Why We Do Ultrasound Guided Access

Why We Do
Ultrasound Guided Access
•  Quality Improvement Initiative
Peter A. Schneider, MD
Kaiser Foundation Hospital
Honolulu, Hawaii
Ultrasound Guided Acess Permits
Optimal Puncture Site Placement
Speaker Name
Why Ultrasound Guided Access?
Endovascular arterial access:
•  Brachial artery
•  Antegrade common femoral
•  Superficial femoral artery
•  Pedal or tibial artery
•  Percutaneous EVAR
•  Retrograde common femoral
Speaker Name
Thresholds for Access Site Complications
•  SIR: MAE threshold
–  hematoma (requires transfusion,
surgery or increased LOS) <0.5%
–  access site occlusion
<0.2%
–  pseudoaneurysm or AVF
<0.2%
•  ACC benchmark
–  After diagnostic
–  After intervention
Singh et al. J Vasc Interv Radiol 2003;14:S283-288.
Bashmore et al. J Am Coll Cardiol 2001;15:2170-2214.
<1.0%
<3.0%
Speaker Name
Contemporary Reports
Access Site Complications
Complication
Rate
Femoral hematoma
Pseudoaneurysm
Arteriovenous fistula
Access site occlusion
Retroperitoneal hematoma
3.6-5.5%
2.0-5.1%
0.6-2.2%
1.0-1.6%
0.1-0.7%
Hirano et al. J Cardiol 2004;43:259-265.
Doyle et al. JACC 2008;1:202-209.
Frank et al. J Interv Cardiol 2010;23:569-574.
Farouque et al. JACC 2005;43:363-368.
Stone et al. Vasc Endovasc Surg 2012;46:617-23.
Speaker Name
Rationale
Why Ultrasound Guided Access?
•  Enhance optimal puncture site placement
•  Reduce access site complications
–  Lower risk of hematoma, bleeding, AV fistula
–  Single puncture, first pass, single wall
–  Avoid-branches, calcification, lesions
•  Best use of closure devices
–  Avoid arterial access site disease
–  Best choice of closure
Speaker Name
atients with suboptimal access 7
optimal access group 10 (4%). The
Optimal
iring blood transfusions (11% vs.
puncture
eritoneal
hematomasite
(3% vs. 2%,
leeding
(3% vs. 2%, P ¼ 0.62),
placement
tion (11% vs. 2%, P ¼ 0.004)
results
a
n patients
with ain
suboptimal
locancture
(Fig. 2).
One of
patient with
lower
rate
d femoral artery thrombosis, but
complications
f pseudoaneurysm or arteriovenous
ients with suboptimal access had
tes of the combined endpoint of
cardial infarction, coronary artery
get vessel redilatation (8% vs. 2%,
dual event data include in-hospital
¼ 0.009) and in-hospital myocardial
P ¼ 0.12). None required in-hospiass grafting or target vessel redilataof stay was 2.4 days for patients
n versus 2Pitladays
(P2011;78:294.
¼ 0.16) for those
et al. CCI
Puncture Site
Fig. 2. Frequency distribution of vascular complications. DisSpeaker Name
tribution of vascular complications based on femoral
artery
access (optimal vs. suboptimal) location.
in 12 patients. Compared with the standard landmark-
Why Ultrasound Guided Access?
Longitudinal
Transverse
Speaker Name
Needle Tip
was
ring
were
st 5
d as
ears
ostical
by
here
was
ll.
for
ical
omomwas
nalage
for
phy
ase-
Ipsilateral iliac arterial disease
Normal
Narrow or occluded
Experience of the operator
More experienced
Less experienced
82 (82%)
18 (18%)
81 (75%)
27 (25%)
0.145
Why Ultrasound Guided Access?
Results for Retrograde Femoral Approach
TABLE II.
ance
49 (45.4%)
59 (54.6%)
0.215
Differences of Variables with Palpation or US Guid-
Variable
Technical success rate
Median number of attempts
The first pass success rate
Mean time to access (sec)
Additional sedoanalgesia
Complication rate
(local hematoma)
TABLE III.
