A single center randomized trial assessing use of a vascular hemostasis device vs. conventional manual compression following PTCA: what are the potential resource savings?

Procedure-Related Complication Rates With the Use of Vascular Closure Devices; Does Size Only Matter? A Large Single Centre Retrospective Study

INTRODUCTION

Our retrospective study aimed at assessing safety of vascular closure devices (VCDs) used in a large single-centre Interventional Radiology (IR) department. Complication and deployment failure rates using collagen-based (Angio-seal) and suture-based (ProGlide) devices for common femoral artery haemostasis were compared.

MATERIALS AND METHODS

Data from VCDs deployed over a 6-year period were retrospectively analysed for patient age, procedure indication, puncture mode (antegrade/retrograde), sheath size, deployment failure and complications (haematoma, pseudoaneurysm formation, limb occlusion). Numerical and statistical analysis was undertaken.

RESULTS

Overall, 1321 common femoral artery punctures in 1217 patients were closed using VCDs. Failure rate using ProGlide was significantly higher when compared with Angio-seal (P=<0.001) in sheath sizes ≤8 Fr. Heparin was not administered in embolisation procedures compared with angioplasty with or without stenting. Therefore, haematoma tended to occur more frequently following angioplasty without stenting (P = 0.003) and angioplasty with stenting (P = 0.001), when compared with embolisation. Deployment failure occurred more frequently when heparin was used during the procedure (P = 0.005).

CONCLUSION

Although complications relating to sheath size are well established in the literature, there remains a paucity of data assessing the impact of procedure specific factors when comparing VCDs. Our study challenges that size is the sole determinant of VCD success and invites a more holistic view of VCD deployment strategies. This study advocates continued research into the nuances of other potential confounding variables to optimise patient outcomes.

Vascular Closure Devices versus Manual Compression in Cardiac Interventional Procedures: Systematic Review and Meta-Analysis

Backgrounds

Manual compression (MC) and vascular closure device (VCD) are two methods of vascular access site hemostasis after cardiac interventional procedures. However, there is still controversial over the use of them and a lack of comprehensive and systematic meta-analysis on this issue.

Methods

Original articles comparing VCD and MC in cardiac interventional procedures were searched in PubMed, EMbase, Cochrane Library, and Web of Science through April 2022. Efficacy, safety, patient satisfaction, and other parameters were assessed between two groups. Heterogeneity among studies was evaluated by I² index and the Cochran Q test, respectively. Publication bias was assessed using the funnel plot and Egger's test.

Results

A total of 32 studies were included after screening with inclusion and exclusion criteria (33481 patients). This meta-analysis found that VCD resulted in shorter time to hemostasis, ambulation, and discharge (p < 0.00001). In terms of vascular complication risks, VCD group might be associated with a lower risk of major complications (p = 0.0001), but the analysis limited to randomized controlled trials did not support this result (p = 0.68). There was no significant difference in total complication rates (p = 0.08) and bleeding-related complication rates (p = 0.05) between the two groups. Patient satisfaction was higher in VCD group (p = 0.002). Meta-regression analysis revealed no specific covariate as an influencing factor for above results (p > 0.05).

Conclusions

Compared with MC, the use of VCDs significantly shortens the time of hemostasis and allows earlier ambulation and discharge, meanwhile without increase in vascular complications. In addition, use of VCDs achieves higher patient satisfaction and leads cost savings for patients and institutions.

Safety and efficacy study of the wound care 360° SiteSeal® vascular closure device in percutaneous cardiac catheterization procedures

OBJECTIVES

Vascular access site complications after percutaneous transfemoral cardiovascular procedures remain a common cause of morbidity and mortality. We evaluated the SiteSeal® VCD for achieving hemostasis following diagnostic cardiac catheterization.

METHODS

We conducted a prospective case control single center study to assess the safety and efficacy of SiteSeal® VCD compared to standard manual compression following diagnostic cardiac catheterization. Forty patients were enrolled in study to receive either SiteSeal® device or manual compression (20 in each group).

RESULTS

Patients in the SiteSeal® group achieved hemostasis in a significantly shorter time (4 ± 2.4 vs. 19 ± 2.4 min, P < 0.001), had shorter time from hemostasis to ambulation (95 ± 44 vs. 388 ± 63 min, P < 0.001) and significantly earlier device deployment to discharge time compared to the manual compression group (4.7 ± 1.1 vs. 8.9 ± 4.8 h, P = 0.001). There was one non-major bleeding event in the SiteSeal® group which occurred >24 h after discharge from the hospital and was managed conservatively. In the remaining device patients, there was no clinical or Doppler ultrasound evidence of major or minor vascular complication with good overall patient comfort at discharge, 7 days and 30 days follow-up.

CONCLUSIONS

In this first clinical experience, the SiteSeal® VCD achieved safe and efficient hemostasis, allowed for earlier ambulation and faster discharge compared to manual compression.

Comparison of manual compression and vascular hemostasis devices after coronary angiography or percutaneous coronary intervention through femoral artery access: A meta-analysis of randomized controlled trials

OBJECTIVES

To compare the efficacy and safety of manual compression (MC) with vascular hemostasis devices (VHD) in patients undergoing coronary angiography (CA) or percutaneous coronary intervention (PCI) through femoral artery access.

INTRODUCTION

The use of femoral artery access for coronary procedures may result in access-related complications, prolonged immobility and discomfort for the patients. MC results in longer time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to VHDs but its role in access-related complications remains unclear in patients undergoing coronary procedures.

METHODS

We searched MEDLINE, EMBASE, Cochrane CENTRAL and relevant references for English language randomized controlled trials (RCT) from inception through September 30, 2016. We performed the meta-analysis using random effects model. The outcomes were time-to-hemostasis, time-to-ambulation, major bleeding, large hematoma >5cm, pseudoaneurysm and other adverse events.

RESULTS

The electronic database search resulted in a total of 44 RCTs with a total of 18,802 patients for analysis. MC, compared to VHD resulted in longer TTH [mean difference (MD): 11.21min; 95% confidence interval (CI) 8.13-14.29; P<0.00001] and TTA [standardized mean difference: 1.2 (0.79-1.62); P<0.00001] along with excess risk of hematoma >5cm formation [risk ratio (RR): 1.38 (1.15-1.67); P=0.0008]. MC resulted in similar risk of major bleeding [1.01 (0.64-1.60); P=0.95] pseudoaneurysm [0.99 (0.75-1.29); P=0.92], infections [0.52 (0.25-1.10); P=0.09], need of surgery [0.60 (0.29-1.22); P=0.16), AV fistula [0.93 (0.68-1.27); P=0.63] and ipsilateral leg ischemia [0.95 (0.57-1.60); P=0.86] compared to VHD.

CONCLUSION

Manual compression increase time-to-hemostasis, time-to-ambulation and risk of hematoma formation compared vascular hemostasis devices.

