IRTB - Arterial
Access and
Angioplasty
Dr Hilary White
Nottingham
Outline
 Vascular access
 Anatomy
 Equipment
 complications
 Angioplasty
 Closure
 Cases
Patient selection

Warfarin and Clopidogrel should be stopped 1 week before (at least 3 days
before). INR <1.5

Stop Heparin 3 hours before

Aspirin omitted on the day

Metformin – stop 48 hours after procedure

Hypertension >180/110 mmHg

Smoking

Diabetes – check blood sugar

Renal failure – contrast induced nephropathy

CAN THEY LIE FLAT?
Pre-op
 What does the request card say?
 Intermittent claudication vs critical limb ischaemia
 side?
 Previous imaging
 Check bloods
 Consider equipment
 Approach
The Kit
 The WHO
 035 vs 018
 Access
 Bail out kit – covered stents/ aspiration
catheters/ angiojet – Call For Help
Access
 Antegrade vs retrograde
 Anatomy
 Hostile groin?
 Time
 Equipment
 Experience
Seldinger Technique
 The desired vessel or cavity is punctured with a
sharp hollow needle called a trocar, with
ultrasound guidance if necessary. A roundtipped guidewire is then advanced through the
lumen of the trocar, and the trocar is withdrawn.
(introduced in 1953)
Wikipedia
Vascular sheaths
 Colour coded – red 4 Fr, grey 5 Fr, Green 6 Fr,
Orange 7 Fr, Blue 8 Fr etc
 Different lenghts – standard 11 cm, 23 cm, 45
cm, 60 cm, 90 cm
 Some are bright tipped
 Different to guide catheters
Heparin
 After access
 Therapeutic anticoagulation for 30mins with 3000
IU IA, 45 mins with 5000 IU IA
 Effect after 10-15 mins
 After 1 hour consider additional bolus
 For flushing – 1000-5000IU heparin/1 L of normal
saline
Other Drugs
 During:
 GTN – 100mcg – 200mcg IA – consider in
intervention in the infrapopliteal region
 Papaverine 20mg IA – good for pressure
measurements (smooth muscle relaxant –
vasodilatation)
 After:
 Clopidogrel
 Aspirin
 Warfarin
Think about the steps
 Access
 Angiogram
IS THIS A STRAIGHT FORWARD ANGIOGRAM?
 Heparin
 Closure
 Do no harm
Brachial artery access
 Easy to compress if bleeding risk
 Easy to find with U/S
 Anatomy ie easier to catheterise
mesenteric vessels, close to subclavians
 Antegrade approach to radial fistula
 Bilateral Femoral occlusions
 Previous femoral surgery or on going
infection
Why Not?
 Subclavian occlusion
 Infection
 Easier to reach from femoral
approach
 Risk of stroke
 Small vessels (particularly women)
Brachial Puncture Technique
 Try to always use U/S
 Map out anatomy with U/S (beware high take
off radial artery)
 Sterile prep
 Infiltrate local under U/S guidance
 Micro puncture kit helps reduce the trauma
Complications of Brachial Artery
Puncture
 Median nerve damage
 Haematoma
 False Aneurysm
 Embolisation to Fingers
 Dissection (with lower arm ischemia)
 Stroke (especially posterior circulation)
Arterial Access Alternatives
 Radial Artery (useful for fistulas and coronary
angios)
 Axiliary Artery (risk of brachial plexus injury but
good calibre vessel)
 Direct Carotid Puncture
 Direct Aortic Puncture (historical)
 Popliteal artery
 Dorsalis pedis
Closure
 Vascular closure devices:
 Angio-Seal (St Jude Medical)
 StarClose (Abbott)
 Perclose/{erclose Proglide (Abbott)
 Mynx (AccessClosure)
 Exo-Seal (Cordis)
Complication rate 2 %
- incorrect deployment,
infection, stenosis, embolus,
local dissection.
Complications
(most common)
 Dissection
 Haematoma
 False Aneurysm (Femoral or Inferior Epigastric)
 Retroperitoneal Haemorrhage (patients can die
from this)
 Infection
Questions?