1. Groin Complication from Access Closure Failures
Aravinda Nanjundappa, MD, FSCAI,FACC
West Virginia University
Charleston. WV

2. Access site complications
Most common complication for endovascular procedures
90% of on table and 24 hour mortality after endovascular case is from access problems
Learn how to safely access and close is the key to a successful case
Know the access puncture site location before patient leaves the lab

3. Access closure Manual compression is the best
However hematoma can occur
Prolongs turn over
Closure devices: Choose what is comfortable
“Devil made MOST of the closure devices” Famous words of my vascular surgeon

4. More tips and tricks Femoral angiogram at start of the case
Use micro puncture plus ultrasound for carotid stenting, AAA, TAA with preclose and thrombolysis cases
If the stick is unsuccessful hold pressure for 5 mins for large bore needle and 2 to 3 mins for micro puncture before the next stick
Heparin only after intervention sheath is placed unless brachial or pedal or radial

5. Femoral artery access Locate medial and lower femoral head
All cases need fluroscopy
Locate medial and lower femoral head
Puncture at least one inch below the lower femoral head
Single front wall puncture
If on anticoagulation use micropuncture needle

6. Tips and Tricks for acess management
Fluoroscopic needle location
Micro puncture : multiple attempts less forgiving, useful in severely calcified arteries
Mirco puncture will not reduce RP bleed
Doppler assisted “SMART” needle can be of help especially obese patients
Use of ultrasound guided puncture probably safe approach: learning curve

7. Management of access site
Use manual compression for diagnostic cases
Interventional case with good femoral puncture use the closure device u r comfortable with and have experience
Small hematoma: manual compression followed by femstop
Large hematoma with with nerve compromise or skin necrosis : needs evacuation

8. Case
72 yr old female with HTN uncontrolled on 3 meds underwent renal angiogram
Bilateral renal artery <60% stenosis
Right femoral artery failed perclose: Angioseal used
3 hours later severe right leg pain, mottled
Patient bought to the lab for angiogram

9. Post closure device

10. Still not a good flow
Failed Snare : Covered stent Balloon expandable

11. Femo stop Case:
76 yr old lady underwent cardiac cath and PCI plus stent sent to floor with fem-stop
30 mins after fem stop removal patient has pain in the groin and discomfort
Hemodynamically stable
Exam shows ABI 0,71 right leg, cool to touch feeble right femoral pulse
ALI Stage 1

12. Cross over femoral angiogram and PTA and stent of the right EIA

13. Femoral- popletal angiogram
Now patient is hypotensive and in pain
Where is the bleed?
What happened?

14. Covered Stent across the profunda femoris artery

15. Case of manual compression
69 yr old underwent catheterization and stent
2 hours after the manual compression on left side patient is hypotensive and left flank pain
What is the next test?
CT scan?
CT scan is as good as sending patient to get a hair cut

16. Cross over and left femoral angiogram

17. Bleed from EIA Rx Covered stent

18. Case of failed Prostar
82 yr old female underwent attempted transcutaneous aortic valve replacement attempt from right femoral artery
2 days later presents with right leg acute limb ischemia stage IIa
Right leg ABI 0.22

20. Balloon PTA via SFA puncture

21. Image of star close

22. What about new closure devices
29 yr old history of CAD, CABG, presents with angina
Post cath minx device placed in right femoral artery
Right leg ABI 0.2
Emergent angiogram planned

23. Right leg Angiogram

24. One more closure device
Patient underwent diagnostic cathetrization of carotid artery
Right femoral angio was not performed at end of the case due to S. creat 1.8
Angioseal deployed
One hour later patient has severe right leg pain
Angiogram planned

25. Right leg angiogram and snare?

26. Management of collagen plug

27. Conclusions Access complications are serious
Angiogram all femoral punctures
Use closure device cautiously and learn one device very well
Know how to use covered stents and embolisation