0:01

So let's transition to closure device complications.

0:02

3 00:00:04,310 --> 00:00:05,640 So what are the risk factors for closure

0:05

device complications in our patient?

0:07

Well, our patient is a 70-year-old with hypertension,

0:10

severe atherosclerotic disease, on antiplatelets

0:12

and anticoagulation therapy, and scheduled

0:16

for diagnostic right leg arteriography

0:18

for probable chronic limb ischemia.

0:20

So what are the factors that we should

0:22

consider that might limit successful

0:24

deployment of a closure device?

0:27

Is there any atypical anatomy of the vessel?

0:29

Any increased age, any sort of atherosclerotic

0:31

disease, any sort of calcification, or any

0:34

chunky deposits, or coral reefs in the vessel.

0:37

So successful initial deployment of the

0:39

device actually decreases the patient’s

0:41

risk for major and minor complications.

0:43

So we want to make sure we get it right.

0:44

We want to know those things that are going to

0:46

work against us in being successful.

0:49

Well, what complications can

0:51

occur with an invasive device?

0:53

You can get dissection of the artery.

0:57

You can have atrial thrombosis that can occur.

0:59

You can have pseudoaneurysms

1:00

that occur, all injuries.

1:03

You can also have bleeding and hematomas

1:05

that form around the access site.

1:09

You can have these devices that

1:11

actually serve as niduses for infection.

1:15

And of course, you can develop a granulomatous

1:17

reaction, pain, secondary to these sites.

1:22

So when you perform a femoral artery

1:24

arteriogram, the whole goal is to ensure that

1:26

the puncture was performed in a good location,

1:29

and the vessel has adequate size.

1:32

So here we see a 38-year-old male presented

1:34

for trauma, status post trauma,

1:38

and had a little bit of a ruptured spleen.

1:39

And the goal here was to control bleeding from

1:42

the spleen by splenic artery embolization.

1:47

So, the interventional radiologist gets

1:49

access to the right common femoral artery.

1:51

And what you see after the fact is they

1:53

perform their common femoral arteriogram

1:55

in preparation to assess the size

1:57

of the vessel and where they accessed.

1:58

They accessed

1:59

medial and sort of middle

2:01

third of the femoral head.

2:03

Great location.

2:04

But what you're seeing is that there's

2:06

minimal contrast around the sheath.

2:09

Because the sheath is almost

2:10

the same caliber as the vessel.

2:12

This is a five French sheath.

2:14

And so, the operator opts

2:16

to deploy a closure device.

2:19

What do you see in angiography here?

2:21

After the closure device was performed, we see

2:23

thrombus formation in the common femoral artery.

2:26

And so, they decide to get

2:31

access on the contralateral side, up and over.

2:35

Left common femoral access.

2:37

Up and over, right common femoral,

2:39

right lower extremity arteriogram,

2:41

demonstrating propagation of clot formation.

2:44

And then, the management became as follows.

2:49

So how do we address this?

2:51

Perhaps you may consider thrombolysis,

2:53

or perhaps you may consider

2:55

the alternative, which is thrombectomy.

2:57

So, the operator decided that, you know,

2:59

in a patient who's post-trauma,

3:00

I'm not going to increase the risk of

3:02

bleeding from this spleen that I just saved.

3:07

I'm going to use thrombectomy, so

3:08

they used suction thrombectomy, a suction

3:10

thrombectomy catheter, to aspirate the thrombus.

3:14

They then went further down to

3:16

the lower thigh region, popliteal vessels,

3:19

the lower branches and region of the

3:22

tibial vessels, tibial-peroneal trunk.

3:24

and was able to actually clean out the vessels.

3:27

We see a little bit of vasospasm in the

3:30

vessels here, but ultimately the thrombus was cleaned

3:33

and was deemed to be a particularly good result in

3:37

a situation that could have been a little hairier.

3:40

So this patient presents with left ischemic

3:43

breast pain and is presenting for

3:47

diagnostic left lower extremity arteriogram.

3:51

So a patient with breast pain is someone that

3:53

should really make you consider risk factors.

3:56

What risk factors?

3:58

Atherosclerotic disease.

4:00

So, when you have a lower extremity vascularization

4:03

that's performed, as we mentioned, in

4:06

this particular case, you, in this particular

4:09

operator, wanted to get some good throughput,

4:11

move from this patient to the next patient,

4:13

wanted to get good hemostasis, and they said,

4:16

you know what, we're going to use this device,

4:17

this collagen-based vascular closure device.

4:21

But the instructions for use for this

4:22

device include ensuring that the vessel

4:25

diameter is four millimeters or more.

4:28

Unfortunately, they deployed their closure

4:33

device on a chunk of atherosclerotic

4:38

disease and immediately after the procedure,

4:41

noticed that the patient's pulses, both

4:43

in the common femoral region as well

4:45

as in the pedal pulses, were absent.

4:49

So what we see here is globular focus,

4:52

no flow in this region, in a patient

4:55

that now has acute limb ischemia.

4:59

No dopplable pulses for all intents and purposes.

5:03

It's something that we need

5:03

to be very concerned about.

5:05

So again, we see this image

5:07

that we've seen before.

5:08

Chunky monkey calcification in this

5:11

patient, extending into the vessel.

5:13

And the patient went to surgery, and they

5:15

removed this footplate from the closure device

5:19

that was lodged on this heavy footplate.

5:22

Large coral reef-like calcification, which was

5:25

responsible for creating this sort of final, sort

5:29

of nidus for thrombus formation at the axis site.

5:33

So in summary, closure devices are particularly

5:36

helpful to facilitate expedited hemostasis.

5:39

But complications are known to be

5:41

associated with these closure devices,

5:42

and we need to be familiar with them.

5:44

We also need to understand the instructions

5:46

for use of each vascular closure device

5:48

deployed in order to minimize the occurrence

5:50

of these known vascular closure complications.

5:54

We also need to know that when we are looking

5:57

at our arteriogram, the common femoral

6:00

arteriogram, we're looking for vessel size.

6:02

We want that to be four millimeters

6:04

or more, depending on the

6:06

instructions for use of that device.

6:08

We want to know that the presence

6:09

of an atherosclerotic plaque at the

6:11

site of access may actually occur

6:13

and reduce the functional diameter of the vessel,

6:15

precluding vascular closure device deployment.

6:20

At the end of the day, we have discussed

6:24

pearls, the pitfalls, and the complications of

6:29

vascular access, particularly arterial access.

6:34

And I hope that you have a deeper

6:37

understanding of this fundamental pillar

6:40

that is really and truly the mainstay

6:45

of all the things that we're able to accomplish

6:47

in the field of interventional radiology.

6:49

If you're able to master this, my

6:50

friends, you can master any aspect

6:53

of interventional radiology.

6:55

Good day, and good night.

6:57

Thank you for your attention.