Techniques for Managing Complications of Arterial Closure Devices

According to data reported by the American Heart Association, more than 5 million diagnostic and therapeutic catheterizations are performed each year in the United States. The number of catheterizations has tripled since 1979. It has been estimated that complications related to the access site result in more than 75,000 surgical procedures annually. Thus, improved management of the access site itself is essential to achieve the greater goals of improved care and reduced cost. Manual compression directly over the site of arterial puncture usually results in adequate hemostasis but has several significant drawbacks. Manual compression is uncomfortable for the patient, is fatiguing and time-consuming for staff, and necessitates several hours of costly in-hospital observation. In addition, it may be ineffective in achieving hemostasis, especially in the setting of systemic anticoagulation or following the use of large-bore devices. Based on the perceived need for an improved method of managing the arterial access site following catheterization, various vascular sealing devices have been developed. There are at least 8 (and the number is increasing) hemostatic vascular closure devices that are currently approved by the FDA for access site closure after femoral arterial catheterization. The chief advantage attributed to vascular sealing devices is accelerated access site hemostasis, even in the setting of anticoagulation, leading to earlier ambulation and hospital discharge following arterial catheterization. The most important drawbacks related to vascular sealing devices include the cost of the devices and the possibility of increased access site complications. Despite the paucity of properly designed studies supporting their use, it is estimated that over one million vascular sealing devices are used annually in the United States, a number that has increased dramatically in the past 5 years.In this review, we present a brief description of the design and function of the most widely used devices, describe the most common mechanisms of failure, and recommend strategies for management of access site complications including hemorrhage, arterial obstruction, and infection.

Vascular closure devices for femoral arterial puncture site haemostasis

BACKGROUND

Vascular closure devices (VCDs) are widely used to achieve haemostasis after procedures requiring percutaneous common femoral artery (CFA) puncture. There is no consensus regarding the benefits of VCDs, including potential reduction in procedure time, length of hospital stay or time to patient ambulation. No robust evidence exists that VCDs reduce the incidence of puncture site complications compared with haemostasis achieved through extrinsic (manual or mechanical) compression.

OBJECTIVES

To determine the efficacy and safety of VCDs versus traditional methods of extrinsic compression in achieving haemostasis after retrograde and antegrade percutaneous arterial puncture of the CFA.

SEARCH METHODS

The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (April 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 3). Clinical trials databases were searched for details of ongoing or unpublished studies. References of articles retrieved by electronic searches were searched for additional citations.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials in which people undergoing a diagnostic or interventional procedure via percutaneous CFA puncture were randomised to one type of VCD versus extrinsic compression or another type of VCD.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the methodological quality of trials. We resolved disagreements by discussion with the third author. We performed meta-analyses when heterogeneity (I(2)) was < 90%. The primary efficacy outcomes were time to haemostasis and time to mobilisation (mean difference (MD) and 95% confidence interval (CI)). The primary safety outcome was a major adverse event (mortality and vascular injury requiring repair) (odds ratio (OR) and 95% CI). Secondary outcomes included adverse events.

MAIN RESULTS

We included 52 studies (19,192 participants) in the review. We found studies comparing VCDs with extrinsic compression (sheath size ≤ 9 Fr), different VCDs with each other after endovascular (EVAR) and percutaneous EVAR procedures and VCDs with surgical closure after open exposure of the artery (sheath size ≥ 10 Fr). For primary outcomes, we assigned the quality of evidence according to GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria as low because of serious imprecision and for secondary outcomes as moderate for precision, consistency and directness.For time to haemostasis, studies comparing collagen-based VCDs and extrinsic compression were too heterogenous to be combined. However, both metal clip-based (MD -14.81 minutes, 95% CI -16.98 to -12.63 minutes; five studies; 1665 participants) and suture-based VCDs (MD -14.58 minutes, 95% CI -16.85 to -12.32 minutes; seven studies; 1664 participants) were associated with reduced time to haemostasis when compared with extrinsic compression.For time to mobilisation, studies comparing collagen-, metal clip- and suture-based devices with extrinsic compression were too heterogeneous to be combined. No deaths were reported in the studies comparing collagen-based, metal clip-based or suture-based VCDs with extrinsic compression. For vascular injury requiring repair, meta-analyses demonstrated that neither collagen (OR 2.81, 95% CI 0.47 to 16.79; six studies; 5731 participants) nor metal clip-based VCDs (OR 0.49, 95% CI 0.03 to 7.95; three studies; 783 participants) were more effective than extrinsic compression. No cases of vascular injury required repair in the study testing suture-based VCD with extrinsic compression.Investigators reported no differences in the incidence of infection between collagen-based (OR 2.14, 95% CI 0.88 to 5.22; nine studies; 7616 participants) or suture-based VCDs (OR 1.66, 95% CI 0.22 to 12.71; three studies; 750 participants) and extrinsic compression. No cases of infection were observed in studies testing suture-based VCD versus extrinsic compression. The incidence of groin haematoma was lower with collagen-based VCDs than with extrinsic compression (OR 0.46, 95% CI 0.40 to 0.54; 25 studies; 10,247 participants), but no difference was evident when metal clip-based (OR 0.79, 95% CI 0.46 to 1.34; four studies; 1523 participants) or suture-based VCDs (OR 0.65, 95% CI 0.41 to 1.02; six studies; 1350 participants) were compared with extrinsic compression. The incidence of pseudoaneurysm was lower with collagen-based devices than with extrinsic compression (OR 0.74, 95% CI 0.55 to 0.99; 21 studies; 9342 participants), but no difference was noted when metal clip-based (OR 0.76, 95% CI 0.20 to 2.89; six studies; 1966 participants) or suture-based VCDs (OR 0.79, 95% CI 0.25 to 2.53; six studies; 1527 participants) were compared with extrinsic compression. For other adverse events, researchers reported no differences between collagen-based, clip-based or suture-based VCDs and extrinsic compression.Limited data were obtained when VCDs were compared with each other. Results of one study showed that metal clip-based VCDs were associated with shorter time to haemostasis (MD -2.24 minutes, 95% CI -2.54 to -1.94 minutes; 469 participants) and shorter time to mobilisation (MD -0.30 hours, 95% CI -0.59 to -0.01 hours; 469 participants) than suture-based devices. Few studies measured (major) adverse events, and those that did found no cases or no differences between VCDs.Percutaneous EVAR procedures revealed no differences in time to haemostasis (MD -3.20 minutes, 95% CI -10.23 to 3.83 minutes; one study; 101 participants), time to mobilisation (MD 1.00 hours, 95% CI -2.20 to 4.20 hours; one study; 101 participants) or major adverse events between PerClose and ProGlide. When compared with sutures after open exposure, VCD was associated with shorter time to haemostasis (MD -11.58 minutes, 95% CI -18.85 to -4.31 minutes; one study; 151 participants) but no difference in time to mobilisation (MD -2.50 hours, 95% CI -7.21 to 2.21 hours; one study; 151 participants) or incidence of major adverse events.

AUTHORS' CONCLUSIONS

For time to haemostasis, studies comparing collagen-based VCDs and extrinsic compression were too heterogeneous to be combined. However, both metal clip-based and suture-based VCDs were associated with reduced time to haemostasis when compared with extrinsic compression. For time to mobilisation, studies comparing VCDs with extrinsic compression were too heterogeneous to be combined. No difference was demonstrated in the incidence of vascular injury or mortality when VCDs were compared with extrinsic compression. No difference was demonstrated in the efficacy or safety of VCDs with different mechanisms of action. Further work is necessary to evaluate the efficacy of devices currently in use and to compare these with one other and extrinsic compression with respect to clearly defined outcome measures.

Early decision-analytic modeling - a case study on vascular closure devices

Background

As economic considerations become more important in healthcare reimbursement, decisions about the further development of medical innovations need to take into account not only medical need and potential clinical effectiveness, but also cost-effectiveness. Already early in the innovation process economic evaluations can support decisions on development in specific indications or patient groups by anticipating future reimbursement and implementation decisions. One potential concept for early assessment is value-based pricing.

