M1 Vascular Access & Vascular Closure Devices_acc

w assignment for w1

What zone is the target site for vascular access

Zone A

what is

1..

2..

3..

1. common iliac artery

2. femoral artery

3. Profunda fem artery ( its actually not, the profunda is medial alongside the femoral bone)

5..

6..

5. popliteal artery POPA

6. PTA posterior tibial artery

7..

8..

7. peroneal artery PeroA

8. dorsalis pedis DP

For 5F to 6F femoral sheaths recovery usually requires ******* hours or more of bed rest

requires 4 hours or more of bed rest

For procedures using sheath of 5F or less or procedures in which hemostasis is obtained w a VCD ****** hours of bed rest with 4 hours of observation before discharge

2 hours of bed rest with 4 hours of observation

Midazolam (Versed@, Dormicum@) ; benzodiazepine dosage

0.5 0 1.0 mg

Main difference between modified Allens test and original allens test

a pulse ox may be used and the test relies on visual cueses

patient reporting allergic reactions to contrast media should be premedicated w ******** and *******************

Prednisone (corticosteroid) and diphenhydramine (Benadryl)

Normal value for hemoglobin is

12.0-16.0 g.dl

The barbeaus test has 4 types

type A no change in waveform

Type B reduced waveform but recovers

Type C *************

Typed D No waveform recovery after release

What artery are we testing for patency ? bonus

Type C

Loss of waveform but recovers after release

Radial artery

The barbeaus test is used to measure the ______ of the _________ artery by objectively measuring restoration of circulation after having the vessel compressed. objectively by using a pulse ox

the patency of the radial artery

Type A in Barbeaus test deems the _______ ___ ____ ____ used

type A - ****************

Radial artery can be used

NO CHANGE

Should the radial artery be used after scoring a type d in the Barbeaus test

NO

NO WAVEFORM RECOVERY AFTER COMPRESSING

DO NOT USE

In femoral access the superior landmark is

Superficial epigastric artery

This vascular complication can occur when the CFA arterial stick is too low

Most common

Pseudoaneurysm formation

or fistula

Postprocedural management checks for bleeding should occur every __________ minutes for the first hour.

15 minutes

How long should manual pressure be held after pulling a 6 fr sheath

18 min.

_________ develop due to a subcutaneous bleeding

Hematomas

What is the potential consequence of a hematoma at the access site?

Compression of surrounding structures and potential loss of access. AKA compartment syndrome

Femoral triangle ACRONYMN is what

5

NAVL

NERVE

ARTERY

VEIN

E Empty space (femoral vanal)

LYMPH

Name one passive closure device

MYNX is a passive closure device that uses a bioabsorbable polymer to seal the access site.

Passive closure device is a device that ********************

promotes natural clot formation rather than actively sealing with mechanical suture based or collagen based closure.

Stat seal is a _____ patch

what kind of closure device is it

Hemostatic patch

hemostatic patches device

Ultrasound guided compression can be used to treat which vascular complication

paseudoaneurysm

What are symptoms of a retroperitoneal bleed

hypotension

tachy

back flank pain

A palpable thrill is present in which vascular complication

AV fistula

What is 1-4

What is 4-8

What is 8-12

1-3

1. Occiptal

2. internal carotid

3. carotid sinus

3-6

3. carotid sinus

4. vertebral

5. superficial temporal

6. maxillary

6-9

6. maxillary

7. facial

8. lingual

A pathological process characterized by the proliferation of smooth muscle cells and extracellular matrix in the intimal layer of a blood vessel, often leading to stenosis after vascular interventions. is known as

neointimal hyperplasia

label

C

E

F

C. Common iliac artery

E. Epigastric artery

F. Femoral head

P.

S

I.

P. Profunda artery

S. Common Femoral artery

I. Vascular sheath

What direction does the guidewire travel in antegrade LCFA access

antegrade would mean wire traveling at the direction of blood, towards the feet away from heart.

TOWARDS FEET AWAY FROM HEART

C.

D.

C. dilator (stylet)

D. micro puncture sheath

Label A.

Anterior tibial arteryLabel A. Dorsalis pedis artery

B.

B. peroneal artery

C.

C. posterior tibial artery

I.

I. Dorsalis Pedis

H.

