Groin Access Research Articles

MINT Registry: Rationale and Study Design

Background Mechanical thrombectomy has become the standard of care for treatment of acute ischemic stroke secondary to large‐vessel occlusion up to 24 hours from last known normal time. Multiple different techniques for mechanical thrombectomy have been described, including a direct aspiration first‐pass technique and stent retriever thrombectomy. With a direct aspiration first‐pass technique, classically, a large‐bore aspiration catheter is delivered over a microcatheter and microwire to the clot. Recently, a novel macrowire has been introduced as a potential alternative to the use of microwire–microcatheter to allow the delivery of the aspiration catheter. The aim of this study is to develop a multicenter registry comparing delivery of an aspiration catheter for intracranial thrombectomy for acute ischemic stroke secondary to emergent large‐vessel occlusion over a macrowire in comparison with traditional use of microcatheter and microwire. Methods MINT (Macrowire for Intracranial Thrombectomy) is a multicenter, observational study currently enrolling patients with large‐vessel occlusion who underwent mechanical thrombectomy using a macrowire to deliver the aspiration catheter to the intracranial occlusion. All the participating sites will screen and report cases on a monthly basis. The decision to use the macrowire and various aspiration catheters is at the discretion of the interventionalist. Results We will collect patient's clinical, demographic, and radiographic data. In addition, we plan to collect procedure variables and postprocedure clinical and imaging data. Outcomes include successful delivery of the reperfusion catheter to the clot interface, time taken from groin access to first pass, and a bailout strategy for thrombectomy in cases where this is not feasible. Conclusion The MINT registry will add to our understanding of safety and efficacy of this novel macrowire in intracranial thrombectomy. This registry will also highlight and allow for understanding in workflow improvements from simplifying setup and possibly cost effectiveness of this technique.

Exploiting endovascular aortic repair as a minimally invasive method – Nine years of experience in a non-university hospital

BackgroundAt the introduction of endovascular aortic repair (EVAR) in 2013 in our non-university hospital, we established a quality registry to monitor our EVAR activity. PurposeTo observe if we over time were able to exploit EVAR as a minimally invasive method in an elective as well as emergency setting, and to monitor our treatment quality in terms of complications, secondary interventions and mortality. Material and methodsFrom November 2013 to March 2022, we treated 207 patients with EVAR, including six patients with rupture. Follow-up regimen was partly based on contrast-enhanced computer tomography, and partly on contrast-enhanced ultrasound in combination with plain radiography. ResultsDuring the observation period, the method of anesthesia changed from general, via spinal, to local anesthesia. The groin access changed from surgical cut down to percutaneous and the median length of postoperative stay decreased from 3 days to 1 day. EVAR on ruptured aneurysm was done for the first time in 2019. Endoleak was detected in 85 patients (42%) and 37 patients (18%) had one or more secondary interventions, of which 85% were endovascular. Estimated five-year survival was 72% in patients below 80 years of age and 45% in patients 80 years or older. ConclusionNine years of experience enabled us to exploit EVAR’s advantages as a minimally invasive method in an elective as well as emergency setting. Complications, secondary interventions and survival rates in our low volume non-university hospital matches results from larger vascular centers.

