Early clinical experience with the 6 French Angio-Seal device: immediate closure of femoral puncture sites after diagnostic and interventional coronary procedures

Arterial thrombosis after using Angio-Seal

Percutaneous closure systems of arterial puncture sites are being used more and more in modern endovascular practice. In this article, we report five cases of thrombotic complications following Angio-Seal deployment which required to be treated in our department between June 2004 and January 2006. We carried out a computerized literature review using "vascular closure" as a keyword and elected 106 articles published between 1992 and 2007. The analysis of this literature review showed that the rate of percutaneous closure complications was similar to the rate of manual compression complications, which is still the reference method. The complications associated with the use of these systems were more complex and more often required surgical repair. The severity and frequency of these complications differ based on the type of closure systems. The vascular surgeon in charge must have a good knowledge of these systems and of the complications each of them entails to be able to treat them in the most appropriate way.

Endovascular management of inadvertent subclavian artery catheterization during subclavian vein cannulation

PURPOSE

To retrospectively review a 9-year experience with endovascular management of inadvertent subclavian artery catheterization during subclavian vein cannulation.

MATERIALS AND METHODS

From June 2000 through July 2009 (109 months), 13 patients underwent endovascular management of inadvertent subclavian artery catheterization. All catheters were still in situ, including one 7-F catheter, six 8-F catheters, and six large-bore 10-11-F catheters. Treatment was performed with an Angio-Seal device (n = 6) or balloon catheters (n = 7) and by additional stent-graft placement (n = 4).

RESULTS

Mean follow-up was 27.3 months (range, 0.4-78 months). The 30-day mortality rate was 7.7% and the late mortality rate was 46.1%. Primary technical success was achieved in nine patients (69.2%), in four with the use of a compliant balloon catheter and in the other five with an Angio-Seal device. Complications required additional stent-graft placement in four patients (30.8%), one because of stenosis after Angio-Seal device deployment and three as a result of insufficient closure of the puncture site by balloon tamponade. Stent-graft repair was successful in all four patients, for a primary assisted technical success rate of 100%.

CONCLUSIONS

Endovascular techniques offer a less invasive alternative to surgery. The present limited experience shows that the use of the Angio-Seal device is not without risks, whereas balloon tamponade is not always reliable in closing the puncture site. Stent-graft placement may be required in patients in whom balloon tamponade fails or in whom the use of the Angio-Seal device is contraindicated.

Experience with the Cardiva Boomerang Catalyst system in pediatric cardiac catheterization

OBJECTIVES

We studied the safety and efficacy of the Cardiva Boomerang Catalyst vascular closure system in pediatric patients after cardiac catheterization with access in femoral and internal jugular vessels.

BACKGROUND

Recurrent catheterization and advances in pediatric interventions increase the need for easy hemostasis without a residual foreign body that may prevent re-accessing the vessel. The Boomerang can be deployed in sheaths as small as 4Fr without residual foreign body, with minimal orientation needed, and few complications reported.

METHODS

In a two-month period, all patients between 18 months and 21 years old catheterized with 4-8Fr sheaths less than 15 cm long were eligible for Boomerang placement. These were compared retrospectively with control patients with manual hemostasis. Anthropomorphic measurements, procedure type, activated clotting time, and sheath size as well as total times of cases, intubation, hemostasis, and extubation were compared between the two groups.

RESULTS

Forty-six Boomerangs were deployed in 31 patients and compared with 40 patients with manual hemostasis. Boomerangs were deployed in femoral vessels and the internal jugular vein. Device success with hemostasis was achieved in 39 patients (85%). There were no significant differences in time to hemostasis or extubation between the two groups. No major complications or operator error occurred, including hematoma, transfusion, retroperitoneal bleed, infection, vessel occlusion, or need for surgery.

CONCLUSIONS

The Boomerang is a safe and easy means of achieving hemostasis in the pediatric population, in femoral vessels as well as internal jugular veins. Its times to hemostasis and extubation were not significantly different from manual hold.