H. Deep plantar arch

The common femoral **** is directly lateral to the common femoral ***** and will be pulsatile and not easily compressible

The common femoral artery is directly lateral to the common femoral vein and will be pulsatile and not easily compressible. (Kandarpa, pg. 3)

"Distal radial artery access involves access to the radial artery in the region of the anatomic *******

"Distal radial artery access involves access to the radial artery in the region of the anatomic snuffbox. 

what is dTRA in regards to access

dTRA stands for distal transradial access, a technique used for catheterization that minimizes complications and improves patient comfort.

What are some advantages of dTRA over TRA?

Patient and operator comfort since the hand can be neutral or pronated and operator and equipment positioning may be similar to femoral access; access is distal to the superficial palmar branch of the radial artery supplying the superficial palmar arch, theoretically reducing risk of hand ischemia with distal radial artery occlusion.

****** artery access remains a viable option if TRA/dTRA is contraindicated due to vessel size, spasm, or lack of suitable device catheter lengths

Brachial artery access

What is the proper protocol for achieving popliteal vein hemostasis?

post procedure

manual compression 5-10 minutes

What is the appropriate ACT level for safe arterial sheath removal on a heparinized patient?

Approximately 150 seconds

If the patient has been heparinized during the procedure, make sure the coagulation parameters have normalized (partial thromboplastin time PTT close to control value or activated time of approximately 150 seconds) before the catheter is removed and the puncture site is compressed.

When evaluating the CFA angiogram for VCD placement

The puncture site should be between the takeoff of the ****** ****** *******  and the **** ****, in a vessel ** mm in caliber.

The puncture site should be between the takeoff of the inferior epigastric artery  and the femoral bifurcation, in a vessel >5 mm in caliber.

What are 5 types of vascular closure devices listed in your textbook

1. active approximators (mechanical suture mediated or clip devices)

2. passive approximators (mechanical plug devices)

3. compression assist devices

4. hemostatic patches

5. mechanical compression aids

name 2 examples of active approximators VCD’s (mechincal suture mediated or clip devices)

Proglide - perclose

starclose

prostar XL

name <2 passive approximators (mechanical plug devices)

Mynx

Angio Seal

EXOSEAL

FISH

Vascade

Name 1 example of compression assist devices

CATALYST

Name 2 examples of hemostatic patches

D-stat-DRY

SYVEK EXCEL

CLO-SUR PAD

chitoclot pad

stat seal disc

quickclot

name one mechincal compression aids

femostop

label these 5

6 p’s of ALI

The 6 P's of Acute Limb Ischemia (ALI) are

pain,

pallor,

pulselessness,

paresthesia,

paralysis, and

poikilothermia. These signs help in diagnosing and assessing the severity of limb ischemia.

term that describes an abnormal sensation of tingling, prickling, burning, or numbness in the skin.

paresthesia,

inability to regulate core body temperature (as by sweating to cool off or by putting on clothes to warm up), found especially in some spinal cord injury patients and in patients under general anesthesia.

poikilothermia

NAVEL acronym

Ultrasound guidance is ideal for patients with poorly **** ****** and patients who are **** or who have bleeding risks

Ultrasound guidance is ideal for patients with poorly palpable pulses and patients who are obese or who have higher bleeding risks

emitting high-frequency sound waves that bounce off moving red blood cells. The changes in frequency of the reflected waves allow the ultrasound machine to determine the speed and direction of blood flow.

Doppler ultrasound

manual compression of both radial and ulnar arteries while the patient clenches their fist until the hand becomes blanched (Fig. 1.9). The hand is opened and compression of the ulnar artery released, observing for the presence of capillary refill in the hand. To see if ulnar arterial flow is sufficient to reperfuse the hand.

Allen test

Tests radial artery perfusion (release radial artery). w no pulse ox

Reverse Allen’s Test

compress both radial and ulnar artery until pulse ox waveform flattens then release ulnar artery

barbeaus test

in barbeaus test if the wave form doesnt return after 2 min it is classified as a

D

These devices physically close the arteriotomy with suture- or nitinol clip-based material that is fixed to the vessel wall to achieve a limited form of surgical closure. With these devices, the arteriotomy is cinched closed. ****** ******* are considered the most secure form of VCD for large arteriotomies. Adjunctive MC is theoretically unnecessary.

These devices physically close the arteriotomy with suture- or nitinol clip-based material that is fixed to the vessel wall to achieve a limited form of surgical closure. With these devices, the arteriotomy is cinched closed. Active approximators are considered the most secure form of VCD for large arteriotomies. Adjunctive MC is theoretically unnecessary.