PO-02-220 IMPROVED EFFICIENCY OF COMBINED CRYOBALLOON PVI AND WATCHMAN COMPARED TO SEPARATE PROCEDURES

There is a significant amount of pressure in EP labs across the country to maximize lab efficiency. Elective pulmonary vein isolation (PVI) and left atrial appendage occlusion (LAAO) devices such as Watchman are being scheduled out several months at most centers. To that end, we have sought to reduce the amount of repeat procedures in select patients by combining cryo PVI ablation with LAAO device implant. This is also beneficial from a patient satisfaction perspective and a safety perspective (e.g. one time groin access, transseptal puncture, and general anesthesia). The goal of this study was to look at total room and procedure times for isolated PVI and LAAO implant cases versus combining the two procedures. We retrospectively analyzed patients from our institution who had a combined PVI and Watchman FLX device placement in the last two years. Forty-two patients underwent the combined procedure. To allow a more direct comparison, patients who received additional lesions beyond PVI were excluded from our analysis. These 18 patients were compared to the last 50 patients who had an isolated PVI and the last 50 patients who had an isolated Watchman implant. Patients were selected for the combined procedure based on clinical criteria and operator preference. For each patient we reviewed the total room time (patient entering the EP lab until exit), procedural time (venous access to sheath removal), patient characteristics, and adverse events. All cases were done under general anesthesia with TEE. The average room time for isolated PVI was 180 minutes, isolated Watchman 114, and combined procedure 209. Procedure time for PVI was 91 minutes, Watchman 35, and the combined procedure 103. Adding 30 minute room turnover, the separate procedures would require 324 min, compared to 209 min for the combined procedure. The time savings of 115 min is the same room time required for an additional standalone Watchman. Patient characteristics are listed in the table below. There were no major adverse events in any of the groups. The implantation of Watchman device in addition to PVI increased room time by 30 minutes and added 12 minutes to the procedural time, without any adverse events. Combining these procedures in a select group of patients may safely and efficiently improve time resources. Any potential reduction in reimbursement for the combined procedures can be offset by the ability to perform one or more additional procedures in the room within the same time period.Tabled 1PVIWatchmanPVI + WatchmanAge63.376.773.4% Male747869CHADS2 VASc (mean)2.14.03.8% LVEF555653Room time (min)179114209Procedure time (min)9034102 Open table in a new tab

Surgical management of a large mycotic aneurysm of the distal popliteal artery.

The patient presented with right calf pain, swelling and fevers following a percutaneous coronary intervention for unstable angina two weeks prior via ipsilateral groin access. Physical exam revealed a diffusely swollen, painful lower extremity. Ankle brachial indices were normal. Blood cultures grew methicillin-sensitive Staphylococcus aureus and ultrasound demonstrated a sub-centimeter distal popliteal artery aneurysm with inflammation and calf deep vein thromboses (DVT). Transesophageal echocardiography and sepsis workup revealed no etiologic source.

Abstract TP148: Anesthesia Protocol For Acute Ischemic Stroke Facilitates General Anesthesia In EVT And Optimizes Key Performance Measures

Background: Currently, there is no consensus on the ideal anesthetic strategy for patients undergoing EVT for an LVO. Recently published clinical trials show no difference in mortality, recanalization, and functional outcome related to anesthetic technique, while ongoing trials look at treatment benefits in patients randomized to general anesthesia (GA) compared to conscious sedation during EVT. Utilizing a well-outlined standardized anesthesia protocol for GA in patients undergoing EVT can optimize key performance measures for EVT without adding unnecessary delays. Methods: This is a retrospective review of a prospectively collected database of patients who underwent EVT for LVO at a single academic CSC between January 2021 and August 2022. A multispecialty work group convened to outline best practices in the angio suite. All procedures were performed under GA while adhering to the “EVT Anesthesia Workflow.” The endorsed workflow outlined the protocol for notification of anesthesia and the angio team; the responsibility for order placements, request for bed, and procedural consent; and the expectations for all teams members to have lead on prior to patient arrival to the angio suite with biplane placement so that groin access could be obtained concurrently with intubation, to perform all cases under GA if deemed appropriate by anesthesia (unless requested otherwise), and that arterial line monitoring should not delay the procedure start time. Furthermore, pre and intraprocedural blood pressure parameters and post-EVT blood pressure goals were outlined. Results: A total of 102 patients were reviewed, all underwent general anesthesia (5% were intubated before angio suite arrival; n=5). Mode of arrival included 47 interfacility transfers, 35 primary facility ED, and 20 inpatients. The overall median angio door-to-intubation time was 6 minutes, and angio door-to-puncture was 10 minutes. The median puncture-to-device time was 24 minutes. Conclusion: A multispecialty collaboration to define agreed-upon workflows that outline responsibilities, expectations and goals can facilitate rapid treatments in an emergent setting. An EVT Anesthesia Workflow facilitated the use of GA in EVT without adding delays to key EVT performance measures.

Use of a Heli-FX System Guide steerable sheath for internal iliac artery bridging stent re-intervention following iliac branch procedure via a contralateral femoral approach

Endovascular aneurysm repair (EVAR) offers lower early morbidity and mortality at the expense of increased long-term re-intervention. Dilatation of distal landing zones is increasingly managed with iliac branch procedures. Re-intervention for endoleak from the internal iliac artery (IIA) bridging stent component is usually approached from arm access due to concerns regarding inducement of displacement of the EVAR caused by traversing the neobifurcation of the stentgraft from contralateral groin access. We present a novel case of successful re-intervention for IIA endoleak in the setting of previous fenestrated repair using the Heli-FX System Guide steerable sheath.

