Chapters Transcript Video Aortic or Iliofemoral Injury Dr Summer discusses vascular complications in TAVR, including vascular access complications and aortic dissection during TAVR. This is uh a jump to the aorto uh ileal uh femoral injury that uh it's basically peripheral complications uh that we had intended to do in a few weeks. We're still uh waiting to do the annular rupture. We've had a busy couple of weeks as, as you all have uh experienced first hand. Um but the idea of all these sessions again is to go through the, the more specific complications that we have a frame of reference for um how we manage them in the operating room. Um particularly with regards to tver, one of the most uh important ones that we uh take on and we're at the highest risk for besides conduction abnormalities is vascular complications. And that can include anything from the aorta uh at, at the annular level. It's actually considered a vascular complication. We talked about pericardial infusions and tamponade last week. Those count as vascular complications, ventricular perforation, right, ventricular and left ventricular. So all these are wrapped up kind of under the same heading, which is vascular injury. But when we talk about it here and how we're going to manage it, we're really talking about aortic and then iliofemoral we of course, have to use femoral access for 95% of our tver. The data that we, we look at and compare TVER versus sr the data that in part 12 and three and in uh CT and the initial core valve and the most recent core valve trials demonstrated benefits over surgery. And all three of those trials were predicated on the use of trans femoral access. And so when we have to take alternative access in the 5% of patients that not just we embark on, but, but nationally, we have to take it into account that we're not comparing uh transfemoral to surgery. We're comparing alternative access to surgery. And so the the benefit over surgery is diminished significantly. Those patients tend to be higher risk patients if you have P AD, but also have renal disease, you're more prone to bleed. There's a variety of coincident things that happen when you have significant P AD and we are seeing an increased uh prevalence of complex vascular cases. So our vascular alternative access rates have historically run around 5% and that is in keeping with most of the country and ours have started creeping up towards the 10% rate. So we're, we're around 8% right now. And so if there's a feeling that you're seeing more vascular issues, it's because we are, we're, we're taking on more complex vascular cases and I'll go through some of the data with that but then we'll, we'll talk about specific cases. The idea here is that this is very practical. So when we call for equipment, you guys know what we're thinking, or at least have a frame of reference for how we're thinking, depending on where the, the injury occurs. Next week. I'm hoping we'll do annular ruptures, more of a surgical issue. I think. Uh, you all could teach me about the equipment and things used in that. Uh more than I could teach you. But I, I know when it does occur, it's really a coin flip just like coronary inclusion on whether someone can survive. And like we've said, all along in these, these conferences, um That's where this tremendous team comes into effect is in those rare situa situations where we have something that's a coin flip, we win more than a coin flip or 50% of those cases because this team is so talented. So we're trying to, to increase our ability to salvage those rare scenarios uh by going through a practical uh structure as far as how we manage those complications. And so the first thing uh is just some background, if you look at dissections and we start at the aorta and then work down dissections are pretty rare. This was the first tver death that I had since when I started here in 2021. Um This is someone that you all salvaged tremendously during this case. Uh That as a team doctor, bro, um in the surgical team, I don't know if this was back in 2020. So it's been a while. Uh but this lady was not a surgical candidate because she had terrible, terrible, terrible lung disease. She had P AD and you can see she had a very large aorta, it's horizontal. So when we're talking about horizontal aortas, it's very difficult for us. You've seen us pull snares out uh to snare the nose cone and try to get this above. We're creating a lot of tension on the inner curve of the aorta when we do that. And when we're riding along, even when we have a SAPIEN, which is what we, we typically preference for horizontal aortas because we can steer that sheath around. We're putting a lot of pressure on the outer surface of the aorta. You can see this lady has a dissection down here just from the delivery catheter coming across uh the aortic arch. She was extreme surgical risk to begin with. Um We were able to, to treat her left Maine beforehand, uh a day before she made it through that with a bav uh and multivessel and left Main PC I and we got a normal valve in, but she unfortunately dissected in the process. So this kind of is, is uh fitting with what we see. This is the only case since I've been here where I've seen a dissection. Uh and I've uh been a part of almost all those procedures. And so it is something that can happen, but it's rare. Um, you all are the expert, you guys know how to treat dissections in the middle of the night and that's what you're, you're