 Welcome to Texas Heart Institute educational programs on innovative technologies and techniques. The topic of today's presentation is how to avoid complications with large bore access. I'm Zvon Mierkreser. I'm a clinical professor of medicine at Baylor College of Medicine and Texas Heart Institute in Houston, Texas. Joining me today is Brianna Costello. She's an international cardiologist at Texas Heart Institute and St. Luke's Baylor College of Medicine. Welcome Brianna to this presentation. Thank you Dr. Kasia for having me. I look forward to our discussion. Here are our disclosures. I have no disclosures and Dr. Costello has no disclosures. So let's talk about incidents of trash femoral access site complications during interventional procedures. As we can see on this list we have many complications that can't be seen due to access site problems such as hematoma, intimal dissection, pseudo aneurysm, av fistula, access of vessel closure and also closure of the vessels in the lower extremity as well as distal embolization and then infection. There are other less common problems or complications that occur such as venous thrombosis, nerve damage, retroperineal bleed and retroperineal hematoma and obviously one of the most complex and dangerous complications with serious consequences is vessel laceration or revulsion. Fortunately this occurs in very rare circumstances. So as far as vascular complications after percutaneous interventions using large bore sheets obviously this can carry significant consequences not only as far as patients well-being is concerned but also it has many other consequences. There is ample evidence in the literature that vascular access site complications increase mortality three-folds and prolong the length of say two-folds and there is a 60% increase in health care costs related to the complication. Now we know that there are many causes so large bore exercise complications some of them are patient-related some of them are physician-related and some of them are device-related. Among patient-related complications what matters is the vessel diameter the smaller the vessel the higher the risk of complications particularly using large bore sheets. The vessel calcification is one of the major deterrents as far as gaining adequate access and closure at the end of the procedure particularly when we are dealing with circumferential calcification of the femoral artery. Vessel tortuosity either alone or in addition to a small vessel diameter and calcification also plays a significant role as far as complications are concerned prior growing procedure prior use of closure devices prior surgical access all can lead to increased incidence of vascular access site complications. Obesity particularly morbid obesity or BMI of more than 40 kilograms per meter square is directly related to higher incidence of complications using large bore sheets. Gender again plays a role probably primarily related to vessel diameter in females and also extent of vascular disease that is seen in older population. As we talk vessel tortuosity plays a role presence of previous diagnosis of peripheral arterial disease of the lower extremities is also a very important factor as well as recent interventions particularly in the presence of hematoma or recent use of vascular closure devices. Emergency procedures certainly carry also higher incidence complications due to a variety of reasons. Then there are physician-related complications such as lack of experience no ultrasound guidance which I think it's nowadays mandatory in a lot of not only interventional but also diagnostic procedures. Aggressive manipulation of catheters, balloons, wires and so on certainly can carry higher incidence of complications. Inaccurate measurements particularly as far as access site is concerned making the decision about the size of the sheets, size of devices can play a significant role. Also the access that's too high above the ignorant ligament or access that's too low in the femoral or profound ephemeris carries higher incidence of complications and also prolonged procedure which adds to the comorbidities that are seen such as hematoma, lower extremities, ischemia and several others. And then there are device-related complications that are often the sheets the higher incidence of vascular complications and obviously the use of closure devices. Different closure devices have different idiosyncrasies or a particular aspect that are important whether it's a learning curve or whether interventionalist is familiar with the use of certain closure device and also using a closure device depending on the anatomy may also play a significant role. Dr. Crazier, since you mentioned prior closure devices in patients and the patients that you know you may have to come back and gain access in that same vessel are there particular closure devices that you would avoid or maybe prefer in those patients? Right. I think that the use of a collagen-based closure devices that particularly if they have been used relatively recently within a few weeks of the procedure could add to the complexity of the procedure. I think that probably this is less commonly seen with such immediate closure devices but in general in all the clinical trials where a large board of closure devices were used patients that had a closure device used within three to four weeks were excluded from the clinical trial. Very good. And additionally your mention of ultrasound guidance I know that it's pretty much a standard of care for all of us in the labs nowadays but there is certainly a learning curve. What is your opinion on you know interventionalists who may have been in practice for a while who just pick up the ultrasound and they may or may not be uncomfortable or it might make their access more difficult while initially using