Approaches to and outcomes of intra-arterial tPA in embolectomy for large vessel occlusion

IntroductionIntra-arterial tissue plasminogen activator (IA tPA) is sometimes used in conjunction with aspiration catheters and stentrievers to achieve recanalization in endovascular thrombectomy (ET) for large vessel occlusion (LVO). Reports of safety and efficacy of this approach are limited by technical heterogeneity and sample size. MethodsWe retrospectively reviewed a data set of patients undergoing ET for LVO between August 2017 and September 2020 to identify those that received IA tPA. IA tPA usage, timing and dosage was at the discretion of the operative neurosurgeon. We identified three broad categories of IA tPA administration: (1) adjunctive with the first pass; (2) salvage with subsequent passes after first pass achieved incomplete revascularization; and (3) post-thrombectomy residual distal occlusions. Univariate and multivariate logistic regression were performed to test associations with recanalization, hemorrhage, and functional independence. ResultsAmong 271 patients, 158 (58%) patients had IA tPA, of which 83 received adjuvant IA tPA, 60 received salvage IA tPA, and 15 received post-thrombectomy IA tPA for distal occlusions. There were no differences in demographics, stroke etiology and premorbid medications between these groups. Patients receiving salvage IA tPA had longer times from groin access to recanalization and more passes, as expected. On multivariate analysis neither adjunctive nor salvage IA tPA was significantly associated with recanalization, post-operative hemorrhage, or functional outcomes. On univariate analysis, patients receiving salvage IA tPA had lower rates of TICI 3 or 2b revascularization (80% vs. 89% adjunctive and 92% no IA tPA, p = 0.003) and higher rates of any postoperative hemorrhage (33% vs. 22% adjunctive and 19% no IA tPA, p = 0.003). ConclusionsIn this retrospective, single-institution series, IA tPA used adjunctively or as salvage therapy in ET for LVO was not associated with recanalization, post-operative hemorrhage, or functional outcomes, suggesting IA tPA is an available modality that can be utilized in cases of recalcitrant clots.

Real-World Data Showing Lack of Complications Without Use of Closure Devices in the Office-based Vascular Procedure Center

Closure devices are available in a range of different schemata to close the percutaneous arteriotomy. Although they may contribute to room turnover and increased time to ambulation, they carry the risk of dissection, thrombosis, failure, and expense that may bring a patient back for an avoidable operation, causing undue stress to a patient who elected to avoid the hospital to seek office-based care. In addition, there is hardship of a foreign object in the skin, increasing inflammation and scarring should the groin need to be reaccessed or exposed. In an office-based setting where adequate manual pressure can be held, their use may be obviated and unnecessary. Without real-world examples of protocols and complication rates, many surgeons may be uncomfortable with this transition. Using our Vascular Quality Initiative database, all patients who underwent an office-based endovascular procedure in which groin access was employed (aortic, iliac, or peripheral stenting, balloon angioplasty, atherectomy, and diagnostic angiograms) from 2015 to 2021 were identified. These procedures were elective and mainly for occlusive disease. Preoperative patient characteristics, procedure characteristics, and access-related outcomes were analyzed. Access guidance was uniformly obtained with ultrasound imaging. In our protocol, protamine is administered routinely. Fifteen minutes of pressure is uniformly held on each groin by the surgical technician, over an area marked out by the surgeon. The patient lays flat for 3-4 hours afterward, depending on sheath size. Patients are reached by telephone 1-3 days after their procedure to assess their immediate postprocedure status. Five hundred eighty-three patients met inclusion criteria. These were 61% male, 67% White, and 30% African American, with an average body mass index of 28. Thirty-six percent needed assistance with daily activities. Thirty percent had coronary artery disease, 22% chronic obstructive pulmonary disease, 45% diabetes mellitus, and 45% were smokers. Preoperative medications that included 73% aspirin and 57% clopidogrel. Redo-groin status was in 61% of patients. On average, largest sheath size was 6F, ranging from 4F to 8F. Protamine was administered in >80% of cases. Access site complication requiring additional observation was 0.5% (n = 3) and these were all hematomas. There were no postprocedure bleeds on follow-up. Any sort of postprocedure complication was 0.9%. Complication causing hospital admission was 0.2%, and none were related to access. The use of closure devices incurs the added risk. These data show a 6-year experience in the office-based setting that not using closure devices and instead using manual pressure is safe without significant complication. This should prompt discussion regarding the necessity of using closure devices in office-based endovascular procedures.