commonly on call for. So, um, you know how, uh tremendously difficult it is to fix these, these patients and get them through something like this and it depends on the extent of the tear and, and sort of its relation to the, the root and all of these things. Um But it is possible, albeit rare life threatening bleeding occurs at 4.6%. That's the current T BT uh rates. So about 5% is what we quote patients. Um but it does increase 30 day mortality. Significant bleeding happens closer to um 6 to 7%. Our vasco complication rates. If you incorporate everything all into one hover between six and 8% which is kind of uh fitting with our, our particular patient population severe P ad, you can see that the, the biggest thing is if you can trace back all of our, we've had five mortalities this year. If you can look at each one of those, almost all of them started with the vascular complication. So it's kind of the, the thing that gets the ball rolling towards a really, really unfortunate scenario where we're not able to salvage these people. And it speaks to the fact that a lot of these patients are so sick that any deviation from perfection uh can lead to their demise. And that that happens, we all of us are taking on very, very, very difficult patients. And so these things will occur and minutes matter as we've talked about. And so even the team working 10 15% more efficiently together, uh can salvage a lot of these scenarios, you know, preventing one unit of blood transfusion, two units of blood transfusion getting on things quicker, getting them out of the or off. A general anesthesia, avoiding a cut down all these things add up to a better patient outcome and uh uh less likely propensity to uh experience the ultimate uh poor outcome, which is mortality. But look at some of these numbers. This is from the initial tver. Um at one year mortality went up to 25% if you had a vascular complication and some of those were up to 20% because the sheets were 24 French. If you look at independent risk factors and a uh Multivariate regression analysis, you can see that these specific factors uh uh lead to or more commonly associated with vascular complications. We see a lot of tortuosity, we see circumferential calcification. Unfortunately, we see a lot of these closure device failures. There's been manufacturing issues with a manta and, and you have seen us throw away an entire box of pur clothes. These things happen. It's, it's part of the process, especially when there's severe p ad. Um these vascular closure devices are sort of working at their, their extreme ends as far as uh function. And so all of those things add up to uh risk factors for vascular injury. We talked a little bit about this. This is something that we hyper focus on when we're looking at had access uh in our valve conference. This is obviously a, a perfect femoral artery. But I tell uh the Cath lab techs and residents that 80% of the bifurcations occur below the femoral head. So if you even stick at the middle of the femoral head, 80% sure you're gonna be above, above the bifurcation, but it's not a given. And so we use three different ways to confirm that we're in the mid C fa that matters because a low stick, which is anything below the bifurcation uh increases your risk of complications like fistulas and pseudoaneurysms, you're getting to a non compressible part of the artery. So that weakening where you create the arteriotomy is much more difficult to control and uh prevent from out pouching and forming a pseudoaneurysm. You're also more likely to go through and through and get into the vein and that's where the fistulas come from. But the, the most devastating one is in a high stick which is above the femoral head. Really. We, we define it as uh above the bottom uh of the inferior epigastric artery takeoff that uh increases your risk of retro perineal hematoma. You can mask a bleed, you can not see a bleed uh until patients are hemodynamically unstable because it's going into their pelvis retro perineum. Um And you have an eight fold increased risk of retroperitoneal hematoma with a high stick. So deepak myself, Adler, we're all looking at this beforehand. And one of our first things that we do is we say, where are we gonna stick? The femoral uh in relation to the femoral head. So we do fleur guidance that way we do ultrasound, which helps us avoid a low stick, but doesn't necessarily help us avoid a high stick. And then we do do DS A angiogram, which is this picture here to make sure that we're in appropriate position with a small micropuncture sheath before we upsize it. So we're meticulously doing things uh that are best practice to avoid these, these problems. And in spite of that, um because of the patient population we deal with and because of just the inherent risk of large bore access, we see uh complication rates um most commonly uh beyond the conduction abnormalities with uh vascular issues. This is the old proglide system. We currently have a uh pro style system. But what this is when you see us using this, we're inserting these foot plates are folded up inside, we're inserting this over a wire, we uh expand the foot plates, bring it back to the front wall of the vessel, shoot sutures through and creates basically AAA purse string suture. It's a percutaneous purse string uh but just on the front wall. Um this is a demonstration of how it works. I think our, our Cath lab techs know this. But um these manta devices