just, um, you know, kind of uh irritating the arteriotomy, but the actual size of the sheath tapers. And so you can, you can wind up with uh considerable bleeding if it comes back too far. So this is the closure options. I'd say these are the two, that we use most and are probably used most nationwide per clothes. Um, has been around for a long time and I think is quite reliable. Um, Manta is like a, a large Angio seal and I've also found that one useful. I've been post closing, um, almost exclusive with Manta because it, you know, you don't have to leave anything in the body. Um I'm not sure everyone does that if anyone else has anything, they do do that work for them. But um uh I think more often than not our sheets are removed de Novo with per clothes. Um So it's, I don't know what the percentage breakdown is here, but whatever your personal preference is, they're both, I think excellent devices. I do a little bit less this, I don't know if anyone wants to speak to this as far as personal experience, but the dry closure options, I've got colleagues at other institutions that do this routinely, um particularly the contra laical dry closure. So if you have um contralateral access, which um I think is, is less and less the case in, in a lot of our PC is anyway, um getting a wire around and then putting a balloon over to cl flow is helpful. Um It makes it a little bit, I guess, um less dramatic when you are deploying your perclose sutures. I've also been told and I can't tell you that I've done this personally, but from, from colleagues of mine that do this in a post closure fashion, even though the arteriotomy is larger than the recommended size. I'm speaking off label to our abbot friends who um when you do this, they've had success at decompressing the vessel enough that they can actually deploy per clothes. Um af you know, when they're removing an impala and have them catch and get, you know, two in, I have taken their word for it, try it at your own risk. But i it's reliable sources that have told me they do this routinely. Um And have you, have you heard technique? No, what they'll do is if you have a patient that's been on support and I think I know they've done this. Uh uh um now more and more often and some of the uh confidence is done when you have a patient, maybe they receive it from an outside hospital. They do the pre closes, they had a patient on support. Then afterwards they keep an 035, put an 035, they take the entire to out, they put the 035 work through the side for, they did call out, they put a 14 she in or seven, put a secondary wire, seven front sheets out the 27 front sheets and over both wires. So now they have a double there and then they'll perclose over one, tighten it down over the seven front and then per close over the second one. So what they do is the 27 front sheets elongated the arterial. So they can actually get a capture on the per. Um So that, that's great. Uh uh We've done that. I haven't done it here as fellows. Occasionally, we would do that with um um Angio seals. So we'd take two sheets, either a seven and an eight or, or two eights and uh then Angioseal using that same principle. Um So that sounds like it works with the, with the 14 French manta measuring stick. We've been taking it out, measuring it and then uh going forward that I don't know what you've been doing, Ron, I think you, you take a fair bit of these out. Um That's, that's worked for me. Um when we get them from other, you know, from, from outside. Um So contralateral dry, uh you know, growing excess is required for this. Generally speaking, in these cases, I'd say more often than not. We have a um a seven French sheath in which you can utilize for balloons large enough. You have a six French sheath and you probably have to upsize it. You do have to put in a longer one if you don't have a longer sheath, so you can take a rim catheter or whatever you want to get around and then you advance it over. Um You, you use your transaction to monitor the wave forms and tell if you're damped or occlusive, which is your goal here when you advance the balloon and then inflate it. Um And then with that balloon deployed, um you may have uh a little more quiet time deploying your, your per clothes. Um Disti angiogram is really important to um document flow in the vessel. Uh It's not uncommon, it's not, thankfully, it's not common, but it's, it's not rare enough to dismiss outright the prospect of closing off the vessel. And so we do routinely get angiograms here. I don't know if we put the uh um buddy access technique, but if you uh deploy a manta, if your manta is your choice. Um That was initially a concern. If you have single access, we've been deploying the manta with a micro wire alongside it and then advancing a micro sheath through and taking a picture of it. And that works quite well. Otherwise you can use her clothes to, to tamp down around whatever sheath you want and confirm that your clothes. Um mm doesn't sound good. Um And then uh if you do have contralateral access, then certainly ee either a nonselective shot with a pigtail can confirm it or I'd, I'd prefer to take a selective shot with uh you know, getting around with a rim catheter or what have you and I can feel like a peripheral interventionist like Ron mckechnie when I do that. It's, it's nice. Um I am not frankly familiar with single access, dry closure. I don't know if anyone's done it. Um And so I'm not really gonna speak much to it. Uh