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 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

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