Safety and feasibility of the paediatric post-cardiac catheterisation Wrap: a pilot study.

The paediatric post-cardiac catheterisation Wrap (Wrap), an innovative medical safety device, swaddles young paediatric patients in a supine position aiding in immobilisation post-cardiac catheterisation. This pilot study investigated the feasibility and safety of using the Wrap on young paediatric patients during their bed rest period following cardiac catheterisation with femoral access. Boston Children's Hospital Cardiac Catheterization Lab. 20 patients, ages 1-5 years and weighing 3-25 kg. Investigator-developed tools used to collect data included the Demographic and Outcome Measures Data Tool, the Parent/Caregiver Satisfaction, and Provider Ease of Use tools. They measured:1.The feasibility of using the Wrap2.Wrap ease of use from the nurse providers' perspective3.Parent satisfaction related to the Wrap4.Frequency of Wrap non-bleeding-related adverse events5.Frequency of rebleeding at femoral groin access sites. The Wrap was feasible and safe; increased nurse provider satisfaction by allowing visualisation of the groin access sites while minimising the need for hands-on care; and increased parent satisfaction by allowing parents to hold and provide comfort while their child was on bed rest. The Wrap is a safe alternative to the current practice of swaddling with a bath blanket. Further studies are warranted to assess the Wrap's effectiveness in reducing the incidence of rebleeding events in the post-cardiac catheterisation period and explore clinical use outside of the Cardiac Catheterization Lab.

Clinical Relevance of Closed-Incision Negative Pressure Therapy (ciNPT) for SSI-Risk Reduction in Vascular Surgery Through a Groin Incision

Vascular surgery, especially lower limb revascularization surgery, has one of the highest rates of surgical complications, predominantly surgical site infections (SSI). Resulting in a significant burden of additional costs due to longer hospital stays, re-admissions and re-interventions, mainly attributable to deep incisional SSIs. Closed incisional negative pressure therapy (ciNPT) is a relatively new strategy in the postoperative management surgical wounds, aiming to reduce surgical wound complications. When discussing the clinical relevance of ciNPT, it is crucial to take into account the outcome of therapy as well as the additional costs related to ciNPT. Since, the additional costs must be justified by an associated decrease in the morbidity and costs associated with groin wound complications, which are particularly attributable to deep incisional SSIs. The current literature evaluating the beneficial effect of ciNPT in groin incisional vascular surgery, predominantly focusses on the decrease in superficial SSIs. Whereas this study aims to address and discuss the clinical relevance of ciNPT over conventional wound dressings, by separately evaluating and comparing the incidence of superficial and deep SSIs and their related re-admissions and re-interventions. In this single center prospective cohort study performed in a non-academic hospital in The Netherlands, 59 consecutive patients (67 incisions) were included between January and October 2019. All underwent elective vascular surgery with groin (access) incisions for either lower limb revascularization surgery or abdominal aortic aneurysm surgery. The study group was treated with six days ciNPT (PREVENA Incision Management System; KCI/3M, San Antonio, TX, USA) and matched for equal comparison to a historical retrospectively analysed cohort of 54 consecutive patients (60 incisions), all of whom have undergone elective vascular surgery for equal indications with groin (access) incisions in our center between January and October 2018. The standard-care group was treated following standard surgical wound care protocol with conventional surgical self-adhesive plaster (10×15cm, Mepore, Mölnlycke Health Care AB, Gothenburg, Sweden). Study groups were comparable at baseline, except for Body Mass Index (BMI), which was significantly higher in the ciNPT-group (P =.021). No significant differences for formation of seroma, hematoma, as well as wound dehiscence and SSIs were found between both groups. Groin SSIs were seen in 12.1% of the patients in the ciNPT-group and in 13.0% in the Standard-care group (OR 0.80, CI ((0.26, 2.48)), deep SSI contributed for 4 out of 7 patients of total SSIs in the ciNPT-group and for 2 out of 7 patients in the standard of care group (P-value >0.05). Analysis for incidence of hospital re-admission and re-intervention in both study groups showed no significant difference. Subset analysis in both study groups for SSIs differentiated in superficial and deep SSIs showed that only deep SSIs resulted in re-interventions. Based on the findings in the population of our single center study, we conclude that routine use of ciNPT was not effective in reducing groin wound complications, and therefore could not replicate the promising findings from some previous studies. Furthermore, we did not find a reduction in the incidence of deep SSIs, which comprise the highest morbidity and costs. Considering our findings as well as the associated additional expenses related to ciNPT, it might be superfluous at this stage to use ciNPT as the new standard of post-operative groin incision care for all lower limb revascularization and abdominal aortic aneurysm surgeries. In our opinion further research is warranted for establishing a risk-factor based model for determination of the indication of ciNPT. To be able to achieve a more substantiated decision for utilizing ciNPT compared to standard surgical wound care in groin incisional vascular surgical interventions.