A modified "preclosure" technique after percutaneous aortic valve replacement

OBJECTIVES

To evaluate the feasibility, safety and efficacy of suture-mediated closure devices using a modified "preclosure" technique for access site management after percutaneous aortic valve replacement (PAVR).

BACKGROUND

PAVR using a retrograde transfemoral approach has recently evolved to an endovascular alternative to open surgery in high-risk patients. However, large-bore femoral artery access is required, commonly demanding surgical closure and general anesthesia. A truly percutaneous intervention would be desirable to reduce procedural complexity and diminish the need of vascular surgery and general anaesthesia.

METHODS

After direct puncture of the common femoral artery, three conventional suture-mediated closure devices (6F Perclose) were deployed. The preloaded sutures were tied at the end of the procedure. If no immediate hemostasis was achieved, an additional device was deployed thereafter.

RESULTS

PAVR with percutaneous access site closure was attempted in 15 consecutive patients and could successfully be achieved in all patients allowing conscious sedation in all but three cases. Following complications occurred: one retroperitoneal bleeding caused by removal of the valve delivery sheath requiring surgical repair, as well as two cases of femoral and iliac artery dissection caused by delivery sheath introduction and treated by stenting and vascular surgery, respectively. Vascular surgery became only necessary due to total vessel occlusion after suture closure and remains the only closure-related complication. However, treatment led to recovery in all patients.

CONCLUSIONS

The modified "preclosure" technique is a feasible and safe method for hemostasis after PAVR improving procedural management and diminishing the need for general anesthesia.

Safety and effectiveness of repeat arterial closure using the AngioSeal device in patients with hepatic malignancy

PURPOSE

To retrospectively evaluate the safety and effectiveness of the use of the AngioSeal device for repeat arterial closure in patients with hepatic malignancy.

MATERIALS AND METHODS

A retrospective analysis of patients with hepatic malignancy who had undergone repeated arterial closure with the AngioSeal device was performed. All charts for patients undergoing transarterial chemoembolization or TheraSphere radioembolization were reviewed for the method of hemostasis and the number of arterial closures. A total of 53 patients (58.5% men, 41.5% women; mean age, 58.7 years) had repeat AngioSeal arterial puncture closure after chemoembolization or TheraSphere treatment. Percutaneous closure of the common femoral artery with the AngioSeal device was performed in accordance with the manufacturer's recommendations. The patients were examined for complications on follow-up. Effectiveness was defined by the ability to obtain satisfactory hemostasis. Safety was assessed by the absence of groin complications and by vessel patency on follow-up angiograms of the puncture site obtained at subsequent liver-directed therapy sessions.

RESULTS

Fifty-three patients in this study group had a total of 203 common femoral artery punctures. There were a total of 161 closures with the AngioSeal device (79.3%): 58 (36%) single closures and 103 (64.0%) repeat closures. Of the 161 attempts at AngioSeal closure, there was one closure failure in the single-puncture group, yielding a success rate of 98.3%; and one closure failure in the repeat-puncture group, yielding a success rate of 99%. In these two patients, hemostasis was achieved with traditional manual compression without the need for any other device, and no complications were noted. The overall success rate of AngioSeal device closure was 98.7%.

CONCLUSIONS

The repeat use of the AngioSeal closure device is safe and effective in patients with hepatic malignancy undergoing regional oncologic interventional procedures.

A randomised controlled trial comparing StarClose and AngioSeal vascular closure devices in a district general hospital--the SCOAST study

AIMS

AngioSeal and StarClose are vascular closure devices (VCDs) that can be used following cardiac catheterisation via the femoral artery to achieve haemostasis. Both devices have been demonstrated to be superior to conventional manual pressure, which reduce time to haemostasis and time to patient ambulation. We sought to compare these devices in a prospective, randomised trial.

METHODS

Patients undergoing elective coronary angiography were randomised to receive either AngioSeal VIP or StarClose VCD with immediate postprocedure mobilisation. Bruising was recorded at 30 min, 60 min and at 1 week postprocedure. Patient satisfaction surveys were taken at 1 h and 1 week postprocedure. Complications for both groups were compared.