ultrasound. How do you think they can gain proficiency early on while they're trying to you know get comfortable with the ultrasound? Well I think I absolutely agree with you. It's mandatory in all the teaching programs whether it's a vascular surgery program residency or interventional radiology or cardiology that physicians in training as well as practicing physicians in those fields should familiarize themselves and should be using ultrasound for access on a regular basis. So I would suggest for the beginners it's important to use the ultrasound not only for international procedures but also for diagnostic procedures and one has to gain expertise by knowing how to get the optimal image how to identify the artery and separate the artery image from the venous image and also to be able to determine where the bifurcation of the SFA and profunda is and to also be able to identify whether you're above the inguinal ligament or below the inguinal ligament. So those are I think the basic and essential things for good practice in performing femoral artery access but not only femoral but any access arterial or venous we use it routinely in all the venous accesses as well gaining access in the radial or brachial or any other location. All right so let's talk about that challenging anatomy and who are and who are not good candidates for the you know large bore devices or what anatomy would you perhaps go for a different site if you saw? Well one thing that's important whenever we use large bore sheets it's almost routine that we are obtaining a CAT scan prior to the procedure because typically for the use of large bore sheets we are either performing EVAR or TIVAR or TAVR and for those procedures access site CT is is mandatory so I think we should use this opportunity to assess the vessel size, vessel long complications whether it's tortuosity or severe calcification prior to the procedure and that would give us a guidance in deciding where is the primary access and whether the patient is a candidate for the procedure or if the patient is not a candidate for the procedure. On the left hand side we can see on the top panel the access site we can see it's at the femoral head which is appropriate location just above the bifurcation of the femoral artery that essentially there is no calcification of the anterior wall. We do see speckles of calcium of the posterior wall but that should not be of any significant or severe consequences as far as access is concerned and also for the use of closure devices. Now on the lower panel we can see a patient that has extensive practically circumferential calcification of the right common femoral artery and anterior wall calcification of the left common femoral artery. Even though those vessels are adequate size but just the presence of calcium would be if not absolute definitely a relative indication for gaining access with large pore sheets but particularly for the use of any current commercially available closure devices. On the right hand side panels we can see again not only that there was a problem with in this particular patient with the access site complication but there was also severe disease and calcification of the common iliac artery and then on the right hand panel we can see another 3D image of a CT of a patient that had extreme tortuosity of the iliac vessels that might preclude advancing devices or sheets above the bifurcation and being able to complete the interventional procedure. And Dr. Crazier while you were on that topic and that severely calcified CFA there on the bottom left in what closure devices since that's you know closure makes or breaks the case what closure device would you prefer if you had to access that artery and what are your thoughts and reasoning for that choice? Well we are using at the present time all commercially available closure devices such as Proglide, ProStar, Manta and we participated in several clinical trials with devices that are commercially still not available and in all of those clinical trials one of the exclusion criteria for those devices whether they were suture mediated or a collagen based one of the exclusion criteria was severe access site complication. So I would say this would pose a problem with most of devices but particularly would be of concern to me for the use of suture mediated closure devices. Very good thank you Dr. Crazier. All right so now that we talked about how the arteries can you know pose some challenges can you show us some more examples of this challenging anatomy? Yes so one thing that we have to consider is what is the proper access site and here is a very basic information we all tend to use a crease as a identification location anatomically where the access should be obtained and that is true in great majority of patients that are not obese particularly for those that are not morbidly obese. However with morbid obesity the anatomy changes significantly and a crease might not be identifiable or it might completely misguide us as far as proper access is concerned. Where you can see on this CT that the distance from the skin level to the common femoral artery on the left side and similarly so on the right side is close to 12 centimeters none of current generation closure devices will work well in this type of a scenario. On the right hand side we can see that it is difficult to determine where is the iliac crease is it the arrow that points above the straight yellow line or is it below with a curvilinear yellow line so we should not use visual landmarks in making the decision for the access we should be using ultrasound as the most reliable guidance to achieve proper access in complex anatomies. This is particularly a challenge when you have a high bifurcation like seeing in this scenario also in a patient with morbid obesity so now you have two complexities