39 (39%)
61 (61%)
Palpationguided
(n ¼100)
US-guided
(n ¼108)
P value
96 (96%)
1 (1–5)
78 (78%)
94.3 6 66.4
18 (18%)
4 (4%)
108 (100%)
1 (1–3)
101 (93.5%)
68.6 6 45.1
16 (15%)
0 (0%)
0.052
0.001
0.001
0.001
0.182
0.052
Ultrasound guidance
results in fewer
complications.
Distribution of the Number of Attempts
Number of attempts
1
2
3
4
5
Palpation guided
78 (78%) 10 (10%) 8 (8%) 2 (2%) 2 (2%)
(n ¼ 100)
US guided (n ¼ 108) 101 (93.5%) 4 (3.7%) 3 (2.8%) 0 (0%) 0 (0%)
Gedikoglu, et al. Catheter Cardiovasc Intervent 2013 Jan, epub.
Speaker Name
No
that routine real-time US guidance of femoral arterial access
Real-Time
Ultrasound Guidance
he
does not improve the rate of CFA cannulation, except in
Femoral Arterial Access andTable 3. Intraprocedural Outcomes
a Facilitates
patients
with high
CFA bifurcations.
Reduces
Vascular
Complications
Fluoroscopy
ter
Ultrasound
guidance
reduced
the
risk
of
vascular
access
Characteristic
(n ! 500)
(Femoral Arterial Access With Ultrasound Trial)
by FAUSTcomplications
by 59%, improved the first pass success rate to
Arnold H. Seto, MD, MPA,* Mazen S. Abu-Fadel, MD,† Jeffrey M. Sparling, MD,†
Number of attempts
3.0 # 3.2
, 7 Soni J.82.7%,
Zacharias, MD,†
Timothy nearly
S. Daly, MD,†eliminated
Alexander T. Harrison, MD,*
and
accidental
venipunctures,
232 (46.4%)
M. Suh, MD,* Jesus A. Vera, MD,* Christopher E. Aston, P D,‡ First pass success
ng William
Rex J.while
Winters, MD,§
Pranav M. Patel,the
MD,* Thomas
MB, BC for
, BAO,†
reducing
timeA. Hennebry,
required
access. The reducVenipuncture
79 (15.8%)
Morton
J.
Kern,
MD*
Ultrasound
guidance
tion in the rate of complicationsNumber
and ofaverage
number1.14of# 0.43
arterial punctures
Orange and Long Beach, California; and Oklahoma City, Oklahoma
e
H
H
results in fewer
Mean time to insertion, s
complications.
Objectives The aim of this study was to compare the procedural and clinical outcomes of femoral
Median time to insertion, s
Table 4. Vascular Access Complications
arterial access with ultrasound (US) guidance with standard fluoroscopic guidance.
Ultrasound
(n ! 502)
p Value
1.3 # 0.9
"0.000001
415 (82.7%)
"0.000001
12 (2.4%)
"0.000001
1.09 # 0.36
0.076
213 # 194
185 # 175
0.016
148 (102–242)
136 (90–212)
0.003
Background Real-time US guidance reduces time to access, number of attempts,Values
and complications
are mean # SD, n (%), or median (interquartile range).
in central venous access but has not been adequately assessed in femoral artery cannulation.
Fluoroscopy
Ultrasound
Methods Patients (nComplication
! 1,004) undergoing retrograde femoral arterial
were randomized(n
1:1 ! 503)
(n !access
501)
p Value
staff in or near the catheterization laboratory, and complete
blinding could not be 0.034
verified. Exclusion of these compliPseudoaneurysm
0 cations
1
NS
increased
the statistical
significance of the result
Results Compared with fluoroscopic guidance, US guidance produced no difference
in CFA cannulation rates (86.4% vs. 83.3%, p ! 0.17), except in the subgroup of patients with CFA bifurcations
Dissection
3 (p in"
0.01).2 There was NSno significant interaction between
occurring over the femoral head (82.6% vs. 69.8%, p " 0.01). US guidance resulted
an improved
first-passPlacement
success rate (83%Success
vs. 46%, p " 0.0001), reduced number of attempts (1.3 vs. 3.0, p " 0.0001),
oral Artery
Access bleeding,
transfusion
2 closure
1 use and bleeding
NS
device
complications (p ! 0.81).
reduced risk of venipuncture (2.4% vs. 15.8%, p " 0.0001), and reduced median time
to access (136
s vs.