RESULTS

Four hundred and one patients were included. Arteriotomy closure was achieved in 144 of 208 (69.2%) patients randomised to AngioSeal and 134 of 193 (69.3%) patients randomised to StarClose (p = ns). There was no significant bruising in either group at either 30 or 60 min postprocedure. However, at 1 week, there was significantly more bruising in the AngioSeal group than the StarClose group (63.1 vs. 38.5cm2, p = 0.02). Patient satisfaction and pain perception with the procedure at closure were not significantly different between the groups. Deployment success and instant mobilisation rates were significantly lower for junior, as compared with senior, operators.

CONCLUSION

Achievement of haemostasis is similar with both AngioSeal and StarClose. The StarClose vascular closure device results in significantly less bruising at 1 week postprocedure as compared with AngioSeal, with no significant differences in complication rates. Patients' pain perception and satisfaction are similar with both VCDs.

Clinical experience of StarClose vascular closure device in patients with first and recurrent femoral punctures

OBJECTIVE

We present our clinical experience of StarClose in patients undergoing coronary interventions, including its use in patients after repeated puncture of the same femoral access site.

BACKGROUND

The StarClose is a novel vascular closure device that deploys a small, flexible, circumferential nitinol clip onto the femoral artery surface.

METHODS

In this study, 103 consecutive patients (24% with repeated punctures) who underwent percutaneous coronary intervention and received a StarClose were followed up prospectively. The patients were assessed for vascular complications prior to hospital discharge. Device success, based on time-to-hemostasis, was divided into (1) immediate success: hemostasis achieved immediately after StarClose deployment without the need for adjunctive manual compression, (2) partial success: occurrence of minor oozing after StarClose deployment and hemostasis achieved after <3 minutes of manual compression, and (3) device failure: need for adjunctive manual compression for >3 minutes.

RESULTS

Immediate success, partial success, and device failure rates were 74% (n = 68), 16% (n = 15), and 10% (n = 9), respectively. There were no major complications attributable to the StarClose device. There were 10 (9.7%) cases of minor complications; all were recurrent wound bleeding requiring manual compression in the wards. Among these 10 cases of recurrent bleeding, 5 (50%) had initial device success (immediate success, n = 2, partial success, n = 3) in the catheterization laboratory. The risk for recurrent bleeding was 2.9% after immediate device success and 20.0% after partial device success.

CONCLUSION

Our study found no major complications but a 10% failure rate and a 9.7% rate of minor complications. Close surveillance is important as there is a risk for recurrent bleeding, especially in patients with partial device success as defined in this report.

Histologic and duplex comparison of the perclose and angio-seal percutaneous closure devices

The intravascular and extravascular effects of percutaneous closure devices have not been well studied. We assessed the performance and healing characteristics in dogs of two devices approved by the US Food and Drug Administration. Nine adult male dogs were anesthesized prior to percutaneous access of both femoral arteries with a 6F sheath. All dogs were systemically heparinized to an activated clotting time (ACT) > 250 seconds. Duplex sonography was performed preoperatively to measure vessel diameter and flow velocity. In each dog, one of two devices (Perclose, Abbot Laboratories, Abbott Park, IL or Angio-Seal, St. Jude Medical, St. Paul, MN) was randomly deployed into one of the two femoral arteries. The other device was deployed on the opposite side. Duplex sonography was repeated immediately after deployment and 28 days later to measure changes in vessel diameter and flow velocity. At 28 days, angiography was performed on both femoral arteries before they were removed for histologic evaluation. The time required to excise each vessel reflected the degree of scarring. Hemostasis time for the Angio-Seal device far surpassed the Perclose device (39 +/- 7 vs 0 minutes; p < .05). Vessel narrowing was observed only at 28 days after deployment of the Angio-Seal device (p < .05). Extensive extravascular scarring was observed with the Angio-Seal device, which resulted in a longer femoral artery dissection time and greater periadventitial scar thickness compared with the Perclose device (p < .05). When compared with the Perclose suture closure device, the Angio-Seal collagen plug closure device prolonged hemostasis time and produced greater vessel narrowing and periadventitial inflammation (extravascular scarring) in a canine model at 4 weeks.