ProGlide venous closure device facilitates early ambulation following cryoablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Heart Foundation Background Same-day discharge following atrial fibrillation (AF) ablation is increasingly common. ProGlide device suture-mediated vascular closure (PD) offers a technique that may expedite mobilisation following large-bore (>12F) venous access. The utility of PD closure following cryoablation of AF has not been reported. Purpose We sought to evaluate haemostasis and early ambulation outcomes in patients receiving the ProGlide compared with conventional techniques. Methods 104 consecutive patients undergoing cryoballoon pulmonary vein isolation (PVI) for paroxysmal or persistent at a single high-volume institution were included. PVI was performed via a standardised approach including sedation, ultrasound-guided vascular access for 14F Cryosheath and second 7F sheath, anticoagulation protocol, transeptal puncture, 28mm cryoballoon and nurse-led same-day discharge protocol. Haemostasis was achieved using the Perclose Proglide device (PD) in the 14F access point ("pre-closure" technique) plus 5 minutes manual pressure at the 7F sheath site. Alternatively, a figure-of-eight/Z-suture (ZS) was employed for closure according to operator preference. Protamine was used for heparin reversal in all patients. Safety outcomes of major bleeding, haematoma and minor bleeding were assessed. Time to ambulation (TTA), time to discharge (TTD), same-day discharge and complications at initial follow-up were measured. Results Overall, mean age was 64 ± 11 years, 65 (64%) were male and 52 (50%) of patients had paroxysmal AF, there were no significant differences between group demographics, with 31 patients (30%) in the PD group and 73 (70%) in the ZS group. All patients had uninterrupted oral anticoagulation throughout the periprocedural period. No major femoral bleeding complications requiring intervention occurred in either group. Haematomas occurred in none of the PD group compared with 2 (2.8%) in the ZS group. Incidence of minor bleeding was not significantly different between groups (PD: 3 [9.7%] vs ZS: 2 [2.7%], p = 0.155). Mean TTA was significantly shorter in the PD group (3.3 ± 1.1 vs 4.1 ± 1.7 hrs, p = 0.025). However, there was no significant difference in same-day discharge (PD: 25 [81%] vs ZS: 53 [73%], p = 0.386) and TTD (5.0 ± 3.6 vs 6.1 ± 4.2 hrs, p = 0.275) between groups. 1 patient complained of groin pain which delayed discharge in the ZS group not seen in the PD group. After a mean follow-up of 2.2 ± 1.4 months, there were no differences in major or minor complications. Conclusion Use of the Proglide closure device was associated with significant reductions in time to ambulation compared with Z-suture haemostasis following cryoablation of AF, and groin access complications were uncommon across groups. PD closure may contribute to further streamlining patient pathways in day-case AF ablation.

Abstract No. 554 Thorough adrenal vein sampling technique decreases procedural fluoroscopy times: results from a large-volume single-institution experience

Adrenal vein sampling (AVS) is the gold-standard to determine laterality of primary hyperaldosteronism. AVS remains a technically challenging procedure with high variability in techniques and success rates. The purpose of this study was to evaluate whether fluoroscopy times and intravenous (IV) contrast usage were increased when using our thorough adrenal vein sampling technique (TAVST) compared to all other AVS techniques. Retrospective analysis of AVS performed by 13 operators in 126 patients from 2013 to 2019 at a large academic center was performed. TAVST was defined as use of bilateral groin access, pre- and post-cosyntropin stimulation aldosterone and cortisol levels, and routine use of cone-beam CT (CBCT). TAVST total fluoroscopy time and IV contrast procedural totals were reviewed and compared to all other techniques. TAVST was performed in 50 of 126 total AVS (39.7%). TAVST utilized significantly less fluoroscopy time 20.4 minutes compared to 28.8 minutes with all other techniques (P = 0.006). TAVST utilized 70.4 mL of IV contrast per case on average compared to 72.4 mL used by all other techniques (P = 0.8). TAVST is significantly associated with lower total fluoroscopy times without an increase in IV contrast usage.