Methods

The objective is to assess the feasibility of value-based pricing and product design for a hypothetical vascular closure device in the pre-clinical stage which aims at decreasing bleeding events. A deterministic decision-analytic model was developed to estimate the cost-effectiveness of established vascular closure devices from the perspective of the Statutory Health Insurance system. To identify early benchmarks for pricing and product design, three strategies of determining the product’s value are explored: 1) savings from complications avoided by the new device; 2) valuation of the avoided complications based on an assumed willingness-to-pay-threshold (the efficiency frontier approach); 3) value associated with modifying the care pathways within which the device would be applied.

Results

Use of established vascular closure devices is dominated by manual compression. The hypothetical vascular closure device reduces overall complication rates at higher costs than manual compression. Maximum cost savings of only about €4 per catheterization could be realized by applying the hypothetical device. Extrapolation of an efficiency frontier is only possible for one subgroup where vascular closure devices are not a dominated strategy. Modifying care in terms of same-day discharge of patients treated with vascular closure devices could result in cost savings of €400-600 per catheterization.

Conclusions

It was partially feasible to calculate value-based prices for the novel closure device which can be used to inform product design. However, modifying the care pathway may generate much more value from the payers’ perspective than modifying the device per se. Manufacturers should thus explore the feasibility of combining reimbursement of their product with arrangements that make same-day discharge attractive also for hospitals. Due to the early nature of the product, the results are afflicted with substantial uncertainty.

Network Meta-analysis of Randomized Trials on the Safety of Vascular Closure Devices for Femoral Arterial Puncture Site Haemostasis

The safety of vascular closure devices (VCDs) is still debated. The emergence of more related randomized controlled trials (RCTs) and newer VCDs makes it necessary to further evaluate the safety of VCDs. Relevant RCTs were identified by searching PubMed, EMBASE, Google Scholar and the Cochrane Central Register of Controlled Trials electronic databases updated in December 2014. Traditional and network meta-analyses were conducted to evaluate the rate of combined adverse vascular events (CAVEs) and haematomas by calculating the risk ratios and 95% confidence intervals. Forty RCTs including 16868 patients were included. Traditional meta-analysis demonstrated that there was no significant difference in the rate of CAVEs between all the VCDs and manual compression (MC). Subgroup analysis showed that FemoSeal and VCDs reported after the year 2005 reduced CAVEs. Moreover, the use of VCDs reduced the risk of haematomas compared with MC. Network meta-analysis showed that AngioSeal, which might be the best VCD among all the included VCDs, was associated with reduced rates of both CAVE and haematomas compared with MC. In conclusion, the use of VCDs is associated with a decreased risk of haematomas, and FemoSeal and AngioSeal appears to be better than MC for reducing the rate of CAVEs.

Vascular closure device failure in contemporary practice

OBJECTIVES

The goal of this study was to assess the frequency and predictors of vascular closure device (VCD) deployment failure, and its association with vascular complications of 3 commonly used VCDs.

BACKGROUND

VCDs are commonly used following percutaneous coronary intervention on the basis of studies demonstrating reduced time to ambulation, increased patient comfort, and possible reduction in vascular complications as compared with manual compression. However, limited data are available on the frequency and predictors of VCD failure, and the association of deployment failure with vascular complications.

METHODS

From a de-identified dataset provided by Massachusetts Department of Health, 23,813 consecutive interventional coronary procedures that used either a collagen plug-based (n = 18,533), a nitinol clip-based (n = 2,284), or a suture-based (n = 2,996) VCD between June 2005 and December 2007 were identified. The authors defined VCD failure as unsuccessful deployment or failure to achieve immediate access site hemostasis.

RESULTS

Among 23,813 procedures, the VCD failed in 781 (3.3%) procedures (2.1% of collagen plug-based, 6.1% of suture-based, 9.5% of nitinol clip-based VCDs). Patients with VCD failure had an excess risk of "any" (7.7% vs. 2.8%; p < 0.001), major (3.3% vs. 0.8%; p < 0.001), or minor (5.8% vs. 2.1%; p < 0.001) vascular complications compared with successful VCD deployment. In a propensity score-adjusted analysis, when compared with collagen plug-based VCD (reference odds ratio [OR] = 1.0), nitinol clip-based VCD had 2-fold increased risk (OR: 2.0, 95% confidence interval [CI]: 1.8 to 2.3, p < 0.001) and suture-based VCD had 1.25-fold increased risk (OR: 1.25, 95% CI: 1.2 to 1.3, p < 0.001) for VCD failure. VCD failure was a significant predictor of subsequent vascular complications for both collagen plug-based VCD and nitinol clip-based VCD, but not for suture-based VCD.

CONCLUSIONS

VCD failure rates vary depending upon the type of VCD used and are associated with significantly higher vascular complications as compared with deployment successes.

The use of vascular closure devices outside the catheterization laboratory after neurointerventional procedures is safe and effective: evidence from a retrospective study

PURPOSE

To investigate the feasibility and safety of vascular closure device (VCD) deployment outside the catheterization laboratory.

METHODS

Medical records were reviewed of all 799 patients (396 men; mean age 56 ± 16 years) who underwent deployment of 918 VCDs following diagnostic or therapeutic neurointerventional procedures over a 2-year period at 2 comprehensive stroke centers. The rates of major vascular complications in patients undergoing VCD deployment in and outside the catheterization laboratory were compared. Major vascular complications were adjudicated using definitions by the Society of Interventional Radiology; comparisons were made between different procedure types and closure devices.

RESULTS

During the observation period, 103 (11.2%) of 918 VCD deployments were performed outside the catheterization laboratory. Age, gender, procedure type, and device types were not different between the groups. A total of 10 (1.1%) major vascular complications occurred, including dissection requiring angioplasty (n = 1), hematoma requiring blood transfusion (n = 4), pseudoaneurysm requiring thrombin injection (n = 2), and lower limb ischemia necessitating surgical removal of the VCD (n = 3). Rates of major vascular complications were not significantly different between VCDs deployed inside the catheterization laboratory [1.0% (8/815)] compared to outside [1.9% (2/103), p = 0.3].

CONCLUSION

VCD deployment outside the catheterization laboratory does not increase the rate of major vascular complications and may be an alternative approach for femoral artery hemostasis when VCD deployment needs to be deferred.

Safety and efficacy of femoral artery closure with the FemoSeal® device after coronary angiography using a 7 French sheath

Post-cardiac catheterization femoral artery hemostasis can be accomplished with several mechanisms, including the FemoSeal® hemostasis device which has been designed and approved for closure of 6 French (F) arterial puncture sites. The aim of this study was to investigate whether the FemoSeal® vascular closure device can effectively and safely seal 7F arterial puncture sites after diagnostic and interventional cardiac catheterizations.

Femoral artery puncture sites of 50 consecutive patients undergoing cardiac catheterization were closed with the FemoSeal® vascular closure device, according to the manufacturer’s instructions. Efficacy endpoints were time to hemostasis and successful ambulation. Safety endpoints included bleeding complications, vessel occlusion and pseudoaneurysms.

Mean time to hemostasis was 57.8±26.3 seconds (0-125 seconds). Hemostasis was achieved in 100 percent of the 50 patients. One patient suffered minor bleeding the next day, i.e. local hematoma.

This clinical study demonstrates that the FemoSeal® vascular closure device, initially approved for closure of 6F arterial puncture sites, shows promising efficacy and safety to seal a larger (7F) femoral arterial puncture sites after diagnostic and interventional cardiac catheterizations.

Meta-analysis of randomized trials on the efficacy of vascular closure devices after diagnostic angiography and angioplasty

BACKGROUND

The aim of this meta-analysis was to evaluate the safety and efficacy of vascular closure devices (VCDs).