148 s, p ! 0.003). Vascular complications occurred in 7 of 503 and 17 of 501 in the US and fluoroscopy
Hematoma
with DVT
1 Learning curve.
0
GreaterNSexperience with the US guidance
not demonstrate
a (1.4%
significantly
superior rate of
groups, respectively
vs. 3.4% p ! 0.04).
common
femoral
artery in the overall population 17real-time
was nonsignificantly
associated withSpeaker
a higher
rate
AnyIn complication
(3.4%)technique
0.041
Conclusions
this multicenter randomized controlled trial, routine
US guidance im- 7 (1.4%)
Name
proved
CFA
cannulation
only
in
patients
with
high
CFA
bifurcations
but
reduced
the
number
of
atal vascular disease (PVD) subgroups. Ultrasound
of arterial
successful
CFA cannulation (Fig. 3). No pre-specified
time
to access,
of venipunctures,
and vascular complications in femoral
access.
Values
are nrisk(%)
or n. sheath
reasedtempts,
common
femoral
artery
placements
(Femoral Arterial Access With Ultrasound Trial [FAUST]; NCT00667381) (J Am Coll Cardiol Intv 2010;
Seto, et al. JACC Intv. 2010;3:751.
subgroup of US experience resulted in a significant improveDVTby
!thedeep
venous
thrombosis.
8) © 2010
American
College
of Cardiology
Foundation
ho had3:751–
a femoral
bifurcation
over
the
femoral
ment in CFA cannulation compared with fluoroscopic
to either fluoroscopic or US guidance. The primary end point was successful common femoral artery
(CFA) cannulation by femoral angiography. Secondary end points included time to sheath insertion,
number ofHematoma
forward needle !5
advancements,
venipunctures, and vascular
cm first pass success, accidental
11 (2.2%)
3 (0.6%)
access complications at 30 days.
1117
CO NFERENCE REPORTS AND EXPERT PANEL
International evidence-based
recommendations
on ultrasound-guided
1112
vascular access
Table 4 Recommendations on ultrasound vascular access in adults and cost-effectiveness
Ultrasound vascular access in adults
Domain
code
Suggested definition
D4.SD2.S1
and
SVA)
erence
etwork
Group
at the
ss
ntains
ilable
Ultrasound guidance should be routinely used for short-term
central venous access in adults
D4.SD2.S2
Ultrasound guidance should be routinely used for long-term
central venousD.access
in adults
Feller-Kopman
M. Blaivas
D4.SD2.S3
PICCs
should
be
routinely
at mid arm level by ultrasound
Bronchoscopyinserted
and Interventional
Department of Emergency Medicine,
micro introducer
technique
Pneumology,
Johns Hopkins
Hospital,
Northside Hospital Forsyth, guidance using
Baltimore,
USAshould be taken into consideration for
Atlanta,
GA, USA
D4.SD2.S4
Use of ultrasound
guidance
any kind of peripheral intravenous line when difficult access is
Schummer
J. G. Augoustides
anticipated W.