Distal Retrograde Access for Infrainguinal Arterial Chronic Total Occlusions: A Prospective, Single Center, Observational Study in the Office-Based Laboratory Setting

Distal Retrograde Access for Infrainguinal Arterial Chronic Total Occlusions: A Prospective, Single Center, Observational Study in the Office-Based Laboratory Setting

Feasibility of Same-Day Discharge Approach After Transcatheter Mitral Valve Repair Procedures.

Early discharge strategies are increasingly adopted after percutaneous cardiac interventions. However, there is a paucity of data on early discharge after transcatheter mitral valve repair (TMVRep) procedures. In this report, we aimed to present our data on same-day discharge after MitraClip (Abbott Structural) procedures. A total of 82 patients who underwent TMVRep and were discharged the same day were included in the study. Patients who underwent the procedure with moderate conscious anesthesia, and without periprocedural complications and a stable early course post procedure, were considered candidates for same-day discharge. A next-day follow-up exam at the cardiology clinic was scheduled for all patients for removal of the groin access figure-of-eight subcutaneous sutures and for echocardiographic examination. Thirty-nine patients had primary mitral regurgitation (MR), while 43 patients had secondary MR. A mean of 1.4 ± 0.4 clips were implanted per patient (range, 1 to 2 clips). Postprocedural MR grade was 1+ or lower in 64 patients (63.6%) and 2+ in 38 patients (36.4%). All patients were evaluated in the office clinic the next day, and had no major complications. Same-day discharge approach can be safely performed in selected patients after TMVRep procedures. However, further studies with larger sample sizes are needed.

Axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation support in cardiogenic shock.

ObjectiveTo review the outcomes of axillary artery (AX) and femoral artery (FA) cannulation for veno-arterial extracorporeal membraneous oxygenation (VA-ECMO).MethodsFrom 2009 to 2019, 371 patients who were supported with VA-ECMO for cardiogenic shock were compared based on the arterial cannulation site: AX (n = 218) versus FA (n = 153).ResultsPatients in the AX group were older (61 years vs 58 years, P = .011), had a greater prevalence of peripheral vascular disease (13.8% vs 5.2%, P = .008), and were less likely to have undergone cardiopulmonary resuscitation preoperatively (18.8% vs 36.6%, P < .001). Other characteristics were similar between groups, as were in-hospital outcomes, including survival to discharge (60.6% vs 56.9%), cerebrovascular accidents (12.4% vs 10.5%), cannulation-related bleeding (15.1% vs 17%), and length of VA-ECMO support (6 days). The incidence of leg ischemia (6.9% vs 15.7%, P = .006), limb ischemia related to VA-ECMO cannulation (0% vs 10.5%), the need to switch the cannulation site (4.6% vs 14.7%), and wound complications (WCs; 2.8% vs 15%) including infection and additional procedure were significantly greater in the FA group (P < .001). In multiple logistic regression analysis, FA cannulation and primary graft failure after heart transplantation were independent risk factors for cannulation-related WC. In subgroup analysis among patients with primary graft failure, WCs were more prevalent in FA cannulation (3.6% vs 39.1%, P = .001).ConclusionsAX cannulation for VA-ECMO is a safe and effective alternative to FA cannulation. It can be considered especially for patients with limited groin access, peripheral vascular disease, or for primary graft failure after heart transplant.

Sequential Catheterization and Progressive Deployment of the Zenith® t-Branch™ Device for Branched Endovascular Aortic Aneurysm Repair.

To describe a sequential deployment technique of the Zenith® t-Branch™ device for branched endovascular aortic aneurysm repair that might reduce potential rotation and increases optimal positioning of the device. After obtaining bilateral groin and right brachial access, the device is advanced over a through-and-through brachio-femoral guidewire and positioned based on prior measurements and landmarks. The t-Branch device is deployed one branch at a time and each visceral branch is sequentially catheterized from brachial access using live CT-fusion and intravascular ultrasound guidance. Full deployment prior to branch catheterization is avoided to maintain device stability, reduced spontaneous rotation, wider working room and freedom in positioning of the device while target artery catheterization is secured. Sequential catheterization amid progressive deployment of the Zenith® t-Branch™ device is an effective method of deployment of the device that ensures optimal positioning and secured catheterization of the target vessels.