are the only purpose built designed large board access closure device and they're post closure device. So we don't have to prep the vessel at all. We do have to measure the arteriotomy depth and this was going to be the uh the greatest sort of thing since sliced bread as far as vascular closure devices. And we had a series of 700 patients where we used this device incredibly successfully at the 1.7% vascular complication rate. And we presented on this because of the, the rates were less than half of what they had in their, their clinical trial. And then we had a quarter where those, those rates kept going up. And this is why it's so important that we look at quality control and, and Q I stuff in our program is because we noticed that there was some manufacturing issues as far as the tolerances and in putting some of these um plugs inside the, the dilator and, and I'm sorry, the delivery system and we stopped using them multiply because of the manufacturing issues. And so I think that demonstrates to us that we are doing best practices and we're sort of at the, the limits of the technology. As far as our vascular complication rates, we uh have rates that are at the, the same uh absolute number is, is uh our competition, the numbers overall can add up when we have quarters where we're taking on more, more complex uh patients. And it ma it mirrors basically our alternative access uh rates. Ok. Sorry. All right. So what, what happens when we, we have a, a true vascular complication. Sorry. This is jacked up on my end. There we go. All right. So the Cath lab techs know this pretty well, but we're trying to get up over as quick as quickly as we can. Vascular complications come in two flavors, perforations and occlusions. Perforations are a bigger immediate problem. You're bleeding out into the pelvis. If it's above the common femoral, you can hold it if it's at the common femoral or potentially a little bit lower depending on where the bifurcation is. So, first and foremost, when we pull our pigtail catheter back at the end and do a completion angiogram, what we're looking for is perforation or occlusion. We're looking for normal blood flow down the S fa and the large bore access site. If we see a perforation, it's gotta be fast. If it's not in the common femoral, where myself or Doctor Campbell, one of the surgeons can hold pressure while we're getting the equipment necessary to come up and over and fix the, the small bleeding at the, the femoral artery, we have to get up very, very, very quickly up and over. So, the first thing is to engage the, the common iliac. We've already got contralateral access. We engage the common iliac. There's a couple different ways you can do it. I do it with a rim catheter. That's probably what you'll most commonly see because, um, Deepak and I use those and we do most of the jabs that helps you engage from the left side, the common Iliac. And then we have to wire. There's a variety of different ways you can do that. But sometimes the tortuosity and angulation can be very difficult. You're pushing the wire up towards the head, but you're trying to get it to direct down the ileo the through tortuous vessels. I like uh glide wire advantages for that. They're floppy, uh they're polymer jacketed, they're non tapered on the tip. So they're very, very friendly in the vasculature and they will find lumens. So basically small areas are easy to wire through and around things, but they've got a stiff backbone and so they can support you coming up and over with a dedicated delivery sheath. So first thing, engage wire as far as we can distally with a wire, usually glide wire V and then you have to exchange that you, you have six French on the other side, right? Most of these stents and things are delivered through a seven French So by standard, we, we take a 745 or 755 destination sheath up and over, over that stiffer wire glide wire vanish kind of splits two steps. It lets you have a working wire on the tip, but also a stiff wire to deliver. So up and over glad wire advantage exchange for your destination sheet. And then we have to wire the lesion, which is usually at the common femoral artery. If it's an occlusion, it's usually not terribly difficult to wire if it's a perforation higher up. But sometimes we get that wire going through the pelvis. If it's uh extensive dissection, usually that's we're putting in co of balloons and including balloons to try to prevent huge, huge bleeding. And the patient is hemodynamically unstable at any point. If you see us calling for this or working for this, we should be waiting to call vascular surgery because it's about 80% of these we can manage without any, any problems as far as hemodynamics just with percutaneous equipment. But those other 20% we either can't cross an occlusion and get uh flow back and vascular has to do a cut down to uh prepare the blood vessel primarily or we're in a dire situation where bleeding, we can't control it. And so vascular surgery should be on, on speed dial as you all know, and they've salvaged us out of a lot of these situations that are inherent problems that come with catheter based treatments and therapies. And so if you get to the, uh, perforation, you've wired past it, then it's just balloon occluding. And the balloon including, uh, size depends on where you're at it as far as the perforation. You know, the ultimate is you can put up a 12 French sheath on that other side. Granted, I, I just said