Access & Closure, Clinical Research & Data, Insertion, Intravascular Imaging, Safety & Efficacy, Protected PCI
Standardize Your Approach to Large Bore Access to Limit Bleeding
Paul D. Mahoney, MD, describes the standardized approach for large bore femoral access at Sentara Heart Hospital in Norfolk, Virginia, where he is the director of the structural heart program. His institution has a large program that performed more than 400 TAVR procedures, 100 MitraClip™ procedures, 100 Watchman™ procedures, as well as many complex interventions and procedures using the Impella® heart pump last year.
“In the radial age,” asks Dr. Mahoney, “how are you going to be good at femoral access as well as large bore management?” He emphasizes that maintaining excellent transfemoral access skills is of critical importance as femoral access is commonly used for TAVR, Impella, ECMO, complex PCI, radial cross-overs, and peripheral intervention procedures.
“Bleeding Predicts Mortality!” is one of the themes of his presentation. He reinforces that theme by reviewing the 7-fold increase in mortality in patients with major bleeding in the ACUITY trial and the PARTNER trial data showing that mortality doubled in patients with major vascular complications in large bore procedures. He describes the risk factors for, clinical signs of, and timing of retroperitoneal bleeding, reminding us that unacceptably high femoral complication rates can undermine the benefits from mechanical support for high-risk PCI or shock.
Dr. Mahoney then describes how his institution aims to reduce bleeding and complications through a standardized approach to femoral access. It begins with careful preoperative planning—having a “roadmap”—and understanding the anatomy. In terms of anatomy he presents the classic teaching: “Stay above the bifurcation and below the inferior epigastric artery in a compressible area.” For preoperative assessment, he presents CTA as the gold standard with IVUS as second best and angiography a distant third. He shows how the level of detail in CTA is vastly superior to angiography.
Dr. Mahoney talks about the equipment and techniques for large bore femoral access, emphasizing the bleeding reduction benefits he has seen using ultrasound as well as clinical evidence (FAUST) demonstrating that ultrasound trends to higher rates of success for complex patient sets compared with fluoroscopic technique. He reviews the micropuncture technique, Perclose deployment, and sheath insertion and removal. He concludes with a reminder to always pay attention to the forgotten contralateral side where, paradoxically, he sometimes sees a higher rate of complications because the focus is on the large bore side.