These devices deploy a sealant, gel, or plug onto the arteriotomy site that creates a mechanical barrier to achieve hemostasis. With some of these devices, hemostasis is augmented through use of a collagen-based plug to promote clot formation. Adjunctive MC is often held for 1 to 3 minutes.

passive approximators (mechanical plug device)

This heterogeneous group of devices mechanically promote hemostasis, but do not leave any material behind at the end of the procedure. With these devices, there is theoretical lower risk of infection or embolization/arterial occlusion given lack of implanted material. Adjunctive MC must be held, but for a shorter duration than expected with MC alone.

compression devices

These patches are placed externally over the dermatotomy at the end of the procedure. With these products, substances interact with blood products to augment hemostasis. Adjunctive MC must be held, but for a shorter duration than expected with MC alone.

Hemostatic patches

These entirely external devices allow MC to be performed by the device rather than an operator. Routine duration of MC is required with these devices.

Mechanical compression aid

what 2 thing are needed for VCD vascular assessment

5 -10 mL contrast hand injection thru sheath

oblique prokection often necessary to seperate sheath and CFA

typically RAO

contrast

RAO

vessel damage is most likely to occur with the use of what kind of VCD

active approximator devices (mechanical suture mediated or clip devices)

name the 6 major complications of VCD

limb ischemia

device embolization

artery occlusion

arterial laceration

retroperitoneal hematoma

access site infection

name 4 minor complications

hematoma

pseudoaneurysm

av fistula

nerve injury

angioseal can not be used to plug a high stick because

The Angioseal collagen plug may get entrapped in the layers of the abdominal muscles and the plug may move once the patient becomes ambulatory.

collagen plug (inside vessel) may get stuck in abs and plug (outside) might move when pt moves

Dr. Birlakis stated in video 1 that inserting the vascular sheath into the lateral circumflex iliac artery instead of the external iliac artery could potentially lead to which complication?

dissection or perforation

What are the measures mentioned to confirm or exclude the presence of a retroperitoneal hematoma in the cath lab?

2 things

1. fluro bladder to see displacement of the bladder

2. access site angiogram to locate site of bleeding

What is the dented bladder sign

bladder displacement to left caused by retroperitoneal hematoma

How do you prevent AV fistulas?

2x

Optimal access technique & removal of the arterial 1st then the venous sheath.

How do you treat an AV fistula?

for most cases treatment is usually not needed for severe cases where there is a lot of shun

No treatment, covered stent of surgery.

What are 6 causes of a pseudoaneurysm?

1. low sticks

2. sub optimal compression 

3. challenging access 

4. access of both artery and vein 

5. intensive coagulation

6. vascular closure device needed

When treating a pseudoaneurysm by thrombin injection, where is the thrombin injected? (video 3)

thrombin is injected in the cavity of the pseudoaneurysm that is found in the cavity by ultrasound 

• Definition: A localized collection of blood outside the vessel but within the adventitia due to inadequate hemostasis.

• Cause: Poor manual compression, patient movement, high anticoagulation, or improper closure device deployment.

• Signs/Symptoms: Swelling, tenderness, and discoloration at the puncture site.

  • Management: Compression, monitoring, and, in severe cases, surgical evacuation.

Hematoma

• Cause: Low puncture leading to simultaneous artery and vein injury.

• Signs/Symptoms: Continuous bruit, palpable thrill, or limb edema if large.

• Diagnosis: Duplex ultrasound or angiography.

• Management: Small fistulas may resolve spontaneously; larger ones may require surgical or endovascular repair.

Arteriovenous fistula

• Definition: A severe, life-threatening hemorrhage occurring when arterial puncture is too high (above the inguinal ligament), allowing blood to track into the retroperitoneal space.

• Cause: High arterial puncture, improper closure device deployment, excessive anticoagulation.

• Signs/Symptoms: Hypotension, back/flank pain, and possible signs of hypovolemic shock.

• Diagnosis: CT scan of the abdomen/pelvis with contrast.

• Management: Fluid resuscitation, blood transfusion if needed, and surgical or interventional repair.

Retroperitoneal hemorrhage

Patient with FFR .8

IFR.85

coronary angiography 70% stenosis in the mid RCA

occasional chest pain

Would we treat this patient?

FFR borderline threshold .8

iFR low iFR threshold is .89

70% borderline

occasional chest pain with moderate excretion

theyre not a diabetic so we could treat them with meds

bp meds