Randomized comparison of effects of suture-based and collagen-based vascular closure devices on post-procedural leg perfusion

BACKGROUND

Vascular closure devices (VCD) are well established to facilitate hemostasis after cardiac catheterization procedures. However, impairment of flow due to the reduction of femoral artery diameter remains a major concern. The present study aims to evaluate leg perfusion before and after application of collagen- and suture-based vascular closure devices.

METHODS

A total of 366 patients (age: 64.3 years+/-10.7, male: 71.3%) were randomized to receive femoral access site closure with either a collagen-based closure device (group A) (n=214) or a suture-mediated device (group B) (n=152), immediately following coronary catheterization procedures. In all patients, the ankle-brachial-index (ABI) was measured before and the day after closure device application.

RESULTS

In group A, mean ABI at baseline was 1.09+/-0.2, in group B 1.11+/-0.2. In both groups, there was a significant, albeit clinically not relevant, reduction in post-procedural ABI (group A: 1.04+/-0.2, p<0.01 vs baseline, group B: 1.06+/-0.2, p<0.01 vs baseline). DeltaABI was not different between both VCD groups (p=0.55). In patients with peripheral vascular disease (PVD), neither the Angioseal device (mean ABI at baseline 0.76+/-0.1) nor the Perclose-device (mean ABI at baseline 0.79+/-0.1) induced a remarkable impairment of leg perfusion (Angioseal: 0.77+/-0.1, p=0.9 vs baseline, Perclose: 0.78+/-0.1, p=1.0 vs baseline). Clinically, no aggravation of claudication was observed in the PVD patient group.

CONCLUSION

Both vascular closure devices are not associated with clinically relevant reduction in ABI. There was no difference between the two groups with respect to the level of flow impairment. Both devices may be safely used in patients with reduced ABI.

Blood Pressure and Risks of Vascular Complications After Percutaneous Coronary Intervention

Evidence-based protocols are needed for care of the nearly 1,000,000 patients in the United States who undergo percutaneous coronary interventional procedures. This article describes a case-matched control study of 300 patients undergoing percutaneous coronary intervention in which specific demographic, physician-sensitive, and nurse-sensitive factors were tested to determine their relative contribution to the incidence of vascular complications. Findings included that patients with a mean systolic blood pressure of 160 mm Hg or higher were 8 times more likely to have vascular complications (P < .001). Patients receiving heparin (with and without glycoprotein IIb/IIIa inhibitors) versus bivalirudin were 3 times more likely to have vascular complications (P = .008). Patients with hemostasis by AngioSeal and those with a history of hypertension were 77% (P =.031) and 61% (P = .005), respectively, less likely to have complications.

Subclavian artery puncture repair with Angio-Seal deployment

BACKGROUND

Inadvertent placement of a port-a-catheter in an artery during central venous cannulation is rare and can result in devastating complications. Although traditional closure devices have been employed as prompt and adequate treatment, more innovative devices such as collagen plugs are being studied for their efficacy.

CASE

We report a case involving a 63-year-old woman who was treated with chemotherapy for recurrent metastatic uterine leiomyosarcoma. During port-a-catheter placement, puncture of the subclavian artery occurred. Vascular surgery and interventional radiology consultation was obtained, wherein an Angio-Seal device was used to seal the exit from the subclavian artery. Angio-Seal placement was successful and the patient has since become clinically stable and was then discharged.

CONCLUSION

Subclavian artery puncture is rare but can occur due to the close proximity between the subclavian artery and vein. Prompt vascular surgery and radiology consultation is necessary. Although traditional manual compression and closure devices have been effective at restoring hemostasis, collagen seals or plugs may be more viable to treat this precarious situation.

