Large Vessel Access and Closure: Tips and Techniques for Success

Hollywood, FL (January 25, 2020) – Tips, techniques, and device information on large vessel access and closure were highlighted during a session at the International Symposium on Endovascular Therapy (ISET).

The first speaker, Cynthia Shortell, MD, talked about the hybrid approach to acute mesenteric ischemia. Traditionally, open surgical revascularization was the treatment of choice for chronic and acute-on-chronic mesenteric ischemia, but the focus has shifted to the endovascular approach when it is technically feasible.

However, Dr. Shortell noted that there are limitations to the endovascular approach, and retrograde superior mesenteric artery (SMA) cannulation has been developed to address those limitations. A modified retrograde technique with access via an SMA side branch minimizes the risks of extensive intra-abdominal surgery and the possibility of SMA injury, she noted

In this technique, the ostial occlusion is traversed in a retrograde fashion with a hydrophilic micro-wire (.014- to .035-inch) passed through the needle. Next, the wire is snared in the aorta and exteriorized through either a femoral or brachial sheath access. The small distal mesenteric access vessel is ligated at the conclusion of the procedure, and the patient undergoes a completion angiogram for the assessment of SMA patency.

“Hybrid retrograde mesenteric stenting is a technically feasible and efficient alternative to surgical revascularization in patients not amenable to antegrade endovascular intervention,” Dr. Shortell said. “It can be done through mini-laparotomy, which limits the intra-abdominal exploration and avoids the need for exposure and manipulation of the proximal SMA.”

She added, “We’ve achieved promising initial results to manage chronic and acute-on-chronic ischemia, but we certainly need to do more studies.”

The next speaker, Zvonimir Krajcer, MD, discussed devices for large vessel closure. He highlighted the Perclose ProGlide device (Abbott Vascular).

“ProGlide has advantages because it’s commonly used and well-accepted,” he said. “It’s been validated with high technical success up to 97%, and it’s relatively inexpensive compared to other devices,” said Dr. Krajcer. However, ProGlide can only be used in a pre-close fashion and emergency cases might present an issue.

Dr. Krajcer also focused on the Manta device (Teleflex). There was a high technical success rate of 97.7% in the MANTA U.S. pivotal trial, but the costs for the Manta may be prohibitive. Costs, in fact, are an issue for both devices. “There is no reimbursement from payors, and that certainly is an issue,” said Dr. Krajcer.

Rahul Patel, MD, came to the podium and spoke about alternative access sites. He broadly covered alternative antegrade access (radial, brachial, and axillary) and retrograde access (popliteal and pedal).

In particular, he emphasized that patients request the radial approach and that trainees benefit greatly from learning radial techniques. Most catheters are designed for femoral approach though, so “the more you do [radial], the better you get,” he said.

Parag Patel, MD, reviewed different types of closure devices for femoral access and described a way to evaluate them as they come on the market. Closure devices include implantable collagen plugs, percutaneous suture devices, and clip or staple devices.

“It’s important to review new devices on the mechanisms of action (intravascular, extravascular both), the closure materials (something inert or absorbable, a plug, a clip, a suture), and additional features such as efficacy with anticoagulation,” he said.

He also noted that there are times when vascular closure devices are not appropriate “Often, heavily calcified or diseased arteries will limit the ability to use these devices safely,” he said. “Morbid obesity can also be a limiting factor.”

“In summary, vascular closure devices improve patient comfort and satisfaction and decrease time to hemostasis and ambulation. I think patient selection is critical, as well as understanding the mechanism of action of the device and tailoring the right device to the right patient,” said Dr. Patel.

Next to the podium, Brian Schiro, MD, discussed antegrade versus retrograde options for lower extremity interventions. In antegrade access, it is important to mark the skin reference location for the acetabulum, and to notice the location in reference to inguinal crease.

Advantages of antegrade access are better “pushability,” as well as a shorter distance to target and decreased radiation exposure. However, patients with a large body habitus may not be able to have antegrade access due to limited access into the common femoral artery. For these patients, alternatives include contralateral femoral, pedal/popliteal, or radial access.

Dr. Schiro also emphasized the importance of involving technologists and nurses in standardizing setup, and of knowing the available inventory, since antegrade access requires long wires and catheters. With proper setup and an experienced operator, outcomes are promising.

“Overall, complications from antegrade access are pretty low,” said Dr. Schiro.

Bret Wiechmann, MD, spoke next and shared tips for pedal access. “The number-one thing I suggest is positioning yourself for success. Make yourself and the patient comfortable. This extends to operator position and how you set up your room, including monitors and ultrasound,” Dr. Wiechmann said. He noted the importance of proper training for technologists and proper planning on the part of the operator. “You need to plan whether you’re going to do the intervention from below. Decide on sheath versus catheter, and limit exchanges,” he said.

Referencing access systems, he advised “Use a 21g needle to make it easier on yourself.” Planning for the end of the procedure important too, he said. “Know your exit strategy.”

The next presenter, John Fritz Angle, MD, spoke about transcaval access for large devices. When planning for transcaval access, computed tomography angiography (CTA) is essential for finding the shortest distance between the aorta and vena cava, avoiding puncture into calcium/plaque, and localizing accessory renal arteries.

Transcaval access is an “important alternative to transapical access and provides safety similar to femoral artery access,” he said. However, it is limited mostly by contraindications and short-term aortocaval fistula creation that creates uncertainty in post-operative management.

The next speaker, Constantino Peña, MD, shared case examples and tips on complex access and solutions. Delivery of devices is one of the greatest limitations, he noted. In particular, a large percentage of women require iliac or direct aortic conduits, and operators must carefully evaluate access when planning thoracic endovascular aortic repair (TEVAR) and case strategies.

“Identifying potential access vessel complications before they occur is essential in complex devices requiring large-bore access,” he said. “Having a number of options to deal with small or calcified access vessels is important to an effective and successful program, and a multispecialty advanced access team may allow for improved results among multiple service lines.”

Concluding the session, Richard Neville, MD, stressed the importance of standardizing quality in access and closure. He shared details about a program at his institution that was implemented to reduce vascular complications.

After investigating the complications, Dr. Neville found that large-bore devices were being placed by a variety of practitioners with a variety of backgrounds and training. Of particular concern, some individuals were not using ultrasound-guided access.

To address these issues, Dr. Neville decided to certify anyone who wanted to place large-bore access. To gain certification, practitioners had to attend didactic lessons and practice at an ultrasound access skill station and a vascular closure device skill station. The program also emphasized provider communication, such as communication with vascular surgery.

A 27-step protocol was developed to share with practitioners. “We asked everyone to read it for the certification,” said Dr. Neville, though it was not required to be used every time in practice. “It’s step by step what you need to think about if you’re going to place once of these large devices in these very sick patients.”

After the course, the complication rate dropped from 20% in 2018 to 8% in 2019, showing the success of the program.