1. Zoltan G. Turi, M.D. Professor of Medicine University of Medicine and Dentistry of New Jersey A Bad Vascular Access and Closure Outcome

2. Disclosure Information Zoltan G. Turi MD, FSCAI Grant/Research Support: Abbott, Arstasis, Cordis, Marine Polymer Technologies, St. Jude Medical

3. History 48 year old hypertensive diabetic ♀ Anterior ischemia Routine PCI  Heparin – ACT 240  Eptifibatide  Aspirin and clopidogrel loading Bifurcation stenting – sheath ↑ 7 F DES placed LAD with good result Agitated during much of case – difficult to sedate  BP ↑

4. Systolic BP during procedure mm Hg 10:48 am12:08 pm

5. Post procedure femoral angio

6. Angio-Seal deployed by fellow ~ 12:10  Attending with little VCD experience Patient sent to step down No special warnings or other communication with staff Initial BP in step down = 120 mm Hg Regular staff went on break ~ 12:30 pm

7. BP now 100 Patient became agitated Fellow sees patient and calls attending Attending – in office - ordered antihistamines and steroids Repeat BP ~ 100 mm Hg Fellow still worried CT scan ordered Staff worried Ask another attending to take a look Other attending worried

8. Patient rushed to lab

11. mm Hg intra- procedure Step- down 10:48 am12:08 am

12. Post mortem Large retroperitoneal bleed Closure device in place – some space between plug and arterial wall

13. Insertion IEA

14. A D C F E B CCI 2011 Freilich

16. What went wrong here 1. High stick 2. Failure to recognize high stick prior to sheath placement/upsizing sheath 3. Failure to recognize high stick prior to anticoagulation 4. Use of closure device after PCI with high stick 5. Failure to recognize “bladder sign”

17. 6. Sending patient to recovery 7. Failure to communicate with nursing staff implications of high stick/bladder compression 8. Shift change 9. Failure to recognize importance of lower BP and agitation 10. Failure to intervene early

18. 11. Failure to transfuse 12. Wrong groin used for access 13. Too little, too late

19. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Preflight

20. Checklist – 1 Preflight History of prior access Examine potential access sites  Palpate, auscultate, distal pulses, ABIs - record Review prior femoral angiograms

21. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Consider alternatives

22. 2 - Consider Radial

23. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Micropuncture

24. 3 - Micropuncture

25. Some simple math ~ 7 th grade Flow =  Pressure/Resistance Resistance = viscosity * length radius 4 If  Pressure, viscosity and length fixed Then  Flow ~  radius 4

26. 5.9 fold  in blood loss  In size = 56% Std needle (18g) = 1.27 mm Micropuncture (21g) =.813 mm

27. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD Ultrasound and/or iterative fluoroscopy

28. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy Optimize access Ultrasound and/or iterative fluoroscopy

29.   BIF IEA Cumulative Target Zone FH Centerline

30. Smallest sheath possible Trimarchi JACC CI 2010

31. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients No VCD or VCD appropriate to situation Femoral angiogram every case

32. Femoral Angio Everyone Age Gender Diabetes ↓ Body surface area Sheath size Vessel size* Anticoagulation Puncture location* Prior instrumentation Vascular disease at puncture site* ? IIb/IIIa * = requires femoral angio Know anatomy for next time

33. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients No VCD or VCD appropriate to situation 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic

34. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients No VCD or VCD appropriate to situation 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg/needle mgmt/groin mgmt

35. Bleeding Complications Blankenship. CCI 2002. Dauerman JACC 2007

36. Strategies Minimizing Bleeding Weight-adjusted heparin Lower heparin dose No postprocedure heparin No venous sheath Smaller guiding catheter Fixed dose heparin should largely disappear

37. Consider bivalirudin Trimarchi JACC CI 2010

38. Needle management Avoid multiple sticks, posterior wall sticks  Stop and compress if failed puncture Anterior wall only, good blood flow, no resistance to wire

39. 1 – Preflight 2 – Consider alternatives 3 – Micropuncture 4 – Ultrasound and/or iterative fluoroscopy 5 – Femoral angiogram every case 6 – If stick approaches within 5 mm of IEA – no anticoagulation or antiplatelet Rx – can do diagnostic 7 – Bivalirudin or weight adjusted heparin – begin with < 40 units/kg 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 – No unanchored devices for anticoagulated patients, VCD appropriate to situation or no VCD 8 –Closure is not for the inexperienced or unsupervised 9 - No VCD for puncture within 5 mm of IEA 10 –VCD appropriate to situation or no VCD

40. Suspicion of RPH Stable CT Scan

41. Suspicion of RPH ShockStable Cath lab* Contralateral Access Tamponade Leak CT Scan Transfuse ! Reverse Anticoagulation !