PVCS AND PES: A CASE OF MASSIVE PULMONARY EMBOLISM AFTER ELECTIVE RADIOFREQUENCY ABLATION

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thromboembolic events are a known but rare complication of radiofrequency ablation despite the frequent use of intra-procedural anticoagulation. CASE PRESENTATION: A 46-year-old male with history of hypertension and dilated cardiomyopathy underwent elective, repeat ablation for refractory premature ventricular contractions (PVCs) localized to the right ventricular outflow tract (RVOT). The procedure was complicated by bleeding at the groin access sites requiring pressure bandages and bed rest. Prior to discharge at 24 hours, the patient suddenly developed tachypnea, tachycardia, diaphoresis, and worsening hypoxemia. He required intubation with inotropic support; bedside echocardiogram showed a dilated right ventricle (RV). CT angiogram demonstrated extensive bilateral pulmonary emboli (PE). Intravenous heparin was started; however, refractory obstructive shock developed. Despite high minute ventilation, the patient’s hypercarbia and acidemia worsened. The decision was made to initiate veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for impending cardiovascular collapse. Transesophageal echocardiogram during cannulation revealed a hypokinetic RV with clot in transit. The patient demonstrated improved hemodynamics and RV function while on ECMO with heparin anticoagulation, and was subsequently decannulated on day 7. He required tracheostomy and prolonged mechanical ventilation secondary to ventilator associated pneumonia and critical illness myopathy, but is now fully recovered and doing well at home. DISCUSSION: Incidence of deep vein thrombosis after non-atrial fibrillation (AF) ablations is as high as 2.38%(1). Periprocedural anticoagulation is recommended in AF and left sided ablations, but expert consensus recommends its use in RV procedures only when risk of thrombosis is considered high. The duration of the procedure and number of venous catheters used may increase the risk of venous thrombosis(2). RVOT ablations can be long and technically challenging, increasing both bleeding risk and endothelial disruption. Patients with bleeding complications may require bed rest and compression leading to stasis, tipping the coagulation balance towards thrombosis. To date, use of ECMO for massive PE is limited to single center case series with promising outcomes. ECMO should be considered in cases of refractory shock or inability to ventilate due to severe V/Q mismatch, especially when further thrombolysis may exacerbate pre-existing bleeding. PE with right heart thrombi in transit are at particularly high risk for deterioration(3). Fortunately, the diagnosis was made early in our patient’s course which allowed for timely initiation of VA-ECMO. CONCLUSIONS: Providers should maintain a high index of suspicion for PE even in patients with brief hospitalizations for elective procedures. Furthermore, VA-ECMO may be especially useful in patients with both massive PE and ongoing bleeding. Reference #1: Burstein B, Barbosa RS, Kalfon E, Joza J, Bernier M, Essebag V. Venous Thrombosis After Electrophysiology Procedures: A Systematic Review. Chest [Internet]. 2017;152(3):574–86. Reference #2: Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, et al. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Hear Rhythm [Internet]. 2020;17(1):e2–154. Reference #3: Kronik G. The european cooperative study on the clinical significance of right heart thrombi. Eur Heart J. 1989;10(12):1046–59. DISCLOSURES: No relevant relationships by Timothy Fernandes, source=Web Response No relevant relationships by Abdurrahman Husain, source=Web Response No relevant relationships by Janna Raphelson, source=Web Response No relevant relationships by Alexandra Rose, source=Web Response

Extract‐stent‐replace for treatment of upper baffle stenosis with pacing leads after atrial switch procedures for transposition of the great arteries: An approach to avoid “jailing” the lead

Venous stenosis is a late complication of the atrial switch (Mustard/Senning) procedure seen in patients with transposition of the great arteries ( d-TGA). Many atrial switch patients require cardiac implantable electronic devices (CIEDs) which further increases the incidence of venous stenosis. Stenosis of the superior limb of the systemic venous pathway (SLSVP) in the presence of CIED leads presents a management challenge. We propose a method for navigating SLSVP stenosis in atrial switch patients with CIEDs. The pulse generator and leads were removed using standard extraction techniques. Axillary access was retained via existing leads or new access was obtained. The interventional cardiology team, via groin access, performed stent-angioplasty of the stenotic SLSVP. After stent deployment, the axillary access wire was snared from below, guided through the stent, and pulled into a long groin sheath. A sheath was then advanced over the axillary wire and into the groin sheath creating a path for passage of leads through the stent. New leads were advanced through the axillary sheath into the heart. Leads were secured using standard techniques. All patients had a history of d-TGA and prior atrial switch procedures. In each case, there was stenosis of the SLSVP in the setting of a CIED lead. There were no immediate complications and there was no restenosis on follow-up. Post-atrial switch patients with CIEDs can develop stenosis of the SLSVP. A collaboration between electrophysiology and interventional cardiology can allow for device extraction, stent-angioplasty, and lead reimplantation to avoid "jailing" the leads.