METHODS

This meta-analysis was performed in accordance with the Cochrane Handbook for Systematic Reviews.

RESULTS

The literature search yielded 31 prospective, randomized studies including 7,528 patients who were randomized to VCDs or manual/mechanical compression after diagnostic angiography and/or endovascular procedures. Most of these studies have excluded patients at high risk of puncture site complications. Meta-analysis showed similar results in the study groups in terms of groin hematoma, bleeding, pseudoaneurysm, and blood transfusion. Lower limb ischemia and other arterial ischemic complications (0.3% vs 0%, P = .07) as well as need of surgery for vascular complications (0.7% vs 0.4%, P = .10) were somewhat more frequent with arterial puncture closure devices. The incidence of groin infection was significantly more frequent with VCDs (0.6% vs 0.2%, P = .02). The use of VCD was uniformly associated with a significantly shorter time to hemostasis. Such differences where more evident in patients undergoing percutaneous coronary intervention, whereas these methods were associated with similar rates of adverse events among patients undergoing diagnostic coronary angiography.

CONCLUSIONS

The use of VCDs is associated with a significantly shorter time to hemostasis and thus may shorten recovery. However, the use of VCDs is associated with a somewhat increased risk of infection, lower limb ischemia/arterial stenosis/device entrapment in the artery, and need of vascular surgery for arterial complications. Further studies are needed to get more conclusive results, particularly in patients at high risk of femoral puncture-related complications.

Vascular closure device failure: frequency and implications: a propensity-matched analysis

BACKGROUND

Vascular closure devices (VCDs) are effective in reducing the time to ambulation for patients undergoing cardiac catheterization procedures and in reducing the risk of vascular complications in selected patient cohorts. However, the frequency and consequence of failure of VCDs is not well defined.

METHODS AND RESULTS

From a prospective registry of consecutive patients undergoing cardiac catheterization at our center, 9823 patients who received either a collagen plug-based (Angio-Seal) or a suture-based (Perclose) VCD were selected for the study. VCD failure was defined as unsuccessful deployment or failure to achieve hemostasis. Major vascular complication was defined as any retroperitoneal hemorrhage, limb ischemia, or any surgical repair. Minor vascular complication was defined as any groin bleeding, hematoma (> or = 5 cm), pseudoaneurysm, or arteriovenous fistula. Any vascular complication was defined as either a major or minor vascular complication. Among the 9823 patients in the study, VCD failed in 268 patients (2.7%; 2.3% diagnostic versus 3.0% percutaneous coronary intervention; P=0.029). Patients with VCD failure had significantly increased risk of any (6.7% versus 1.4%; P<0.0001), major (1.9% versus 0.6%; P=0.006), or minor (6.0% versus 1.1%; P<0.0001) vascular complication compared with the group with successful deployment of VCD. The increased risk of vascular complication was unchanged in a propensity score-matched cohort.

CONCLUSIONS

In contemporary practice, VCD failure is rare, but when it does fail, it is associated with a significant increase in the risk of vascular complications. Patients with VCD failure should be closely monitored.

Ischemic complications of percutaneous femoral artery catheterization

Ischemic injuries following percutaneous femoral artery catheterization are uncommon but have been associated with vascular closure devices (VCDs). The purpose of this study was to retrospectively compare ischemic and hemorrhagic complications of femoral artery catheterization and to identify factors associated with ischemic injuries. The operative registries of the attending vascular surgeons at one academic and two community hospitals were retrospectively reviewed to identify all complications of femoral artery catheterization requiring operative intervention. Demographic, clinical, procedural, operative, and outcome data were compared between patients who sustained ischemic and hemorrhagic complications. From January 2001 to December 2006, 95 patients required operative management of complications related to femoral artery catheterization including 40 patients who experienced ischemic (group 1) and 55 patients who experienced hemorrhagic (group 2) complications. Compared to those sustaining hemorrhagic complications, ischemic complications were more frequently associated with younger age, smoking, VCD deployment, and, when controlling for VCD use, female gender. Time to presentation was also significantly longer in patients experiencing ischemic complications. Ischemic complications are increasingly recognized following femoral artery catheterization. Vascular surgeons should anticipate a new pattern of injury following femoral artery catheterization, one that often requires complex arterial reconstruction.

Effect of local anesthesia and intravenous sedation on pain perception and vasovagal reactions during femoral arterial sheath removal after percutaneous coronary intervention

BACKGROUND

There is no consensus with respect to the use of analgesia during femoral arterial sheath removal after percutaneous coronary intervention (PCI). We performed a randomized controlled trial to assess the impact of intravenous sedation and local anesthesia during femoral sheath removal after PCI on patient comfort and the incidence of vasovagal reactions.

METHODS

All patients undergoing PCI whose femoral sheaths were to be removed with assisted manual compression were eligible. Patients were randomized to receive either intravenous sedation (Fentanyl and Midazolam) or local anesthesia (1% lignocaine) infiltrated around the sheath site or both or neither. The primary endpoint of the study was the patients reported worst pain according to a Visual Analogue scale (VAS) after sheath removal. The incidence and predictors of vasovagal reactions during sheath removal and occurrence of vascular complications was also determined.

RESULTS

A total of 611 patients were randomized into this study. The mean pain score was highest in the local anesthesia only arm as compared to the sedation only arm, the combined local and sedation arm and the neither sedation or local arm (p=0.001). vasovagal reactions were experienced by 35 patients (5.1%) with the highest percentage in the local anesthesia only group (9.8%). Multivariate logistic regression analysis identified a higher pain score (OR 1.18, 95% CI 1.12-1.24, p=0.001), use of glyceryl trinitrate during sheath removal (OR 9.05, 95% CI 5.06-16.1, p<0.001), a lower body mass index (OR 1.12, 95% CI 1.08-1.18, p=0.009) and the left anterior descending artery as the treated vessel (OR 5.2, 95% CI 3.41-7.87, p<0.001) as independent predictors of the occurrence of a vasovagal reaction. There was no significant difference in vascular complications between the 4 study groups.

CONCLUSIONS

The routine use of fentanyl and midazolam prior to sheath removal leads to a reduction in pain perception and vasovagal incidence, whilst the routine use of local infiltration during sheath removal should be discouraged as it leads to more pain and a trend to more vasovagal reactions.

Initial experience with the cardiva Boomerang™ vascular closure device in diagnostic catheterization

OBJECTIVES

The authors studied the safety and efficacy of the Cardiva Boomerang vascular closure device in patients undergoing diagnostic cardiac catheterization.

BACKGROUND

Conventional vascular closure devices (sutures, collagen plugs, or metal clips) have been associated with catastrophic complications including arterial occlusion and foreign body infections; furthermore, they cannot be utilized in patients with peripheral vascular disease or vascular access site in a vessel other than the common femoral artery. The Cardiva Boomerang device facilitates vascular hemostasis without leaving any foreign body behind at the access site, can be used in peripheral vascular disease, and can be used in vessels other than the common femoral artery

METHODS

A total of 96 patients undergoing transfemoral diagnostic cardiac catheterization were included in this study, including 25 (26%) patients with contraindications to conventional closure devices. Femoral angiography was performed prior to deployment of the Cardiva Boomerang closure device. Patients were ambulated at 1 hr after hemostasis was achieved.

RESULTS

The device was successfully deployed and hemostasis achieved with the device alone in 95 (99%) patients. The device failed to deploy in 1 (1%) patient and required conversion to standard manual compression. Minor complications were observed in 5 (5%) patients. No patients experienced major complications including femoral hematoma > 4 cm, red blood cell transfusion, retroperitoneal bleed, arteriovenous fistula, pseudoaneurysm, infection, arterial occlusion, or vascular surgery.