that most of these patients have P AD when they have vascular complications. So the biggest issue is being able to deliver a 12 French sheath from the other side, we've already picked the best side for large bore access. We've taken the worst side as our contralateral access for imaging. And now we're trying to take that worst side and upsize it to a 12 French to deliver an including balloon. Those including balloons are dangerous. They can rupture the aorta. I've seen that twice. And so you generally don't get to that point, but we have to be ready for it. If you hear us call for a coda or a lion balloon, know what size sheet that goes through. It's 12 or 14. Almost all the ones we have are 12 French. And that is basically what they use in traumas and things like that to include blood flow internally while we're waiting to do a primary repair of vascular. If the occlusion or if the perforation is happening lower in the inflow, it's about getting the appropriate size charger balloon down for an internal uh tampon out of that, that bleed, basically holding internal pressure because you can't control it externally with pressure on the femoral artery, uh or femoral head. Um And then once you have bleeding controlled, it's about uh deciding on how to fix the vessel primarily. So, maintaining, getting wire access, uh is the, the most important thing up and over wiring to the S fa whether it's a perforation or occlusion. And then for perforations, you're trying to internally tamp a nod and control bleeding for occlusions, you have time. It takes a long time. They six hours uh is what they teach medical students as far as how long you can have a blood vessel shut down uh in your leg or in your arm or in your periphery before you have uh limb loss. And we never take that long because it's a little bit unpredictable. Once you get past an hour or two, we would never let someone uh uh stay without blood flow down their leg. And uh you know, at the end of a tab or, but it, it speaks to the urgency when you see these things. If you see a perforation, we're flying and you all should be flying too. If you see a occlusion, we've got a little bit of time. Let's, let's try to wire this without dissecting the vessel. Let's get uh coronary equipment down. If we can't wire it with 035 equipment and those kind of things and then this is busy, but this is our uh manifest of all the equipment that I've asked for to be in the or, and I want to break it down into covered, non covered stents and balloon expandable and self expanding. The gist of this is that in the femoral arteries, you want um stents that can deal with uh tortuosity when you're bending down your pelvis, uh bends, you can't have rigid balloon expandable stents in those areas because the stent will crush. And so the the classic teaching is that you don't put stents in the common femoral artery, but in reality, you don't put balloon expandable stents in the common femoral artery. You can use self expanding stents because they adopt the tortuosity of the vessel and also accommodate when the vessel moves or bends. So if we start at the top and down, um if you have a perforation or bleed in the common or external, you're gonna wanna use a covered stent, but you're gonna want the rigidity of a balloon expandable stent. So I use Viaan vbxs. Those are covered, balloon expandable for occlusions when you're not trying to control a bleed. Remember, the covered is just sealing that bleed an open cell. You're just propping open the blood vessel. The reason we use one versus the other is covered, you have to cover it to stop the bleeding. In inclusion, you don't. But in inclusion, there's a little bit more radial force uh and, and potentially more durability as far as patency if you don't have that PTFE material in the, the gore in the, in the Vons uh that are being used to cover the, the perforation. So in those scenarios, I like to use these Visy pros, there's a bunch of them. They're all basically peripheral uh stents, biliary stents, but they're open cell, non covered balloon expandable stents. So above the femorals using balloon expandable at the femorals, you're using self expanding and whether it's a bleed or a occlusion determines whether you're covered or not covered. The most confusing thing that happens every single time is that when we call for a a von, we get handed a VBX and that's because these, I mean, they really should have changed the name, but you can see on this, this is a regular vab on it does not have the balloon expandable end prot prosthesis on it. When we're talking about the common femorals. This is the one that we're talking about and what you need to know is that a lot of those are 018 wires too. So we have to exchange out for an 035 to 018. The ever flexes are the open cell self expanding uh stents. So really almost always the percutaneous bailouts that we're, we're using or the percutaneous uh salvages that we're, we're doing are at the common femoral, the access site and we're using regular via bonds, the self expanding and we're using uh ever flexes. Ok. And if we don't, if we can't get wire access, if we can't get the blood vessel open, if the injury is extensive enough or if it's involving the bifurcation, then we'll call vascular surgery to do a primary repair. It's all that makes sense. So to summarize, uh, aortic or iliofemoral injuries are the most common complication we come across besides conduction abnormalities, we can