Department of Anesthesiology
Anesthesiology and Critical Care,
D4.SD2.S5
Ultrasound-guided
improves first-pass
and arterial
Intensive catheterization
Care Medicine,
Perelman
School of Medicine,
be used routinely
SHR Zentralklinikum
Suhl, in adults
University of Pennsylvania, success and should
Jena, Germanydetect pneumothorax and should be
Philadelphia,
USA
D4.SD2.S6
Ultrasound can accurately
routinely performed after central venous catheter cannulation
R. Biffi
M. Elbarbary
when the pleura
could have been damaged
Division of Abdominopelvic Surgery,
National and Gulf Center for Evidence
D4.SD2.S7
CEUS
(contrast-enhanced
ultrasound)
is a valid method for
European Institute
of Oncology,
Based Health Practice, King Saud
detecting a central
catheter tip in the right atrium
Milan, venous
Italy
University for Health Sciences,
Riyadh,
Saudi Arabia
Cost-effectiveness
of the use of ultrasound for vascular cannulation
E. Desruennes
D5.S1–3
Ultrasound-guided
vascular access has to be used because it
Department of Anesthesia,
T. Pirotte
results
in
clinical
benefits and reduced overall costs of care
Institute Gustave Roussy,
Department of Anesthesia and Intensive
makes
it
cost-effective
Villejuif, France
Care Medicine, Cliniques Universitaires
Saint-Luc, Brussels, Belgium
Lamperti et al. Intensive Care Med 2012;38:1105
L. A. Melniker
Department of Emergency Medicine,
D. Karakitsos
venous
access
device
with
York Methodist
Hospital
and Clinical
IntensivePICCs
Care Unit,were considered aNew
Level of
evidence
Degree of
consensus
Strength of
recommendation
A
Very good
Strong
A
Very good
Strong
A
Very good
Strong
B
Very good
Strong
A
Very good
Strong
B
Very good
Strong
B
Very good
Strong
A
Very good
Strong
Speaker
Name
pulsation of the artery is not evident, or when the artery is
Percutaneous EVAR
•  1999-­‐2012: more than 2200 cases reported –  > 3,600 access sites •  High technical success, fewer complicaAons, shorter operaAve Ame, shorter length of stay •  Increased risk: BMI > 40, sheath >20Fr, CFA <5mm or calcified •  Decrease risk: use of ultrasound guidance Smith et al. Ann Vasc Surg 2009;23:621.
Bensley et al. J Vasc Surg 2012;55:1554.
Bechara et al. J Vasc Surg. 2013;57:72.
Jaffan et al. Cariovasc Intervent Radiol 2013 March, epub
Al-Khatib et al. Ann Vasc Surg 2012;26:476.
Speaker Name
Ultrasound Guidance for Percutaneous EVAR
A.A.A. Jaffan et al.: Preclose in PEVAR
Table 4 Outcomes pertaining to some variables in the PEVAR group
Variable
US-guided access
Variable present
Variable absent
n
n
% (n)
P valuea
% (n)
Success rate
447
96.4 (431)
3159
93.5 (2954)
0.0150
Groin complication rate
447
3.6 (16)
3159
3.6 (115)
1.000
Antibiotic prophylaxis
Groin infection
592
Anticoagulation reversal
Success
817
95 (776)
432
94.3 (414)
0.5758
Hemorrhagic complications
817
2 (16)
432
2.7 (12)
0.4217
Ischemic complications
817
432
0.7 (3)
0.4327
94.2 (1222)
93.2 (41)
654
94
88.7 (580)
87.2 (82)
0.0001
0.3870
87 (73)
164
94 (154)
0.0892
Sheath size \20F
Obesity (BMI [30 kg/m2)
Success
Success
1297
44
Severe vascular calcification
Success
84
0.003 (2)
3014
0.5 (4)
0.002 (5)
0.3232
PEVAR percutaneous endovascular aortic repair, US ultrasound, BMI body mass index
Ultrasound guidance results in fewer complications.
n represents the number of arterial accesses; the number in parentheses in the outcome columns is the number of subjects where the outcome was
positive
Jaffan et al. Cariovasc Intervent Radiol 2013 March, epub
Speaker Name
a
Fisher’s exact test
Table 5 Groin complications in PEVAR series
The excellent results and the low groin complication
rates should be considered in the context of patient selec-
Table IV. Multivariate analysis of the effect of
Access
technique
Table II.
Intraoperative
characteristics
patient
characteristics
on
conversion and
rate
outcomes
stratified byPFA
access technique
Variable
US-guided
p
and sheath
In oursize
cohort, mecha
Table
III. Univariate
compab
device
was handled
Access tec
related outcomes stratified
b
Glide at initial place
P valueand sheath size
PFA (n ¼ 9
Patient characteristics
OR (95% CI)
Access
technique
manual compression
Sheath size "20F
22 (24%)
24 (41%) <0.05
Variable
sites)
Access
Blood
lossyears
(mL)
144
105
(±95) p 0.311
failure. Instead,
we tec
ke
Age
!66
1.01 (0.13e8.02)
0.9939
Variable
PFA (±100)
US-guided
Blood transfusion
5 (11%)
0.161
Smoker
current versus 8 (10%)
1.51 (0.14e16.8)
0.7362Access-specific
devices until we
PFA had
(n ¼ 9
complications
Sheath size
"20F(mL) 78
22 (±34)
(24%) 71
24 (±34)
(41%) <0.05
Contrast
volume
0.235
Variable
sites)
never
stasis.