CONCLUSIONS

The Cardiva Boomerang device is safe and effective in patients undergoing diagnostic cardiac catheterization using the transfemoral approach, facilitating early ambulation with low rates of vascular complications.

Randomized controlled trial of topical hemostasis pad use for achieving vascular hemostasis following percutaneous coronary intervention

OBJECTIVES

We conducted a randomized trial to determine the efficacy of two topical hemostasis pads in promoting vascular hemostasis following PCI, and to assess the appropriate level of anticoagulation for sheath removal.

BACKGROUND

Pads coated with procoagulant materials are widely marketed and used to augment vascular hemostasis following PCI, yet clinical effectiveness and safety data are lacking.

METHODS

184 patients who underwent PCI using the femoral approach were randomized to one of four methods of sheath removal: (1) at ACT < 250 using the Chito-Seal pad; (2) at ACT < 250 using the Clo-Sur PAD; (3) at ACT < 250 using manual compression alone; (4) at ACT < 170 using manual compression alone.

RESULTS

Time to hemostasis was significantly shorter in the hemostasis pad groups compared to the conventional compression groups (16.2 +/- 4.9, 16.0 +/- 5.3, 19.3 +/- 7.8, and 18.3 +/- 5.7 min, respectively, P = 0.027), however overall bed rest times following intervention were not reduced by use of either hemostasis pad. The incidence of major or minor bleeding complications did not differ among groups. Irrespective of hemostasis pad use, removal of sheaths at higher ACT levels allowed shorter time to ambulation following PCI without an increase in bleeding events.

CONCLUSIONS

The hemostasis pads tested shortened time to hemostasis compared to standard manual compression, although the absolute reduction in time to hemostasis was relatively small and did not translate into a reduction in overall bed rest time. Independent of hemostasis pad use, removal of arterial sheaths at higher than conventional activated clotting times was safe and resulted in significant reductions in time to ambulation.

Postinterventional percutaneous closure of femoral artery access sites using the Clo-Sur PAD device: initial findings

The purpose of this study was to evaluate a percutaneous hemostatic device in patients to achieve immediate hemostasis at the vascular access site as well as early ambulation after vascular interventional procedures. In a randomized trial, a hemostatic device (Clo-Sur PAD, Medtronic AVE, Inc., Santa Rosa, CA, USA; n=60) was compared with manual compression (n=60) in patients after endoluminal intervention through an inguinal access (sheath sizes: 5-7 French). Device safety was evaluated by assessing complications within 24 h and 14 days. System efficacy was measured by the percentage of achieved immediate hemostasis and early ambulation. Device application was possible in 57 cases (95.0%), with 93.3% (56/60) of the patients rising 2 h after application. Hemostasis time was 10.15+/-1.96 min (control group: 16.20+/-1.79 min), with a pressure bandage time of 3.47+/-5.53 h (control group: 13.8+/-4.32 h). Ambulation was possible after 2.13+/-0.50 h (control group: 8.57+/-3.47 h). Complications encountered were access-site bleeding with hematoma (device: n=3; control: n=9). All complications were managed conventionally without blood transfusion or surgical intervention. The system is an easy to use device permitting early ambulation without additional pressure bandaging in the majority of patients. Preliminary data show that hemostasis does not depend on the level of anticoagulation.

Early mobilization after diagnostic cardiac catheterization with the use of a hemostatic bandage containing thrombin

The aim of the present study was to assess the efficacy and safety of a thrombin-containing bandage for local hemostasis after femoral sheath removal in patients undergoing diagnostic cardiac catheterization. Forty-one patients undergoing diagnostic coronary angiography using a 6-F femoral sheath were included. The sheath was removed immediately after the procedure using the bandage according to a prespecified protocol. Mean compression time was 7.3+/-1.7 min and mean time from sheath removal to mobilization was 132+/-34 min. None of the patients suffered recurrent bleeding or any in-hospital and 7-day vascular complications. We conclude that in patients undergoing femoral-access diagnostic cardiac catheterization, the use of a hemostatic bandage containing thrombin was associated with short time to hemostasis with the ability for early patient mobilization without vascular complications.

Vascular Complications with Newer Generations of Angioseal Vascular Closure Devices

OBJECTIVES

To evaluate the safety and efficacy of newer generations of a single vascular closure device (VCD), Angioseal, compared to contemporaneous manual compression.

BACKGROUND

Previous assessment of VCD safety and efficacy has been based primarily on outcomes associated with the original VCD. Few data exist comparing safety and efficacy of modifications of the original VCDs.

METHODS

We evaluated in-hospital outcomes of patients undergoing diagnostic cath and percutaneous coronary intervention at a single center: 3,898 with manual compression and 3,898 with the Angioseal VCD. Three generations of the Angioseal device were studied: Generation 1, 7/97-4/00; Generation 2, 5/00-6/02; and Generation 3, 7/02-12/03. Propensity analysis was used to match patients within each generation for clinical and procedural covariates.

RESULTS

Closure success was 98.5% for Generation 1, 98.6% for Generation 2, and 98.1% for Generation 3, P = NS. The odds ratio for any vascular complication comparing Angioseal to manual compression was 0.92 (0.42-2.01) for Generation 1; 0.83 (0.49-1.41) for Generation 2; and 0.75 (0.32-1.77) for Generation 3. Multivariate logistic regression identified closure success and Angioseal device Generation 3 versus Generation 1 as predictive of reduced vascular complications during the entire study period.

CONCLUSION

These data indicate that the newest generation of the Angioseal VCD is at least as effective as the original device. Moreover, use of the Angioseal VCD was associated with vascular complications similar to or lower than vascular complications following manual compression for each generation of Angioseal device analyzed.

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.

Case-controlled comparison of a percutaneous collagen arteriotomy closure device versus manual compression after liver chemoembolization

PURPOSE

To compare complications and outcomes between the use of the Duett collagen closure device after one or multiple deployments and manual compression in patients treated with transcatheter arterial chemoembolization (TACE) for primary or metastatic liver cancer.

MATERIALS AND METHODS

A database of 214 patients who underwent a total of 426 TACE procedures between July 2001 and July 2003 was retrospectively analyzed with regard to the use of the Duett closure device to obtain hemostasis. The Duett device was used in 211 cases (121 patients), whereas manual compression was performed in 215 cases (93 patients). Primary endpoints included complications related to hemostasis, time to hemostasis (TTH), time to ambulation (TTA), and time to discharge (TTD). Risk factors were tested for correlation with complications (P < .05). Other endpoints included descriptive data regarding the Duett treatment group.

RESULTS

Only minor complications were observed in both groups, without a statistically significant difference (P = .16). The mean TTH and TTA were significantly shorter (P < .0001) in the Duett group, whereas there was no difference in TTD between groups (P = .59). Reaccessing the same arterial site for separate procedures was not a significant risk factor for complications in the Duett group (P < .0001).

CONCLUSION

The Duett closure device achieves similar safety and efficacy as manual compression in this distinct group of patients. In addition, this device can be safely and repetitively deployed at the arteriotomy site after each TACE procedure.

Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: a meta-analysis

OBJECTIVES

This study was designed to assess the safety of arteriotomy closure devices (ACDs) versus mechanical compression by meta-analysis in patients undergoing percutaneous transfemoral coronary procedures.

