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Core 1 > Day 2: AngioSeal > Flashcards

Day 2: AngioSeal Flashcards

1
Q

What are the 4 main components of the AngioSeal VCD?

A

1) AngioSeal VCD
2) Arteriotomy/puncture locator
3) Sheath
4) 70cm J-wire

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2
Q

AngioSeal is indicated for use in:

A

Closing and reducing time to HEMOSTASIS at the FEMORAL ARTERIAL PUNCTURE SITE for diagnostic or interventional procedures using 6/8Fr procedural sheaths.

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3
Q

What are the primary differences between the 6 & 8Fr AngioSeal devices?

A

6Fr: Green, smaller sheath, 035 wire, less collagen
8Fr: blue, larger sheath, 038 wire, more collagen

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4
Q

What complication can occur if the puncture site is ABOVE the inguinal ligament and inferior epigastric artery and why?

A

RP BLEED if poor access was gained because there could be back wall injury or perforation. The artery dips behind the pelvic bone and therefore there is no bone to apply pressure against the artery for closure. Therefore the staff calls these “push and pray” closures since manual is also not an option.

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5
Q

What is SUTURE LOCK UP and how do you appropriately mitigate it?

A

This is when the suture spool gets stuck or tangled within the VCD like a fishing reel. It is not common but can happen via defect. To resolve or mitigate the issue, you will need to cut the suture in the small gap BETWEEN the VCD and Sheath cap. DO NOT cut below the sheath cap, as you could accidentally cut the tamper tube. Once suture is cut, proceed with removal of sheath and device and pushing compression tube etc.

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6
Q

What should you do to mitigate collagen exposure after AngioSeal deployment?

A

1) Maintain slight tension on suture.
2) Wet exposed collagen w/sterile gauze & saline.
2) Attempt to advance collagen under skin with compression tube or hemostat clamp.
3) Attempt to tent skin around site in N/W/E/S fashion.
4) Generate lidocaine wheel at puncture site.

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7
Q

What does NAVEL stand for?

A

N: femoral Nerve
A: femoral Artery
V: femoral Vein
E: Empty space
L: inguinal Ligament

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8
Q

Where is the External Iliac located?

A

Above the IEA and IL, and crossing over the pelvic girdle.

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9
Q

Where is the Inferior Epigastric Artery located?

A

Below the External Iliac, above the IL and in the empty space of the pelvic girdle.

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10
Q

Where is the CFA located?

A

Below the External Iliac and IEA, below the IL but above the bifurcation in SFA/DFA. It should be at the top 1/3 of the femoral head.

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11
Q

Where is the SFA and DFA located?

A

Both are below the CFA. The SFA is the continuation of the CFA down towards the foot and closest to the inside of the leg. The DFA or Deep Femoral Artery/Profunda juts out at the bifurcation with the SFA and is more visible on the outside of the leg.

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12
Q

What percentage of patients have a bifurcation that is proximal to the inguinal crease?

A

72 - 75% which leaves a hefty gap of patients that cannot rely on that landmark.

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13
Q

The maximal impulse is what percentage over the femoral head?

A

92.7% over the femoral head

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14
Q

How can you accurately gain access without using Ultrasound?

A

1) Physically find the hip bone and pelvic bone.
2) Visually find the halfway point between them and place a hemostat.
3) Under fluoro, locate the femoral head. Then line the CFA and hemostat.

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15
Q

What are the 3 main considerations for AngioSeal usage?

A

1) Puncture Location
2) Vessel Size
3) Deterrents

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16
Q

What is the indicated puncture location for AngioSeal?

A

CFA, proximal to the bifurcation of the SFA/Profunda and distal to the inguinal ligament and IEA

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17
Q

What is the indicated vessel size for AngioSeal usage?

A

4mm or greater, unless disease is present (then 5-5-40 rule)

18
Q

What is the 5-5-40 Rule?

A

If disease is present at the puncture site, AngioSeal is safe to deploy if:
No disease within 5mm of access site
Vessel is 5mm or greater
Luminal narrowing is <40%

19
Q

What are some of the deterrents for AngioSeal usage?

A

Significant, diffuse disease
Focal stenosis near the puncture site (within 2 mm)
Pre-existing VAC
Access through graft
Tortuous tissue tract or compromised sheath

20
Q

What are the storage requirements for AngioSeal?

A

Keep AS away from ALL light sources (including Pyxis, sunlight, overhead lights etc,)
Maintain temperature between 59-77F and never over 100F.

21
Q

What type of box is AngioSeal shipped in?

A

An insulated box with cold packs.

22
Q

What requirements or restrictions are placed on AngioSeal shipments?

A

They are always shipped OVERNIGHT and only shipped MON-THURS.

23
Q

What UOMs are associated with AngioSeal?