you have morbid obesity is a long distance from the skin to the artery and you have very high bifurcation where for all practical purposes you have probably less than the centimeter over target zone were to enter into the artery. As we can see on the left hand panel and right hand panel we can see inferior fugastric artery that curves from just below the inguinal ligament and we can see the distance is here probably less than a centimeter and that is even more challenging when you have like in this particular patient anterior wall calcification and that's another complexity so in this type of scenario maybe it will be prudent to use for alternate access for your interventional procedure whether it's a clavian or whatever other access might be better. Very good so what is a good practice technique Dr. Krazier to gain access for large birthsheets and interventions? Well Rihanna we already mentioned that the use of ultrasound is mandatory nowadays and not only that it avoids complications but it gives you assurance where you enter into the artery. One of the great issues and problems that I have seen in my experiences when we gain access with so-called side stick it means it's not anterior wall stick. Now none of the closure devices at the present time work very well with side sticks so you have to make sure that your access with a needle using ultrasound is through the anterior wall at 45 degree angle that is true for all the closure devices that we use nowadays and here are examples on the left hand panel using ultrasound we can see the needle that projects into the artery we can even measure the depth from the skin level to the artery and we have to again pay attention that we are entering it over the head of femur because this is very important to achieve good manual hemostasis in case of any the closure devices that you might use would fail. Now as you know Rihanna we use routinely in addition to the ultrasound micro puncture kit and I've been using that routinely on all of the cases including the diagnostic cases it's a low profile needle low profile wire 0.018 wire it is also a device or a catheter system that has a dilator and a sheath that a very low profile and you can obtain the image through the dilator which is three French in size and if you're not satisfied with the access location you can safely remove it hold pressure for a minute and you can achieve good hemostasis now on the right hand side is a fluoroscopic image of access with a micro function needle and introduction of the micro puncture wire you can see that the access was obtained in ideal location over the head of the femur but also what is very important is that there is a coaxiality between the needle and the micro puncture wire if there would be a severe angle or any degree of angle between the needle and the micro puncture wire this would indicate that you actually obtain a side stick entry into the artery and again as I mentioned that might pose a problem at the time of closure with such immediate or any other closure devices for that particular reason now we use quite frequently roadmap in many scenarios and the left hand lower panel we can see actually the micro puncture needle entering into the artery and it's a safe and reliable way of using this technique particularly if for whatever reason we are not using the ultrasound but that should certainly not exclude the use of ultrasound in most of scenarios now what is also important is on the right hand side we can see that micro puncture dilator is placed into the common femoral artery just above the bifurcation which is ideal location and we almost routinely obtain angiograms in oblique view typically it's 30 to 35 to 40 degree angle if we are on the right side it's a RAO projection if we do it on the left side it's LAO projection and in this projection we can clearly separate the origin of the SFA and profunda and determine the exact entry of the micro puncture catheter into the common femoral artery so those are good techniques and essential steps for meticulous access and essential components to avoid problems and complications particularly when using large bore sheets very good so now for the interesting complications can you show us some of the complications you've encountered or you've heard about with the use of large bore sheets here is an image of a femoral angiogram that was obtained in a patient that was 71 year old and admitted for a EVAR procedure this patient had a significant disease of the iliac artery he was status posed to a PTA and stenting of the right common external common and external iliac arteries and a self-expanding stent was placed on that location the interventionalist here was attempting to recanolize CTO of the left external iliac artery via left common femoral artery approach and what he encountered is CTO at the origin of actually the inferior pigastric artery and as you can see this particular individual decided to recanolize this vessel using just a plain straight 035 wire which did not advance well and caused eventually sub intimal dissection so to address this problem and to salvage the case this particular interventionist approached this patient with a right femoral artery percutator access on the left hand side panel you can see that there is a self-expanding stent present in the right common iliac and external iliac arteries he used up and over technique with a poor french catheter and he used that in this scenario hydrophilic quoted wire but that attempt eventually failed because now we can see that there is extensive dissection from above and extensive dissection from below so do you have any suggestion Brianna what would be what are the options in this type of a scenario what shouldn't have been done and how would you salvage this case right so I think that using that standard 