BACKGROUND

Although ACDs are widely applied for hemostasis after percutaneous endovascular procedures, their safety is controversial.

METHODS

Randomized, case-control, and cohort studies comparing access-related complications using ACDs versus mechanical compression were analyzed. The primary end point was the cumulative incidence of vascular complications, including pseudoaneurysm, arteriovenous fistula, retroperitoneal hematoma, femoral artery thrombosis, surgical vascular repair, access site infection, and blood transfusion.

RESULTS

A total of 30 studies involving 37,066 patients were identified. No difference in complication incidence between Angio-Seal and mechanical compression was revealed in the diagnostic (Dx) setting (odds ratio [OR] 1.08, 95% confidence interval [CI] 0.11 to 10.0) or percutaneous coronary interventions (PCI) (OR 0.86, 95% CI 0.65 to 1.12). Meta-analysis of randomized trials only showed a trend toward less complications using Angio-Seal in a PCI setting (OR 0.46, 95% CI 0.20 to 1.04; p = 0.062). No differences were observed regarding Perclose in either Dx (OR 1.51, 95% CI 0.24 to 9.47) or PCI (OR 1.21, 95% CI 0.94 to 1.54) setting. An increased risk in complication rates using VasoSeal in the PCI setting (OR 2.25, 95% CI 1.07 to 4.71) was found. The overall analysis favored mechanical compression over ACD (OR 1.34, 95% CI 1.01 to 1.79).

CONCLUSIONS

In the setting of Dx angiography, the risk of access-site-related complications was similar for ACD compared with mechanical compression. In the setting of PCI, the rate of complications appeared higher with VasoSeal.

The use of closure devices

The use of arterial closure devices offers significant benefits over manual compression in achieving groin hemostasis following catheter-based procedures. Several currently available devices provide rapid puncture site closure with complication rates similar to that of manual compression. Closure devices allow for early times to ambulation and hospital discharge, and have a high degree of patient satisfaction. Their use may be of particular benefit inpatients that are anticoagulated. We believe that their use should be strongly considered in all patients following femoral artery catheterization.

Patient tolerance and resource utilization associated with an arterial closure versus an external compression device after percutaneous coronary intervention

We assessed patient tolerance and resource utilization of using the AngioSeal closure device versus assisted manual compression using the Femostop device after percutaneous coronary intervention (PCI). Patients undergoing PCI with clean arterial access and no procedural hematoma were randomized to receive the AngioSeal or Femostop device to achieve femoral arterial hemostasis. Times from procedure end to removal from angiography table, hemostasis, ambulation, and hospital discharge were recorded. Bedside nursing/medical officer care time, vascular complications, and disposable use were also documented. Patient comfort was assessed using Present Pain Intensity and Visual Analogue scales at baseline, 4 hr, 8 hr, and the morning after the procedure. One hundred twenty-two patients were enrolled (62 AngioSeal, 60 Femostop). Patients in the AngioSeal group took longer to be removed from the angiography table (11 +/- 4 vs. 9 +/- 3 min; P = 0.002) compared with the Femostop group. Time to hemostasis (0.4 +/- 1.1 vs. 6.4 +/- 1.7 hr; P < 0.001) and ambulation (17 +/- 8 vs. 22 +/- 13 hr; P = 0.004) were less in the AngioSeal group, although time to discharge was not different. Nursing and medical officer time was no different. Disposables including device cost were higher in the AngioSeal group (209 dollars +/- 13 vs. 53 dollars +/- 9; P < 0.001). On a Visual Analogue scale, patients reported more pain at 4 hr (P < 0.001) and 8 hr (P < 0.001) in the Femostop group. The worst amount of pain at any time point was also more severe in the Femostop group (P < 0.001). Similar results were found on a Present Pain Intensity scale of pain. There were no differences in ultrasound-determined vascular complications (two each). Femoral access site closure using the AngioSeal device resulted in a small delay in leaving the angiography suite and a higher disposable cost compared to using the Femostop device. However, patients receiving the AngioSeal were able to ambulate sooner and reported less pain, which may justify the increased costs involved.

Percutaneous arterial closure devices

Advances in interventional angiography such as covered stent technology and adjunctive anticoagulation and antiplatelet therapy for arterial recanalization have reached the margins of percutaneous application. In these circumstances, compression methods of arterial closure require prolonged compression or long arterial sheath dwell times that increase procedural time, complication rates, and patient discomfort. Percutaneous arterial closure devices offer the potential of rapid hemostasis and shorter times to ambulation and discharge. These benefits have costs, in terms of the price of the devices and complications of their use. A Web search identified approved and pending devices. A Medline search identified device studies that were reviewed to assess the efficacy and complication rates of device-mediated closure versus the gold standard of manual compression. Studies that compared devices were evaluated to determine if any particular device was superior. The arterial closure devices were equivalent to manual compression in the establishment of hemostasis in the diagnostic population. However, complication rates were higher. In the therapeutic populations, the devices were as efficacious as manual compression, without correction of anticoagulation, and the complication rates were similar. No individual device was clearly superior.

Arterial puncture closure using a collagen plug, II. (VasoSeal)

Various vascular closure devices have come into common usage by most angio/interventional radiologists and cardiologists over the past 6 or 7 years. This has occurred despite the "real angiographers hold their own punctures" mindset that many of us learned in training. In our practice, we tried a number of different devices, but began using VasoSeal as our primary closure method in mid-1998. Since then, we have performed approximately 2400 procedures in which the VasoSeal device was deployed. The purpose of this article is to review the technique of VaseSeal closure of percutaneous arteriotomy sites.

Postinterventional transcutaneous suture of femoral artery access sites in patients with peripheral arterial occlusive disease: a study of 930 patients

The purpose of this study was to evaluate a percutaneous vascular suture (PVS) device in patients with peripheral arterial occlusive disease (PAOD) for achievement of immediate hemostasis at the vascular access site and early ambulation of fully anticoagulated patients after peripheral interventional procedures. From June 1995 to March 2000, a vascular suture using a PVS device (6-10 Fr) was applied in 930 patients with PAOD. All patients had received an endoluminal intervention in the pelvic and/or the contralateral femoropopliteal region via a retrograde access through the common femoral artery (CFA). The incidence of complications within 12 hr after intervention, prior to discharge, and at 30-day follow-up was assessed employing clinical examination, treadmill test, and color Doppler ultrasound and the safety of the PVS device was determined. The efficacy of the system was measured by the percentage of achieved immediate hemostasis and early ambulation. PVS was technically successful in 92.2% independently from the degree of calcification at the access site. In 7.8%, an appropriate suture delivery could not be performed and these patients were successfully treated by conventional compression technique. Device malfunction or insufficient suture closure occurred in 1.7% and 2.1%, respectively. In 7.0%, groin-related complications occurred. Ambulation within 2-4 hr after successful suture was possible in 96.1%. All patients were free of any local symptoms at 30-day follow-up. The PVS device provides a safe and effective solution to achieve immediate hemostasis, thus permitting early ambulation in fully anticoagulated patients with PAOD after peripheral interventional procedures.

Complications of femoral artery closure devices

We have examined our prospectively collected experience with femoral artery closure devices. Vasoseal (n = 937), Angioseal (N-742), and Techstar (n = 1001) were utilized consecutively in our laboratory for diagnostic and interventional femoral artery closures. Complications were compared to a similar number of closures with manual compression (MC; n = 1019) before closure devices were utilized. The incidence of surgical repair, acute femoral closure, transfusion due to groin complications, readmission for groin complications, infection, and total complications were examined. We found that the Vasoseal and Angioseal devices were associated with higher rates of total complications than manual compression. The Techstar and manual compression had similar total complication rates. Acute femoral artery occlusion was a potentially serious complication with the Angioseal device. Groin infection occurred with each of the closure devices but not with manual compression.