A

Each box contains 2 cartons of 5 devices each for a total of 10 devices.

24
Q

What are the 5 main features and benefits of AngioSeal?

A

1) Lower complication rates
2) Higher deployment success rates
3) Shorter time to hemostasis
4) Faster time to ambulation
5) Provide cost savings via SDD and shorter LOS

25
Q

What are the 3 main steps of AngioSeal deployment?

A

1) LOCATE the artery
2) SET the arteriotomy locator
3) SEAL the puncture

26
Q

How far apart are the letters on the AngioSeal sheath?

A

1cm apart between each letter.

27
Q

What should you align when connecting the VCD and sheath during AngioSeal deployment?

A

The Reference Indicator arrows on the Hemo Cap and the Arteriotomy Cap should point towards each other.

28
Q

What AngioSeal component starts absorption first, and what additional components follow in absorption?

A

The ANCHOR begins absorption first (almost immediately) and then the suture and lastly the collagen follow.

29
Q

At ____ days the anchor is almost completely absorbed at ______%

A

42 days, 95%

30
Q

Should we AngioSeal?
The puncture site is located in the CFA and the vessel is 8mm. There is disease located in the Latium of the IEA and proximal to the SFA.

A

Yes - disease is not clinically significant or relevant to the access site and closure area. The vessel is well above the 4mm threshold and in the correct vessel.

31
Q

Should we AngioSeal?
The puncture site is is distal to the SFA/Profunda bifurcation and the vessel is 8mm.

A

No - the access is in the SFA not the CFA and very close to the bifurcation, therefore the potential of dual wall puncture or getting the anchor struck at the bifurcation is high.

32
Q

Should we AngioSeal?
The puncture site is located in the CFA above the bifurcation and below the ligament. The vessel looks to be about 4-5mm.

A

Yes - this is an optimal AngioSeal target.

33
Q

Should we AngioSeal?
The puncture site is at or below the bifurcation and the sheath is within the SFA. The patient is female, with a ram vessel.

A

No - females are at higher risk of bleeding complications and the puncture site is not in the CFA. Also, since it is at the bifurcation, it could lead to a dual wall puncture or the anchor getting caught at the bifurcation.

34
Q

Should we AngioSeal?
The patient is in advanced age, female and currently heavily anticoagulated. The puncture site is located above the ligament and the sheath is inserted above the IEA. The CFA is between 5-6mm.

A

No - not only is this patient at a higher risk for bleeding complications due to age and gender, but the heavy anticoagulation compounds the issue. The high stick means that manual pressure will be challenging if even feasible, and there is a high risk of RP Bleed or poor closure if not using a active VCD off label.

35
Q

Should we AngioSeal?
The puncture site is located in the CFA and the vessel is between 5-6mm. There is a flow limiting dissection located within 5mm of the puncture site.

A

No - deploying AngioSeal within a dissection plane can cause the anchor to prop open the dissection flap, severely disrupting flow and causing ischemia.

36
Q

Should we AngioSeal?
The puncture site is in the CFA and it measures between 2-3mm. There is diffuse disease present through out the vessel.

A

No - the vessel is too small and there is diffuse disease within 2-5mm of the puncture site.

37
Q

What complications are related to LOW STICKS?

A

AV Fistulas and Psuedoaneurysms.

38
Q

What may result if AngioSeal is placed near or at the bifurcation?

A

The anchor may catch on the bifurcation or be positioned incorrectly, which could cause collagen deposition into the vessel and subsequent cold leg/foot.

39
Q

Resistance is encountered when advancing AngioSeal through the sheath. What should you do?

A

1) Do not continue advancing device
2) Reposition sheath by reducing angle or pulling back 1-2mm
3) If resistance is still felt, remove device and apply manual pressure

40
Q

What should you do if you are unable to visualize the black marker after the completion of tamping?

A

1) Ensure VCD has been pulled back completely and the clear stop is visible.
2) Allow time for the tissue tract to moisten the collagen and then attempt to tamp with compaction tube
3) Check angulation and maintain tension.

41
Q

No blood emerges from the drip hole when locating the artery. What should you do?

A

1) Maintain wire access and remove the arteriotomy locator and sheath assembly
2) Ensure that the components are snapped together properly and the reference indicators are aligned (arrow to arrow)
3) Reinsert OTW and continue deployment

42
Q

What should you do if the insertion sheath moves forwards or backwards as AngioSeal is inserted into the sheath?

A

1) If sheath is pulled < 1.5cm, readvancement is necessary. Sheath should still be within the vessel. Guidewire and arteriotomy locator must be re-inserted and repeat vessel location steps.

2) If sheath is pulled > 1.5cm, remove device and apply manual compression as sheath will no longer be within the vessel.

Use sheath letters for measurements. If pushed forward too far, simply pull back into correct position.

Core 1 (7 decks)

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