035 wire may have been a bit aggressive at the beginning so that was probably step one of maybe things you can change going up and over to salvage this situation doesn't seem like a bad idea maybe just doing an aorticram to see where exactly how far you've dissected up is probably an ideal initial step before just going up and over because you don't know if you that dissection flap has extended into the aorta you might have to actually cover it higher and come you know come from higher up perhaps break ill approach if you had to again you know injecting with that I see that for french catheter you may just be perpetuating more dissection if you inject right away if you don't know exactly where the dissection starts so that's another thing that maybe you'd want a bigger picture from above first to see what damage has been done and then if you can recanalyze you know in the true lumen from wherever it dissected to I think then you can start and approach it from above but knowing where it goes to is important right I agree with your comments I would add also that there are several CTO devices available and CTO wires available as well I practically would never approach this with 035 straight wire there are gentler wires lower in profile either 014 or 018 that are easily torqueable and that are safer to be used for that particular complication or or problem and also there are CTO devices available that might help us such as a front runner and several other ones that are of benefit and then there are devices that once you cause dissection to find a true lumen and re-enter a true lumen you can use re-entry devices but in this particular scenario this particular interventionist did not have experience or expertise with using CTO wires CTO devices or re-entry devices so this is when he actually asked for help anyhow but if you don't have that experience I would say the most important thing is knowing when to stop so far what we can see there is no extravisation to any significant degree there is actually perforation in the common iliac vein as you can see and communication between the artery and the vein but there is no retropartial bleed so fortunately enough this particular interventionist stopped right there because he didn't have comfort level or expertise to remedy this particular problem and this eventually healed on its own and a no major trauma occurred in this particular scenario so let's let's talk a little bit about the sections and you are familiar with this because you experience it on a daily basis not necessarily in your personal practice but observing procedures doing coordinate interventions peripheral interventions and dissections are not uncommon particularly when you're dealing with complex anatomy and what you're dealing with a CTO and so on they can be either caused by retrograde approach like what we've seen in the previous case or integrate they could be mild moderate and severe or what we call flow limiting dissections usually the ones that occur in a retrograde fashion are relatively benign because they're against the flow and the flap typically heals that area of dissection integrate a section could be a little bit more cumbersome to remedy particularly if there are flow limiting the causes are many but the most common one is lack of experience inappropriate procedural planning where you didn't anticipate something like this happening no pre-procedural imaging such as CT or ultrasound or sub optimal procedural imaging where you have not used all the modalities that you have available including intravascular ultrasound or no ultrasound for access no roadmap which would be very helpful inappropriate use of wires like we discussed in the previous case and no experience or no availability of CTO devices and then how to prevent this would you like to discuss this a little bit yes you prevent those currently so I think you really hit home the point of you know gaining expertise not only with the access but dealing with complications of both access and your procedure um IVAS guided I mean we have a peripheral IVAS that is um wildly widely available and using it more if you're just not sure what's going on or you're not certain if you've dissected that's hugely important in deciding what your next step is in the case and then of course like you said familiarizing yourself even if you're not using them every day because you're not doing CTOs peripheral CTOs or even coronary CTOs every day knowing what the the wire characteristics are what the tip you know what the weight is at the tip and you know the stiffness etc is important because when you have to go for a wire you know the cath lab staff like you might not know exactly what you're looking for so you have to have a plan before you start your case again like you said knowing that retrograde is a little more forgiving that's important but anti-grade of course it goes with the flow of the blood so it could be a little more challenging so you know maybe planning a procedure around that if you think it's going to be a difficult CTO maybe you would prefer going at a retrograde to start and then if you have to meet and go anti-grade with it you know plan accordingly and then just be ready with a covered you know stent or you know covered stent graft if you have to if you perforate or you have a complication having alternative access is also if you're using a large horsesheath or you're doing a peripheral intervention that you think you know it might be high risk having extra access even if it's contralateral a small french size sheath maybe especially for beginners can be a backup plan that you can always bail out if you need to go up and over one thing that we see often doctor crazier especially you a lot of our patients have stent grafts which make going up and over very difficult so being able to