Vasoseal after intra-aortic balloon pump removal: a pilot study

Vascular complications after removal of an intra-aortic balloon pump (IABP) have been reported to occur in up to 15% of patients. Vasoseal, a vascular hemostasis device (VHD), has been shown to be safe and effective in rapidly achieving hemostasis after a cardiac catheterization or percutaneous coronary intervention. We propose that similar results can be obtained with the VHD when removing an IABP. However, it is necessary to first gain first the experience of deploying the VHD without insertion of a guidewire. We studied 10 patients in whom Vasoseal was utilized after an IABP was removed. The primary endpoint was a composite of major or minor bleeding, infection, and any vascular complication at 7 days. The time to achieve hemostasis was also assessed. There was not a single episode of bleeding, infection, or vascular injury at 7 days. The time to hemostasis ranged between 8 and 17 min (mean, 12.9 min). This VHD can be utilized safely and efficaciously when removing an IABP.

A randomised controlled trial of Prostar Plus for haemostasis in patients after coronary angioplasty

OBJECTIVES

to clarify the efficacy and safety of Prostar Plus, a new percutaneous vascular surgical device (PVS) for vascular haemostasis.

DESIGN

prospective randomised controlled trial.

METHODS

a consecutive series of 60 patients were randomised to either PVS (n =30) or conventional manual compression ( n =30) following coronary angioplasty or stenting with femoral access using an 8-F sheath.

RESULTS

PVS significantly shortened the time to haemostasis (10 s.d. 3 vs. 27 s.d. 9 min, p <0.001), ambulation (2.2 s.d. 0.9 vs. 11.0 s.d. 1.4 h, p <0.001), and discharge (2.2 s.d. 0.4 vs. 3.1 s.d. 0.7 days, p <0.01), compared with the manual compression group with no major complications. PVS also increased patient comfort assessed by using a visual-analogue scale method. Although these clinical benefits reduced the hospital cost ($1301 s. d. 248 vs. 1613 s.d. 460, p <0.05), the cost of the PVS device (approximately $350) cancelled the cost-saving benefit.

CONCLUSIONS

this randomised study indicates that Prostar Plus is safe, more effective and comfortable than conventional manual compression.

Randomized comparison of hemostasis techniques after invasive cardiovascular procedures

BACKGROUND

The arterial access required during most invasive vascular procedures provides a common source of complications and morbidity. This problem has been made worse by recent trends in earlier ambulation and more aggressive antihemostatic drug regimens. Despite these trends, no randomized trials have been reported comparing the 3 most commonly used techniques in achieving hemostasis at the arterial puncture site.

METHODS

A cohort of 400 patients undergoing catheterization laboratory procedures were randomly assigned to 1 of 3 groups of arterial compression: manual compression, mechanical clamp, and pneumatic compression device. Standard requirements of the trial included uniformity in initial compression times, patient instructions, nursing follow-up, and timing of ambulation as well as a structured interview and physical examination at 24 hours.

RESULTS

Prolonged compression was required in 13% of the manual group, 20% of the clamp group, and 35% of the pneumatic group (P <.0001). In-lab bleeding was more common in the pneumatic group (3%, 4%, and 16%, respectively, P <.0001), as was the need for an alternate compression technique (1%, 1%, and 27%, P <.0001). The groups also differed in respect to mean hematoma size (3.9 cm(2), 7.8 cm(2), and 19.8 cm(2), P =.036) and level of discomfort during compression (1.9, 2.2, and 3.1 on a 1- to 10-point scale, P <.0001). Comparable findings were observed in the subgroup of patients eligible for outpatient procedures.

CONCLUSIONS

Use of the pneumatic compression device leads to longer compression times, greater discomfort, more bleeding, and larger hematomas. Differences between manual compression and the mechanical clamp were more subtle but tend to favor use of the manual technique.

Surgical complications from hemostatic puncture closure devices

BACKGROUND

For securing immediate hemostasis following percutaneous arterial catheterization, the Food and Drug Administration has approved three hemostatic puncture closure devices. We reviewed our institutional experience with one device (Angio-Seal).

METHODS

A retrospective, single-center, nonrandomized observational study was made of all vascular complications following femoral cardiac catheterization.

RESULTS

An immediate mechanical failure of the device was experienced in 34 (8%) patients. Surgical repair was required in 1.6% (7 of 425) of patients following Angio-Seal versus 0.3% (5 of 1662) following routine manual compression (P = 0.004). In 5 patients, the device caused either complete occlusion or stenosis of the femoral artery. The polymer anchor embolized in 1 patient and was retrieved with a balloon catheter at surgery.

CONCLUSION

During the first year of utilization of a percutaneous hemostatic closure device following cardiac catheterization, we observed a marked increase in arterial occlusive complications requiring surgical repair. Surgeons must be familiar with the design of these devices to achieve precise repair of surgical complications.

Predictors of complications and learning curve using the Angio-Seal closure device following interventional and diagnostic catheterization

A retrospective study was conducted to determine the frequency and nature of groin complications when the Angio-Seal device was used on 252 occasions by one operator immediately following interventional (66%) and diagnostic (34%) procedures. Sixty-nine percent of the 238 successfully deployed cases received ticlopidine or clopidogrel, 16% received abciximab, and 15% received heparin postprocedure. Complications included vascular surgery for collagen plug perforation into the femoral artery (0.8%), failure to deploy (5.6%), pseudoaneurysm (0.4%), brisk, visible bleeding (9%), persistent ooze (14%), hematoma > 6 cm (0.8%), hematoma </= 6 cm (2.4%), and ecchymosis > 1 cm(2) (10%). Multivariate analysis identified diagnostic cases (6 Fr sheaths) to be associated with a reduced risk of complications [odds ratio (OR) 0.1] while interventional procedures (8 Fr sheaths), postprocedure heparin, and body mass index (BMI) < 28 (OR 10.1, 3.2, and 2.8, respectively) were associated with increased risk. Gender, age, ticlopidine, clopidogrel, and abciximab were not independent predictors of complications. A learning curve for device deployment was observed in the first 50 cases (14% nondeployment vs. 3.5% for the subsequent 202 procedures, P = 0.009) and failure to deploy was independent of sheath size used. Angio-Seal can be used with reasonable safety and efficacy immediately after diagnostic and interventional procedures. Cathet. Cardiovasc. Intervent. 48:162-166, 1999.

Use of vascular sealing devices (VasoSeal and Perclose) versus assisted manual compression (Femostop) in transcatheter coronary interventions requiring abciximab (ReoPro)

Transcatheter coronary interventions requiring abciximab (ReoPro) are associated with vascular access site complications. Several devices have been developed to aid in the closure of the femoral arteriotomy, including collagen plug devices (VasoSeal, AngioSeal), percutaneous suture closure (Perclose), and aids to manual compression (Femostop). In 185 patients who received abciximab plus aspirin and heparin for transcatheter coronary interventions, we compared femoral arteriotomy closure by three different methods: VasoSeal, Perclose, and Femostop. A composite endpoint of late complications defined as an access site-related bleed or hematoma that required blood transfusion or an extended hospital stay, pseudoaneurysm, arteriovenous fistula, arterial or venous thrombosis was compared. VasoSeal was initially successful in 41/52 patients (78.8%). The 11 patients who failed to have adequate hemostasis with VasoSeal required manual compression aided by Femostop, but had no late complications. There was one access site infection and one fatal retroperitoneal hematoma unrelated to the vascular access site (surgically explored). There were no late complications. Perclose was successful in 48/56 patients (85.7%). One Perclose failure required surgical repair for an extensive arteriotomy. The other Perclose failure required manual compression aided by Femostop, but had no late complications. There were no access site infections requiring intravenous antibiotics. There was one retroperitoneal bleed that extended the patient's hospital stay and for which a blood transfusion was required. Femostop was successful in 77/77 patients (100%). There were no infections. Late complications occurred in four patients. These included three episodes of bleeding or hematomas requiring blood transfusion, and one pseudoaneurysm.