Manual
Ultrasound
guidance
<20F
3comp
(4%)
Blood
loss time
(mL)(min) 154
144 (±64)
(±100) 101
105 (±51)
(±95) <0.05
0.311
Operative
Smoker
past
v
never
11.9
(1.09e131)
0.0426
closures
only after
results
in fewer
Access-specific
>20F
3 (14%a
Blood transfusion
8 (7%)
(10%)
5 (0%)
(11%) <0.05
0.161
Access
complications
6
0
a
Male
0.52 (0.08e3.50)
0.5002Conversions
complications
Contrast
volume (mL)
78
(±34)
71
(±34)
0.235
All
conversions
6
(7%)
1
(2%)
0.113
complications.
was
achieved.
2
BMI
of !30
kg/m
7.50 (1.40e40.1)
0.0186 <20F The main limitatio
3 (4%)
Technical
success
87 (94%)
58 (98%)
0.164
Operative
time
(min) 154
(±64)
101
(±51) <0.05
>20F
3 (14%
Access complications
6 (7%)
0 (0%) <0.05
from
Arthurs et al. Ann Vasc Surg 2008;22:736
aits nonrandomi
Technical
success
Conversions
All conversions
6 (7%)
1 (2%)
0.113
relatively low 69sample
3 (97%
(4%)
<20F
Technical success
87 (94%) 58 (98%) 0.164
patients (7%) undergoing PFA. Four of the six pafactor in our study
w
>20F
18
3 (82%
(14%
Table
V. Multivariate analysis of the effect of
tients experienced hematomas, while two patients
Technical
success
percutaneous
techniq
a
treatment
characteristics
on
conversion
rate
Recorded
conversions
to
open
repai
developed pseudoaneurysms.
<20F
69 (97%
to
femoral
cutdown
sions related to the percutaneous cl
patients
(7%) undergoing
PFA. Four
of sheath
the six size
paThe impacts
of access technique
and
18 (82%
Treatment
characteristics
OR (95% CI)
P value >20F
the last one was seen
tients
experienced
hematomas,
two
patients
on outcomes
are listed
in Table while
III. The
US-guided
a
Recorded
conversions
to
open
repai
to
the
true
developed
pseudoaneurysms.
for ascertain
patients to
experien
US-guided
(0.02e1.95)
0.1690rare
cohort didPEVAR
not
experience a0.21
complication
in 59 sites
sions related to the percutaneous cl
The
impacts
of
access
technique
and
sheath
size
tions
from percutaneous
neous
access onclosc
Severe
2.81of(0.26e30.3)
0.3954
over acalcification
mean follow-up period
9 (±5) months. USon
outcomes
are
Table
III.reduction
The US-guided
majoritySpeaker
of data
publi
surgeons
had
accumu
guided
access
did listed
have in
an14.0
overall
in the
Mechanical
failure
(2.49e78.7)
0.0028 The
Name
rare for patients
to experien
cohort
did not
complication
in 59 sites
represent
frombef
sin
conversion
rateexperience
for sheathasizes
>20F, whereas
the
ence case
withseries
PEVAR
tions from
percutaneous
clos
over
aet mean
Sarmiento
al. Ann Vascfollow-up
2012;26:906 period of 9 (±5) months. USever,
several
authors
have
re
difference
forSurgsmaller
sheath sizes was negligible.
introduced
at
our
i
The
majority
of
data
publi
guided
access
did
have
an
overall
reduction
in
the
technical failures and for in
Utilizingaccess
US guidance,
the technical
success
for
guided
and incorporated
it in
the PEVAR
factor is that surgeo
Why Ultrasounds Guided Access?
Conclusion
•  Ultrasound guided access provides added
safety and reduces our most common
complications.
•  Readily available.
•  More accurate puncture placement.
•  Enhances use of closure devices.
•  Fewer complications and conversions.
Speaker Name