be comfortable going brachial or even radial if you need to for your alternate access if you have an issue during the procedure is also important in your procedure planning very good thank you very much for this information so here is a one of the patients what I would say with inappropriate access and in this particular scenario the interventionalist did not use the ultrasound to gain access this was obtained in a patient with a severe obesity and during the procedure their interventionalist noticed that the blood pressure dropped down to below 80 millimeters of mercury and the patient was explaining or experiencing severe back pain obviously you immediately you immediately suspect that there is a retropyrtineal bleed and in this particular scenario the angiogram clearly shown with a red arrow where they're bleeding and you can see on the right hand side the angiogram showing a extravization of the contrast in the retropyrtineum this practically should never occur if you use an ultrasound and gain proper access and particularly if you're using a micro puncture kit and obtain an angiogram in a blink view because in scenario for whatever reason if the axis is too high you can abort the procedure after just entering with a micro puncture kit and no serious complications would occur and you know I think as as teaching fellows and you know working with fellows who are new to gaining access to the femoral artery you know get using the ultrasound and checking that needle under fluoroscopy right before you enter the artery is a very simple maneuver that especially in obese people if you're just not sure how far your needle traveled because you've been chasing the ultrasound picture it's an easy way to bail out before you even enter the artery so if you're unsure I say just take your time it's the most important part of the whole procedure look under fluoro because it's also you know a tool in our toolbox that we have readily available and can avoid major problems at the end of the case and remember that 45 degree angle is important regardless whether you have morbid obesity or normal anatomy that is extremely important now in this particular patient this was easily remedied I was asked to intervene and we gained access via a contralateral approach I suggested to the interventionist to inflate the balloon on the right side this was a seven millimeter balloon seven by 40 in a common the origin of common and external iliac artery at a very low pressure to stop the bleeding and then we gain access via a contralateral approach and deploy the stem graft placing it in ideal position where we still preserve the origin of the inferior pigastric artery this relatively young individual and control the bleeding in a very efficient way in a relatively short period of time very good looks it's a good save looks great at the end here is another scenario with the use of large bore sheath and we can see here on the left hand side after the use of 24 French sheath that there is a very significant narrowing of the common ferrule artery but also extravasation which occurred after the use of one of the closure devices this could happen with any of the closure devices and what typically has been done in the past in a lot of scenarios with a lot of you know experiences that you have access from up and over as we can see here you can easily advance the wire and advance the balloon of appropriate size but typically it's like six millimeter in diameter and 40 millimeters in length and inflated at a very low pressure and this way you have hemostasis until you figure out what to do and of course there are several options available and one option obviously would be to explore it surgically and correct the problem another option would be as you can see the wire is over the out from the artery so you don't have ipsilateral access to the artery so the other option would be to put a covered stem which we did in this particular scenario you do not necessarily burn any bridges with it because you could do it temporarily until the surgical correction is achieved even if you have to occlude the origin of the profunda because that can be remedied then surgically but in most of the instances if you have appropriate location of access you can avoid occluding profunda femoris by placing a in this particular scenario and I will always suggest it's self-expanding stenograph because this is at the bending point and at the inguinal crease and you certainly do not want to use balloon expandable stenographs here is another scenario this is a very interesting it occurred in my experience I would say close to 20 years ago this patient as you can see had a pretty relatively decent size iliac arteries free of disease and this patient's primary problem was a pseudo aneurysm just above the origin of the celiac artery and this was related to a surgical procedure that this patient had previously and the pseudo aneurysm as you can see is pretty large in size but it was also enlarging on the CT over a period of a year or so so we made a decision to gain access via left a formal approach for the international procedure a large sheath at that time was required to place a aortic cuff at the site of pseudo aneurysm and here we can see the angiogram when the sheath was placed as you can see there is no flow distally on the left side indicating that this sheath is occlusive now what is interesting also is that that sheath size when you measure it because we have a pigtail with calibration markers is larger than the origin of the right common iliac artery and both common iliac arteries are the same size so this indicates that we really stretch the origin now or the whole iliac artery to a significant degree upon removal of the sheath as we can see the super thick wire is still there we see this major extroversation that