CONCLUSION

In patients receiving abciximab in addition to aspirin and heparin, VasoSeal and Perclose are at least as safe as Femostop when used to achieve homeostasis after sheath removal. VasoSeal and Perclose have a significantly lower initial rate of successful hemostasis than Femostop. The numbers of late complications between the VasoSeal, Perclose, and Femostop groups were not significantly different. In those patients in whom VasoSeal or Perclose failed, no late complications occurred. Access site infections were no different between VasoSeal, Perclose, and Femostop.

Suture-mediated percutaneous closure of antegrade femoral arterial access sites in patients who have received full anticoagulation therapy

PURPOSE

To assess the feasibility and clinical usefulness of suture-mediated closure of femoral arterial access sites after antegrade puncture for peripheral arterial interventions.

MATERIALS AND METHODS

Eighty consecutive patients (49 men, 31 women; mean age +/- SD, 65.4 years +/- 12.3) who had undergone femoropopliteal angioplasty underwent suture-mediated percutaneous closure with 6-, 7-, or 8-F devices. Patients received heparin intravenously and aspirin orally and were immobilized for 1 hour after the intervention. All patients underwent a physical examination the day after the procedure. Color-coded duplex ultrasonography was performed in those patients (n = 27 [33%]) who were obese, were experiencing pain, and had suspicious clinical findings. After 3 months, an identical clinical examination was performed in every third patient.

RESULTS

Hemostasis was achieved in 77 (96%) patients; one of 80 patients required blood transfusions and surgery despite an initially successful closure. The closure devices could be deployed in 78 (98%) patients; two of 80 patients needed compression because of a steep angulation of the puncture track and suture entrapment. Adjunctive compression was necessary in two (3%) of the remaining 78 patients. Mean time to hemostasis in the 78 patients who had successful device deployment was 5.2 minutes (range, 3.0-21.0 minutes). Minor complications (i.e., three small hematomas, a pseudoaneurysm, and a small lymphatic fistula) occurred in five (6%) patients.

CONCLUSION

Suture-mediated percutaneous closure of antegrade puncture sites in the groin is feasible. Problems may arise in antegrade punctures owing to steep device angulation.

Vasoseal hemostasis following coronary interventions with Abciximab

Femoral arteriotomy management using a collagen vascular hemostasis device (VasoSeal) was studied in 50 consecutive patients following interventional coronary procedures performed with Abciximab (ReoPro). Low dose weight adjusted or no heparin was employed. The first 25 patients were permitted to sit up after 6 hours with ambulation the following day. The second 25 patients were allowed to sit up after 1 hour and ambulate after 6 hours. Despite early activity and ambulation, there were no hemorrhagic complications including hematoma, pseudoaneurysm, blood transfusion, or surgical repair. Hemoglobin and platelet counts remained stable overnight prior to discharge. This pilot study demonstrates the potential efficacy of VasoSeal in achieving early sheath removal and ambulation in patients undergoing interventional procedures using ReoPro.

Usefulness of collagen plugging with VasoSeal after PTCA as compared to manual compression with identical sheath dwell times

This study investigated the usefulness of collagen plugging with VasoSeal in patients after PTCA compared to a control group having identical sheath dwell times and therefore comparable levels of anticoagulation. A total of 150 patients were enrolled in this prospective and randomized study. Sheaths were pulled at exactly 5 h after arterial puncture. Time to hemostasis and local complications were determined. There were no statistical differences in baseline characteristics. The mean time to hemostasis in the collagen group was significantly shorter (3 +/- 3 min) than that of the control group (17.4 +/- 7 min). At 24 h, 23% of the collagen group patients had a small, 1% a medium and 4% a large hematoma. In the control group, 32% had a small, 4% a medium sized, but no patient a large hematoma. After collagen, one patient developed a pseudoaneurysm needing vascular surgery. In the control group, no major complication occurred. Compared to patients with manual compression at an identical sheath dwell time and an identical level of anticoagulation, there was a significant reduction in time to hemostasis but no statistical difference regarding local complications. Although the incidence of medium or large hematoma was low, the trend towards a decreased risk of smaller hematomas seemed to be counterbalanced by an increased risk of larger hematomas.

Hemostasis success rates and local complications with collagen after femoral access for cardiac catheterization: analysis of 6007 published patients

Since the first clinical studies regarding sealing of arterial puncture sites with collagen with the use of the vascular hemostatic device (VHD) and the hemostatic puncture closing device (HPCD) in the early 1990s were performed, no analysis summarizing the published patients has been reported. Therefore we performed a Medline search of data as far back as 1990 and included abstracts presented at the major scientific meetings in the United States (American Heart Association, American College of Cardiology), Europe (European Society of Cardiology), and Germany (German Society of Cardiology). A total of 6007 patients were found to have been enrolled in studies with VHD (4448 patients) or with HPCD (1559 patients). Parameters analyzed in this review were hemostasis success rates and local complications. To assess the impact of the sealing devices on local complications, studies without control groups were excluded. The hemostasis success rates immediately after deployment seemed to be higher for HPCD, but at 2' to 5' after sheath removal, they were in the same range for VHD and HPCD. In controlled studies minor local complications occurred at a rate of 7.6% in the VHD group and in 6.7% of the HPCD group. Because the control group in the HPCD studies showed a considerably higher rate of minor complications than the VHD group (11.7% vs 5.7%), the reduction in minor complications was statistically significant for HPCD, whereas VHD did not reduce minor local complications. Major local complications were reported in 3.8% of the VHD group but in only 1.8% of the HPCD group. The increase of major local complications was statistically significant with VHD (control, 1.7%) but not with HPCD (control, 1.4%). Our analysis shows that some differences between collagen devices may exist, but neither device has been proven to reduce major local complications.

Is lidocaine infiltration during femoral sheath removal really necessary?

OBJECTIVES

To compare the effectiveness of intravenous morphine sulfate to intravenous morphine sulfate plus 1% lidocaine infiltration in pain management associated with femoral sheath removal, and to evaluate pain intensity and associated complications during femoral sheath removal in patients with heart disease receiving interventional treatment.

DESIGN

Descriptive, correlational, case-control study.

SETTING

Mid-metropolitan, university-affiliated, tertiary care medical center.

SAMPLE

Fifty patients with heart disease, who had no known allergies to morphine or lidocaine and who had not had an acute myocardial infarction, admitted to the cardiovascular intervention unit.

MEASURES

Vertical visual analogue scale, short-form McGill Pain Questionnaire, and demographic tool for complications.

RESULTS

No significant differences in pain intensity, sensation, affect, and total scores were found between the analgesic regimens. Six (12%) patients had vasovagal reactions develop, but no statistical differences were found between pain intensity scores and associated complications.

CONCLUSION

Morphine sulfate does appear effective in controlling pain associated with femoral sheath removal. The benefit of lidocaine infiltration during this procedure is questionable.