Managing Large Bore Access Complications

August 13, 2019

Step by Step Approach

Paul D. Mahoney, MD, director of the structural heart program at Sentara Heart Hospital in Norfolk, VA, discusses step-by-step approaches to managing complications associated with large bore access. Dr. Mahoney notes that in addition to developing a systematic approach to transfemoral large bore access, it is very important to prepare for managing complications. “All operators get complications,” he says. “It’s how you handle them that separates you from the masses.” Invoking the Boy Scout motto, “Be Prepared,” Dr. Mahoney explains the importance of preparing for sheath removal by paying attention to hemodynamics and having the necessary equipment available. He also stresses the importance of completion angiograms.

Before discussing particular complication scenarios, Dr. Mahoney emphasizes his conservative approach to non-flow limiting stenosis: Leave it alone if less than severe. “Don’t go looking for trouble,” he warns. If, however, you need to intervene, he describes how to do so.

Dr. Mahoney walks through the steps of managing an ileofemoral occlusion where the occlusion was identified at the Perclose site. He describes the process of balloon insertion and repeated inflations until acceptable results were achieved.

But what happens if you get suboptimal results after balloon? While emphasizing that your approach should be determined by your level of expertise and comfort, Dr. Mahoney presents the latest thinking on covered stent versus cut-down. He explains that vascular surgeons see cut-down as reliable, durable, and able to be done under local anesthesia. Yet studies such as the TECCO trial reveal that stenting is superior to surgical repair in atherosclerotic CFA lesions. In the trial, major adverse events were seen in 12.5% of the stent group compared to 26% of the surgery group. In fact, SCAI guidelines now have a class IIb recommendation to stent for isolated CFA lesions.

Dr. Mahoney suggests discussing the data with vascular surgeons as way to build bridges. And if you don’t have the experience, ask the vascular surgeon, “Can we stent this?” Insert the covered stent with the surgeon or let the surgeon insert it. Dr. Mahoney states that while there is no clear-cut optimal practice right now, stenting appears to be safe and, at least in the TECCO trial, superior to surgical repair.

Dr. Mahoney also touches on approaches to managing iliac dissection, iliac perforation, and retroperitoneal bleeding.

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