Large Bore Access Critical Skills with Dr. Adhir Shroff
Using Multimodality Approach for Femoral Access
Adhir Shroff, MD, MPH, presents data supporting a multimodal approach to femoral access. Dr. Shroff is Associate Professor of Medicine at the University of Illinois, Chicago and Jesse Brown VA Medical Center Co-Chair of the Vascular Access Working Group. He also recently co-authored a free SCAI Best Practices for Access and Closure eBook. He gave this presentation during the Large Bore Access: Critical Skills for Advanced Interventional Operators course at ACC on March 15th, 2019.
Dr. Shroff acknowledges that access site complications are more common in procedures requiring large bore arterial and venous access. Such complications are, in fact, the most common complication in large bore procedures and can dampen the impact of these procedures. He emphasizes paying attention to high quality vascular access in every procedure to help improve outcomes and reinforces the importance of preventing bleeding complications with a reminder that there is a 3-fold increase in mortality in patients who have an adverse bleeding event post TAVR.
“Where should the target zone for femoral access be?” he asks, showing a sketch from Dr. Zoltan Turi, pioneer in femoral access. He then presents results from a worldwide survey of transfemoral operators revealing significant variability in access and closure techniques ranging from palpation alone to a combination of palpation, fluoroscopy, and ultrasound.
Dr. Shroff describes the benefits of ultrasound—helping clinicians avoid high bifurcation sticks, improving the rate of first pass success in femoral access, and reducing the likelihood of accidentally hitting a vein—as presented in the FAUST trial. He reassures clinicians that after about 10 to 15 ultrasound procedures they will develop a comfort level with ultrasound and procedures will became faster. He also discusses a non-statistically significant trend toward reduction in adverse events using micropuncture (18G needles compared to 21G).
He concludes by presenting a contemporary, state-of-the-art approach to femoral access that entails a multimodal approach using fluoroscopy, ultrasound, and micropuncture. “Be thoughtful,” he tells clinicians, “and use more than one modality to help put in sheaths and get access.”
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