I just don't have the experience with it. Um I think we all know the implications of high or low femoral access, but they, you know, they bear repeating just uh in that when you have a large sheath in everything that happens in these lists happens more quickly and more dramatically. Um But with high puncture, you're, you're really worried about the prospect of retro perineal bleed and there's very little recourse when you have uh a, a very large sheath in and you can't hold compression, low puncture, complications sound a little bit less scary on the surface because you can generally compress these things, but they can be catastrophic as well. Um We generally think of the risk of things like um pseudoaneurysm or a v fistula, but even the risk of bleeding is higher when you're, you know, particularly from below the femoral head and you have a large sheep in a small vessel. Um Here is the uh AAA picture of a hematoma so that you can recognize it when you see it. Um Same thing I I'd say if you have a 14 plus sheath in and by the time you recognize the flank, uh you know, discoloration, you're probably not in a good place if they're alive. Um Somebody say something. Um So, yeah, uh th this is a little bit more difficult to do, I'd say for the most part. Um If you're, if you have a completion angiogram and you're comfortable with what that shows, then uh you should be rather confident that you're not bleeding. So that's really pivotal. If you do have an evident perforation and prolonged balloon inflation in consideration of a covered stent is important. Um I am, I cannot tell you, I'm an expert at using ultrasound to rule out the early signs of an RP bleed. Um Some people that, you know, I don't know, uh have done fast uh scans and whatnot may be able to catch that earlier by the time they have enough blood for me to see it with an ultrasound is probably a problem. So we use CT generally um here in my experience to confirm that quickly. Um You wanna make sure you're not giving uh copious amounts of anticoagulation to someone that you think is bleeding, I will say, and this is, I guess maybe somewhat controversial. But in PC I, once all of your equipment is out, if someone's bleeding, giving protamine isn't the most comforting thing, but generally well tolerated and probably better than bleeding. Uh significantly stent, thrombosis and a well deployed stent in a patient that's on DAPT um and gets protamine is, is not particularly common. Um So, you know, this is no different than our small sheets, different P and arterial bleed and uh track ooze, making sure that your angle of entry is maintained and that your sheath is, you know, sutured in place to maintain forward tension. Um sometimes uh particularly with a movement of the patient into the bed in the IC U with the repositioning sheath in for the impella by placing small uh uh I don't know stack of gauze under the sheath and reorienting the sheath to the um angle consistent with access. uh needle will prevent further bleeding and can solve some problems when you're faced with the decision of whether or not to take it out when they need hemodynamic support and tolerate the bleeding um or leave it in and do so. Um ischemia uh is, is a significant complication particularly for these patients that were leaving in large bore access, uh sheaths to maintain mechanical support. And so making sure that you're assessing pulses routinely um slightly pulling back on the repositioning sheath. If you have that in can be important. I know sometimes we leave the peel away sheath in place which in patients with larger vessels is generally well tolerated. I I know not recommended but um making sure that it is indeed removed. And repositioning sheaths inserted is important before you consider taking it out. And then consideration of an external fem fem bypass with a uh an antegrade sheath. Um downstream of the access side with contralateral access can be helpful. And we've seen in a few instances, limb salvaging and does not require specific technical expertise, although it can be a little bit frustrating trying to get an antegrade sheath in. Once you've already occluded the vessel with your mechanical support, it can be done. It just takes some, I, I, it, it takes some perseverance. Have you ever, did you ever put it in? I have not done it up front. Um, and I don't know that it would be a bad idea. Um I thankfully haven't had one where I couldn't get it in afterward, but I can tell you that it wasn't as easy as getting the antegrade sheet in. Um But yeah, no, I've, uh you know, it, it may be, I've done it uh with a, with a very small sheath. I can't recall an instance but it, it's much, it's much easier. It is much easier. Um But then you're dealing with, when you remove it, you've got, it's harder to remove an integrated sheath and you're almost always below the head. So it's harder to compress. So even with a small sheath, I'd like to not have two arteriotomy in that vessel if I can avoid it. Yeah, that would make sense. Or a micro sheet or something. I'm sure there are, you know, clever ways to make sure you maintain access. Um So I, I don't know. That's, that's a review of, again, everything, things that I'm sure everyone here knows, but ii I think it's good to review it and and hope you found some of that stuff, uh, a nice refresher on, on things that we should be paying close attention to, um, all the time and with that anyone have anything to add.
BROADCASTMED