Can vascular closure devices reduce complications?

Vascular closure devices have demonstrated their ability to reduce hemostasis and ambulation times, as well as improve patient comfort, without increasing vascular complications in their initial industry-sponsored, randomized clinical trials. However, in the early years of first-generation closure devices, there was an initial concern about the risk of higher complication rates. As devices have improved, it appears that there may now be a trend towards reduced vascular complications compared with manual compression, especially in patients undergoing percutaneous coronary interventions.

Safety and efficacy of staple-mediated femoral arteriotomy closure: Results from a randomized multicenter study

BACKGROUND

Mechanical closure of percutaneous femoral arteriotomies following catheter based procedures remains problematic.

METHODS

The EVS closure device is the first to utilize a staple to effect arteriotomy closure and was compared to manual compression following sheath removal in a 362 patient randomized (2:1 to device) multicenter trial. As pre-specified, one half of the patients underwent coronary intervention.

RESULTS

Time to hemostasis was significantly reduced in the EVS group for both diagnostic (3.3 +/- 2.6 vs. 19.3 +/- 5.7 minutes; p < 0.001) and interventional procedures (5.5 +/- 5.1 vs. 22.3 +/- 9.9 minutes; p < 0.0001). Time to ambulation was similarly reduced in the EVS group following diagnostic (2.4 +/- 3.3 vs. 6.0 +/- 5.2 hours; p < 0.001) and interventional procedures (3.4 +/- 4.5 vs. 7.6 +/- 7.0 hours; p < 0.001). The incidence of major complications was similar between the EVS and manual compression groups at discharge (0.4% vs. 1.7%; p = NS) and at 30 day follow-up (0.4% vs. 2.5%; p = NS).

CONCLUSION

Compared to manual compression, the EVS device provides a safe and effective method of femoral artery closure.

Status of Femoral Closure Devices

Both sealing and suturing closure devices have been shown to shorten hemostasis time, reduce the discomfort of manual or mechanical compression, and allow for earlier ambulation after cardiac catheterization and percutaneous coronary interventions without increasing vascular complications compared with conventional compression techniques. Several studies now report a reduction in vascular complications for percutaneous coronary intervention patients treated with closure devices compared with manual compression with pronounced benefit seen in patients receiving glycoprotein IIb/IIIa receptor inhibitors. Adoption of a simple predeployment femoral angiogram is now standard practice for use of a closure device. In an attempt to develop devices that are safer and more "user friendly," considerable modifications and improvements have been made in newer generation devices. Ultimately, the acceptance of femoral closure devices will depend on which device provides a simple approach with reliable hemostasis and a cost that can justify their incorporation into routine practice.

Complications of arterial closure devices

As of July 2000, there were 4 closure devices with Food and Drug Administration (FDA) approval. The devices are successfully deployed in 89% to 98% of cases, and the complication rates are comparable to those seen with manual compression. Minor access site complications are defined as bleeding not requiring transfusion or surgical repair, hematoma (<5 cm), and pain at the puncture site. Major complications include hematoma (>5 cm), bleeding at the site requiring transfusion, pseudoaneurysm, arteriovenous fistula, retroperitoneal hemorrhage, plug embolization, groin infection, and death.

Restick following initial Angioseal use

The Angioseal hemostatic device is currently in widespread use for arterial closure after both diagnostic and interventional procedures. Resticking of the artery in which an Angioseal device has been placed has been discouraged for up to 90 days after the initial device placement because of theoretical concerns of disruption or dislodgment of the hemostatic plug. However, no data are available to address this concern. We evaluated the incidence of vascular complications following restick of the artery in which an Angioseal device had been deployed </= 90 days previously in 181 patients. Restick occurred 1-7 days after device placement in 80 patients, 8-30 days in 34 patients, and 31-90 days in 66 patients. There were no major bleeding, vascular repair, vessel occlusion, or embolizations. Three large hematomas (1.7%) were noted. These data suggest that restick can be performed safely after initial Angioseal deployment.