Sheathless use of Supera stent minimizes access complications in antegrade femoral puncture: Technical note with case series

Antegrade femoral puncture (AFP) is the preferred strategy to treat lower limb obstructive disease. However, the presence of vascular calcification may be associated with procedure related adverse events, impairing endovascular device strategies. We describe a case series of superficial femoral and popliteal artery treatments by Supera stent implantation using a simple technique to significantly minimize the dimension of the antegrade femoral puncture from 6 to 4 French (Fr). All antegrade femoral punctures, crossing femoro-popliteal lesion and predilation were made with 4 Fr introducer. After preparation the Supera stent was navigated in sheathless fashion via 0.018-inch guidewire. Postdilation and final control were made replacing the 4 Fr introducer via the same guidewire. A good final result was achieved. Patients were discharged early without any complications. This minimally invasive technique in cases of infrainguinal peripheral artery disease could be feasible and effective for minimizing the risk of complications in patients with critical limb ischemia.

470 Percutaneous arterial closure devices and ultrasound-guided trans-femoral puncture observational investigation: insights from the PETRONIO registry

Aims To evaluate the safety of a single and combined use of ultrasound-guided femoral puncture (U) and percutaneous arterial closure devices (P) in femoral artery procedures (FAP) compared to fluoroscopic guidance (F) and manual compression (M) in a large radial-focused interventional centre. U and P, taken individually, have improved safety in femoral arterial access procedures compared to traditional techniques. Methods and results All FAP performed between July 2017 and December 2018 in our centre were divided into three phases: (i) control period with F and M mainly performed; (ii) phase out period where U and P were introduced; and (iii) intervention period where a 6-month expertise on the novel techniques was acquired. The overall population was further stratified into subgroups: F/M, U/M, F/P, and U/P. The primary study endpoint was in-hospital access site bleeding events (BE) according to the BARC criteria. The secondary endpoint was vascular site complications (VASC). 418 procedures (14%) out of 3025 were performed via FA access during the study period. The overall access-site in-hospital BE were 97 (23%). Decreasing rates of BE (phase 1: n = 46, 29%; phase 2: n = 38, 22% e phase 3: n = 13, 15%; P = 0.027) and VASC were observed during the three periods. BE occurred significantly more often in F/M group (F/M: n = 48; 32%; U/M: n = 12, 16%; F/P: n = 18, 21%; U/P: n = 19, 17%; P = 0.008). F/M subgroup was an independent predictor of BE both in multivariable analysis and propensity score matching analysis. Conclusions The introduction of ultrasound-guided femoral puncture and percutaneous arterial closure devices has reduced access site bleeding with a progressive improvement after the first 6 months learning period.

To Ultrasound or not to Ultrasound: A REBOA Femoral Access Analysis from the ABOTrauma and AORTA Registries

IntroductionResuscitative endovascular balloon occlusion of the aorta (REBOA) is becoming a standardizedadjunct in the management of non-compressible hemorrhage. Ultrasound (US)-guided femoralaccess has been taught as the best practice for femoral artery cannulation. However, there is lackof evidence to support its use in patients in extremis with severe hemorrhage. We hypothesizethat no differences in outcome will exist between US-guided in comparison to blindpercutaneous or cutdown access methods.MethodsThis was an international, multicenter retrospective review of all patients managed with REBOAfrom the ABOTrauma Registry and the AORTA database. REBOA characteristics and outcomeswere compared among puncture access methods. Significance was set at P < 0.05.ResultsThe cohort included 523 patients, primarily male (74%), blunt injured (77%) with median age 40(27 – 58), ISS 34 (25 – 45). Percutaneous using external landmarks/palpation was the mostcommon femoral puncture method (53%) used followed by US-guided (27.9%). There was nosignificant difference in overall complication rates (37.4% vs 34.9%; P = 0.615) or mortality(47.8% vs 50.3%; P = 0.599) between percutaneous and US-guided methods; however, access bycutdown was significantly associated with emergency department (ED) mortality (P = 0.004), 24hour mortality (P = 0.002), and in-hospital mortality (P = 0.007).ConclusionsIn patients with severe hemorrhage in need of REBOA placement, the percutaneous approachusing anatomic landmarks and palpation, when compared to ultrasound-guided femoral access, was used more frequently without an increase in complications, access attempts, or mortality.Surgical cutdown was associated with highest ED, 24-hour, and in-hospital mortality. Level of Evidence: Level III; Prognostic