occurred in retropertinium and there was obviously significant hemodynamic compromise that occurred immediately with drop of the blood pressure and and that obviously needed urgent intervention do you have any suggestion what will be your choice in this particular scenario how to address it yeah so it was certainly there's a perforation which was likely as you mentioned from the sheath you have a wire across it so at this point I would either you know take a big aortic occluding balloon or just a balloon right over the where you think that this perforation is to temporize um temporize the patient it's and you know in the iliac which makes me think it's going to need surgical repair so a balloon um temporizing measure to stop this massive you know rph and then calling surgery is probably your best option but temporizing it with a balloon I think would just be perfectly adequate if you don't get good if you're not getting occlusion with the balloon of course you can put a coda balloon up and into the aorta as well um to temporize the measure until you can get to surgery right so we were lucky in this particular scenario because we had access from both sides so uh our primary um goal was to stop the bleeding and one of the best way how to do it is to re-advance the dilator and advance the sheath upward and stop the bleeding until you are ready to gain access from the contralateral side and put a real uh compliant balloon in abdominal aorta distal abdominal aorta occluded and this is the scenario we can see now there is no more bleeding because we were able to advance the sheath upward when you obtain this image or angiogram and you don't see the origin of the internal iliac artery or you just see a glimpse of it but no not all the branches this would indicate that actually you uh evolved the internal iliac artery and the external iliac artery uh and separated from uh the common iliac artery and if that is the case then uh you do have a serious problem because if the left internal iliac artery is totally now separated from either the common or external iliac artery and you put a stand graft covering the area of perforation or laceration you will still have retroperneal bleed because there is a communication between the left and right internal iliac artery so actually uh you might not resolve the problem on permanent basis you might be able to address it on temporary basis until surgery is done but not on permanent basis that's a really good point to remember about the communication if this were to happen right so as we mentioned we inflated the balloon as you suggested in that uh proximal left uh common iliac artery we via a contralateral approach uh uh placed in a distalata compliant balloon and then we were able to uh actually in controlled circumstances prepare the patient for surgical repair of this particular problem and the reason that we chose surgery not a stand graft because as you can see here we have actually evolved this artery and uh this can only be safely prepared with surgery and not necessarily with a stand graft because this is how schematically it looks like so it's very important to pay attention to angiographic image uh at the time when this problem occurs because this will guide you how to correct the problem and as I mentioned we use compliant balloon and placed it in the infravenal abdominal aorta the stand graft was placed only temporarily and the surgeon then exposed uh uh via oblique projection the area and found that uh we were correct that the internal iliac was separated from the origin of the internal or external and the surgical graft had to be placed from the common to the external uh iliac artery on the left side and uh internal iliac was re implanted and the patient did well here is another scenario of a patient that that again underwent tabular with the use of 22 french sheet and we can see on the left hand side in the stationary image there is extravization and retropasneal glee now uh we obtained immediately access from the contralateral approach and we can see that actually uh this extravization or perforation of the external iliac artery is below the origin of the right internal iliac artery so this means that the endovascular approach with the stand graft is a reasonable approach in this particular scenario and surgery is not absolutely needed like it was needed in the previous case so we can see the placement of a again a self-expanding stand just below the origin of the right internal iliac uh with a complete hemostasis and uh no serious consequences because this was corrected in a very short period of time and we had already available in the room uh self-expanding stand graft and we were prepared with the contralateral approach for visualization and also for intervention now here's another really concerning scenario of a patient that was admitted with acute myocardial infarction in placement of impella device the patient's lower extremity became ischemic and the device had to be removed the internationalist placed the wire at the access side and obtained an angiogram via a contralateral approach and as you can see here there is a major extravization and bleeding that occurred because this vessel was lacerated at the access side we don't see any distal vessels and this patient's lower extremity was ischemic we can see the origin of the uh profund of hemorrhage on the right side but no non esophage so uh my recommendation was for this particular scenario to the internationalist that uh was performing the procedure to inflate the balloon in the external iliac artery and ask for surgical help to remove there was a thrombus there and also extravization i think that brings up a good point doctor crazier when we're using these large sheets it's important to have good catheter hygiene and sheath hygiene with um anticoagulation