treat almost all of those percutaneously. But there's a subs um a subgroup of those that we just can't either extensive dissections or perforations, things we can't control with internal balloon t but not if we can't regain distal wire access or distal perfusion or for involving a side branch like the Profunda. Those are the main reasons why we wouldn't be able to convert these percutaneously when they happen. We have to be quick just like every one of these complications. Um There's a lot of different pieces of equipment and that's why I think it's important to standardize these things. Glad wire advantage is very expensive. There's other ways to do it, but it takes two or three wires. It's just more things that we all have to remember as a team during the throws of a, a complication when time is of the essence. So it's helpful, I think to familiarize yourself with these pieces of equipment. And again, the goal here is that we have active participation by every member in the team uh during these complications. So when, when you have this, if you don't have a role, pull this powerpoint up and start thinking about what size sheets we need, what size the vessel is. You know, everyone can be, be an active participant in these kind of things, we know them all, but we're also technically trying to work very, very diligently and quickly to get the problem taken care of. So again, uh multiple eyes is always a good thing. We wanna encourage input from every member of the team. OK. Um And then we are seeing an increased risk uh of these complications because of an increasing P ad uh prevalence. Um We have adopted a very formalized process to deal with alternative access. You'll see us do a lot of trans crowded. That's because registry data has shown that that's got lower stroke rates then uh Subclavian access or other alternative access uh modalities. I think sites generally nowadays choose between trans cable and trans carotid. We've done two trans cables in the past year and those were people that didn't have crowded access. You saw it a lot before this last year. I think in my mind it's something that technically we we can do when we can pull out if we need it, but it's also very, very, very high risk and there's no bail out. Ok? I would much rather have uh Doctor Kemp doing a crowd at having full control of the vessel. And that's feasible versus me taking an electrified sharp wire in the belly perforating through the Vena cava into the aorta. And then relying on my ability to put a ductal clutter that was designed 30 years ago to fix PDAs to close that hole, literally a gunshot wound in the aorta percutaneously. I don't like doing those. Um And I think we should be able to do it when, when we have to uh but we have a much, much, much safer uh and just as good outcome uh procedure which is trans carotid access. That's that. So with that, I'll take any other questions and Deepak if, if you're still on, do you have any, any comments, additions things we didn't talk about. Let me uh get your, I can't hear you. Deepak. Um Sorry, could you hear me? I, I can hear you. Ah hold on one second. Can you hear me now? Speak now? Deepak. Can I hear you? Can you hear me? Yes. Ok. That, that was such a great review. Every time I hear these, I learn something and these are complex situations that you take on top of the type of patients into the great reviews. Thanks for it. What questions do we have? All right, any questions from, from other sessions we've had, I think one takeaway from you all is that when we're, we're focusing on vascular access. Um That's something that our Cath lab techs do a good job on in stem and in corries and all those things. We've encouraged them to be active participants in these procedures beyond what their, their initial primary focus and role is. I was in a semi, two weeks ago, uh, on a, a little old lady that was very, very, very sick. She had arrested several times in the emergency department and, uh, I knew she had an RC A stem. He couldn't find the right, couldn't find the right, couldn't find the right. We're working, couldn't find a lesion on the left. And Sidra uh from the back of the room at three in the morning noticed a very small dissection at the root. Something that wasn't apparent until we did a full angiogram and it was very, very subtle. And so those kind of things help everyone. If you see something, say something, it's bottom line. You all have seen enough of these cases. Even if you're not a interventional cardiologist or cardiothoracic surgeon, you've seen enough of these cases with the volume that we do that your eyes are as good as anyone else's eyes. You've seen the problems as they've risen and so you should speak up if you see something, don't just depend on the fact that in all the chaos, one of the two or three physicians who's focused on all the technical aspects of this has recognized something potentially very subtle. So again, I think that the most important thing through these sessions is to encourage the active participation by all team members regardless of what your assigned role is. See something, speak up. Anything else? Excellent. Hopefully next week we'll do annular uh issues. Um I think Deepak and I will learn from that one. And then uh that'll be that. Thank you. Published September 12, 2024 Created by Related Presenters Matthew Summers, M.D. Sentara Cardiology Specialists View full profile
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