P451Optimizing the EP lab workflow in atrial fibrillation ablation - The use of Z stitch for groin access closure

Abstract Introduction As catheter ablation became the standard therapy for atrial fibrillation (AF), the number of AF procedures has risen exponentially. Therefore, workflow optimization is crucial in order to meet the rising demands for EP interventions. Recently, instead of standard groin compression we have started using the "Z stitch" for introducers’ removal. This novel method does not necessitate protamine administration and often lengthy manual compression. Purpose We aim to demonstrate utilization of "Z stitch" for groin access closure in cryoballoon (CB) ablation and its impact on EP lab workflow. Methods We have analyzed all patients having undergone CB ablation utilizing the "Z stitch" (Z group) and the last 50 consecutive CB patients who received standard groin compression (non-Z group). Procedures were performed under conscious sedation. Both femoral veins were punctured and a single introducer was placed in each vein. A single transeptal puncture was preformed guided by intracardial ultrasound and a 28 mm cryoballoon was used. A single 180 seconds freeze strategy was employed. In the past, protamine was slowly administered after ablation and at least 15 minute manual groin compression was applied until no visual bleeding could be detected. Elastic bandage was placed around both groins. Later on, the "Z stitch" was used around both introducers without the need for protamine administration, manual compression and bandage placement (Picture). The stitches were removed next morning. Results A total of 100 consecutive patients (79% male, 61.2 ± 10.6 years old) were evaluated, 50 in both groups. There was no difference in the mean procedure duration ("skin to skin") between two groups. However, a total lab time was significantly longer in non-Z group. There was no differences in complication rates, which consisted solely of phrenic nerve palsy and groin complications. There was no AV fistula or pseudoaneurysms detected in our cohort (Table). Conclusion Utilization of Z stitches for introduces’ removal seems safe and effective way to achieve hemostasis after cryoballoon ablation. It abolishes the need for protamine administration which can cause serious advert events. Manual compression is no longer required. Consequently, EP lab workflow is improved, since the total lab time utilization per patient is significantly shortened. Results non-Z group Z group p Procedure duration (min) 69.4 ± 20.4 73.4 ± 24.8 0.380 Lab time (min) 129.9 ± 35.3 109.1 ± 30.6 0.002 Complications (N) 5 (2 hematoma) 4 (2 hematoma) NS Abstract Figure. Z stich

Use of figure of eight suture for groin closure with no heparin reversal in patients undergoing cryoballoon ablation for atrial fibrillation.

We aimed to demonstrate the feasibility of figure of eight (FoE) suture for groin access closure in cryoballoon (CB) ablation and its impact on the lab workflow. We retrospectively analyzed all patients who underwent CB ablation in our institution from June 2018. From June 2019, we have been consistently using FoE suture for hemostasis (FoE+ group), and before that conventional manual compression was utilized (FoE- group). Ablations were performed under uninterrupted oral anticoagulant strategy. Both femoral veins were punctured, and a single introducer was placed in each vein. In the FoE- group, after ablation, protamine was administered, and manual compression was applied. In the FoE+ group, the suture was placed in both groins without protamine administration and manual compression. All patients were in decubitus position until the next morning. A total of 190 consecutive patients (73.2% male, 59.7 ± 11.0years old) were evaluated, 90 being in the FoE+ group. There was no difference in the mean procedure duration between two groups (72.7 ± 23.1min vs 73.7 ± 27.1min, p = 0.784). However, the total lab time was significantly longer in FoE- group (132.9 ± 35.3min vs 109.9 ± 32.6min, p < 0.0001). There was no difference in complication rates. No major vascular complications were found in our cohort. Utilization of FoE sutures for hemostasis seems to be a safe and effective after cryoballoon ablation. It abolishes the need for protamine administration which can cause serious adverse events. As manual compression is unrequired, EP lab workflow improves due to significantly shortened total lab time per patient.