Feasibility and effectiveness of a single-catheter approach for adrenal vein sampling in patients with primary aldosteronism

Background Adrenal vein sampling (AVS) is the preferred method for subtyping patients with primary aldosteronism, while the procedure is technically challenging. This study evaluated the feasibility and effectiveness of a single-catheter approach for AVS. Methods A retrospective analysis of 106 consecutive patients who underwent AVS was performed to determine the procedural success and complication rates. Bilateral AVS procedures were performed using a single 5-Fr Tiger catheter with repeated manual reshaping. Results We successfully advanced the catheter into the bilateral adrenal veins of all patients and reached a 90.6% procedural success rate of AVS. The procedural period was 33.0 ± 8.2 min, the fluoroscopy period was 5.8 ± 1.7 min, and the diagnostic contrast used was 17.3 ± 5.5 ml. Only one patient (0.9%) had a hematoma at the femoral puncture site. No other complications were observed. The operation period gradually shortened as the cumulative number of operations increased. The number of procedures required to overcome the learning curve was about 33 cases. Conclusions The single-catheter approach is feasible and effective for AVS. Moreover, this approach required a relatively short learning curve for an inexperienced trainee.

Abstract 14097: A 3D Print Low Cost Aortic Arch Endovascular Simulator

Introduction: Simulation-based medical teaching and learning enables trainees to gain competencies in a realistic setting without imposing risks to patients. Within endovascular training, simulations improve patient safety and decrease health care costs. Access of the aortic arch from a femoral puncture site is a key competency in the endovascular field. Here, we show how a low-cost artificial vascular simulator enables accurate replicated catheterization of the aortic arch. Hypothesis: Methods: Digital Imaging and Communications in Medicine (DICOM) data extracted from a computed-angio tomograph (CTA) using an image processing software was selected to include the arterial region of interest. A mold was made with plastisol from the printed 3D toolpath (Fig. 1). After maturation of the mold, the separate sections were assembled into the simulator (Fig. 2). Results: Data extracted from a CTA was processed to create a vascular model that was accessed using an arterial access kit, and guided under fluoroscopy, a radiopaque catheter was navigated to the aortic arch. The total consumable cost of the simulator was U$194.64. Conclusions: In this proof-of-concept study, we demonstrate the process of producing a low-cost 3D printed artificial vascular simulator made from 3-D printing and image examination. This simulator faithfully replicated the endovascular access of the aortic arch from a femoral puncture site. We recognize the scalability of our technique and its possibility of assisting in endovascular navigation of various interventional radiology procedures in a patient specific manner.

Safety and Effectiveness of Percutaneous Low-Dose Thrombin Injection for Femoral Puncture Site Pseudoaneurysms in Neurointervention: Single-Center Experience

Purpose: We present ultrasound-guided percutaneous low-dose thrombin (200–250 IU) injection for the treatment of iatrogenic femoral pseudoaneurysms. Second, we compared patient and procedure factors between subcutaneous hematoma and pseudoaneurysm groups.Materials and Methods: From April 2012 to May 2018, 8425 patients underwent neurointervention. Among these patients, 18 had small subcutaneous hematomas and 6 had pseudoaneurysms. Pseudoaneurysms in the neck and entire sac were visualized, and low-dose thrombins were injected while visualizing a “whirlpool” hyperechoic core in the pseudoaneurysm sac. Subcutaneous hematomas were treated with simple compression. We compared the following parameters between the subcutaneous hematoma group and pseudoaneurysm group: sex, age, body mass index (BMI), type of procedure, heparin usage, sheath size, procedure time, and number of previous neurointervention procedures with the Mann-Whitney U test.Results: Most of the pseudoaneurysms were successfully occluded with 200 IU of thrombin (n=5). Only 1 pseudoaneurysm required a slightly higher thrombin concentration (250 IU, n=1). During the short-term follow-up, no residual sac was observed and no surgical repair was necessary. Pain in the groin region was alleviated. During the 1-month follow-up, no evidence of pseudoaneurysm recurrence nor subcutaneous hematoma was noted. Patient factors (sex, age, and BMI) and procedure factors (heparin usage, sheath size, procedure time, number of previous procedures) were not statistically different between the subcutaneous hematoma and pseudoaneurysm groups.Conclusion: Ultrasound-guided percutaneous low-dose thrombin injection (200–250 IU) is safe, effective, and less invasive for treating iatrogenic femoral pseudoaneurysm in neurointervention.