um and check your ac t and then um aspirating and flushing as necessary because these bigger sheets are more prone to clotting as we've seen another thing that's very important is uh and we didn't mention that on the first case that uh you could have a problem due to uh oversized sheets in disease vessel or a problem due to a spasm so one of the safest ways to deal with this type of scenario is always to reintroduce the dilator appropriate dilator that comes with that sheet over a super stiff wire and then gradually try to pull uh typically i try to pull the sheath over the dilator because that gives me a little bit less uh pulling and trauma to the vessel and you do it in stepwise fashion and that frequently works very well if this scenario doesn't work very well and you have a spasm i have also used a pavarin typically i will give it intra-arterially uh 30 milligrams up to 60 milligrams or nitroglycerin intra-arterially and wait for a couple minutes and that might help as well particularly when you're dealing with a scenario spasm you certainly don't want to see this so-called iliac artery on the stick which is a function of the iliac artery that obviously leads to serious bleeding and serious sometimes catastrophic consequences yeah i never want to see that effect or creature right so uh another important step or feature is whenever dealing with spastic arteries or arteries that are relatively small and when you're not sure whether adequate size sheath for large board intervention will work or not is uh use dilators you start with a smaller dilators advance to a larger dilator without even opening the device some of the timer devices are extremely expensive and you certainly don't want to waste the device if you cannot gain access with appropriate size sheath so using dilators is an inexpensive way to establish whether you'll be able to do the procedure and not be able to do the procedure of course there is a learning curve in all of it but as the sheet sizes decrease in profile uh particularly when we talk about tabar evar and t-bar procedure the incidence of vascular complications decreases tremendously as well of course learning curve is important as well and your level of expertise is important as well but here we can see just with one valve for tabar procedures and that's from a clinical trial where the incidence of vascular complications just by decreasing the profile of the sheath decreased from close to 16 percent to actually the present time even lower than five percent uh with current experiences so obviously size matters so what usually uh my recommendations are as listed here uh when having difficulty in advancing large bore or large profile sheaths to the iliac artery anticipate potential complications as i mentioned such as spasm rupture laceration or revulsion and be prepared for it one of the most important thing is to maintain wire access until you're satisfied with level of hemostasis and that's probably one of the most important things is as long as you have the wire you can remedy this problem by placing the balloon uh in the ips lateral artery and controlling the hemostasis until you address it in a definitive way always maintain control lateral femoral artery access in case of any complications or emergencies and then you can address it as we discussed previously by placing a compliant balloon in a farina of don louis or gain access to the ips lateral vessel and then corrected either with balloon or stand graft or surgical repair as we have seen in the previous case and it's very important to identify the site and type of bleeding whether it's common iliac whether it's a junction of the external and internal iliac whether you have a waltzed any of the vessels and that will also guide you on your mode of therapy that is the most reasonable for that particular scenario you should always have appropriate sized endographed available in the room when you're performing interventional procedure using large bore sheaths and Dr. Crazier if you don't mind it just want to you know sometimes when you are in an emergency and you you know you've evolved through it or you've perforated or you've done something and you are having an art retroperitoneal hematoma you know a lot of these cases we already have cts on these patients as you mentioned it's almost mandatory that we're getting CAT scans so you have the size so you don't have to really guess so you know after you get balloon control over the bleeding just taking a deep breath and looking back at the ct to help guide you can be very helpful should you find yourself in this situation right we have also participated trial where we use saranis early bird uh sheet that is extremely beneficial in anticipating not only whether you have a bleeding but whether it's a minor or whether it's a major whether it's just retroperitoneal hematoma or is it just hematoma at the access site so obviously with the large ball sheets that is helpful but what is also very important is to have blood available in case of any emergencies and we always do that on routine basis and the blood has to be available in the room as well as all the other devices that we might need on urgent basis well Briana thank you very much for the opportunity to participate with you in this Texas Heart Institute educational program and innovative technologies and techniques particularly dealing with the issue of access site complications with the use of large board sheets I hope this will be helpful to those that are in future going to be interested in doing this program yes thank you for having me dr crazier and you know truly um it's we're lucky here at Texas Heart Institute to have people like you who are so vested in large board access to learn from it's a pleasure to be here and a pleasure to be talking about it with you thank you