Technique of temporary subcutaneous "Figure-of-Eight" sutures to achieve hemostasis after removal of large-caliber femoral venous sheaths

Purse string suture for rapid access hemostasis after removal of large-caliber femoral venous delivery sheaths in children with atrial septal defects

OBJECTIVES

To evaluate the efficacy and safety of purse-string sutures (PSS) compared with manual compression for access hemostasis in children with atrial septal defects (ASDs) after large-caliber venous delivery sheaths removal.

METHODS

We conducted a retrospective clinical data review of 271 children with ASDs who underwent transcatheter device closure through large-caliber venous delivery sheaths (≥ 8 Fr) at our institution from January 2018 to January 2023. The PSS group (n = 144) was compared to the control group (n = 127), which underwent manual compression for femoral venous hemostasis after sheath removal, focusing on hemostatic time, limb braking time, bed rest time, hospital stay, and vascular access complications. Two days post-catheterization, the sutures were taken out and a vascular ultrasound found the evidence of thrombosis, embolism, or venous narrowing.

RESULTS

Compared to the control group, the PSS group had significantly shorter average hemostatic time (4.63 ± 1.95 min vs. 19.69 ± 5.64 min), limb braking time (6.83 ± 2.25 h vs. 13.45 ± 2.87 h), and bed rest time (8.69 ± 1.43 h vs. 22.93 ± 2.24 h) (all, p < 0.001). There were no statistically significant differences in hospital stay and complications between the two groups.

CONCLUSIONS

The PSS is a simple, effective, and safe procedure that may play a valuable role in achieving rapid hemostasis after the removal of the large-caliber venous delivery sheaths in children. It allows earlier mobilization, reduces bed rest time, and alleviates discomfort compared to manual compression.

A Novel Suture-Based Vascular Closure Device to Achieve Hemostasis after Venous or Arterial Access While Leaving Nothing behind: A Review of the Technological Assessment and Early Clinical Outcomes

Vascular hemostasis after venous and arterial access in cardiovascular procedures remains a challenge. As sheath size gets larger for structural heart and vascular procedures, no dedicated closure devices exist that can overcome all the challenges of achieving vascular hemostasis, in particular on the venous side. Efficiently and reliably ensuring hemostasis at the access point is crucial for enhancing the safety of a procedure. Historically, hemostasis relied on manually compressing venous access sites. However, the shift towards larger sheaths and the more frequent use of continuous anticoagulation has strained this approach. Achieving hemostasis solely through compression in these scenarios demands heightened vigilance and prolonged application, resulting in increased patient discomfort and extended immobility. Consequently, manual compression may consume more time for healthcare providers and contribute to bed occupancy in hospitals. This review article summarizes the development of the SiteSeal® Vascular Closure Device, a novel leave-nothing-behind approach to achieve hemostasis. The introduction of this technology has provided clinicians with a safer and more effective way to achieve immediate hemostasis, facilitate early ambulation, and enable earlier discharges with fewer access site complications compared with traditional manual compression.

Leadless cardiac ventricular pacing using helix fixation: Step-by-step guide to implantation

INTRODUCTION

Leadless cardiac pacemakers are an alternative modality to traditional transvenous pacemaker systems. Recently receiving Food and Drug Administration approval, the AVEIR VR leadless pacemaker system provides a helix based active fixation leadless pacemaker system. This step-by-step review will cover patient selection, preprocedural planning, device implantation technique, implant site evaluation, troubleshooting, short- and long-term complications as well as future directions for leadless pacing.

METHODS

We collected and reviewed cases from primary operators to provide a step-by-step review for implanters.

RESULTS

Our paper provides a guide to patient selection, pre-procedural planning, device im plantation technique, implant site evaluation, troubleshooting, short- and long-term complications as well as future directions for leadless pacing.

CONCLUSION

The helix based active fixation leadless pacemaker system is a safe and efficacious way to provide pacing support to patients and provides an alternative to transvenous pacing systems. Our review provides a step-by-step guide to implantation.

Management of Vascular Access in the Setting of Percutaneous Mechanical Circulatory Support (pMCS): Sheaths, Vascular Access and Closure Systems

The use of percutaneous mechanical circulatory support (pMCS), such as intra-aortic balloon pump, Impella, TandemHeart and VA-ECMO, in the setting of cardiogenic shock or in protect percutaneous coronary intervention (protect-PCI) is rapidly increasing in clinical practice. The major problem related to the use of pMCS is the management of all the device-related complications and of any vascular injury. MCS often requires large-bore access, if compared with common PCI, and for this reason the correct management of vascular access is a crucial point. The correct use of these devices in catheterization laboratories requires specific knowledge such as the correct evaluation of the vascular access performed, when possible, with advance imaging techniques in order to choose a percutaneous or a surgical approach. In addition to conventional transfemoral access, other types of access, such as transaxillary/subclavial access and the transcaval approach, have emerged over the years. These other approaches require advanced skills of the operators and a multidisciplinary team with dedicated physicians. Another important part of the management of vascular access is the closure systems used for hemostasis. Currently, two types of devices are typically used in the lab: suture-based or plug-based ones. In this review we want to describe all these aspects related to the management of vascular access in pMCS and describe, finally, a case report from our center's experience.

Femoral venous haemostasis in children and young adults using the 'figure-of-eight' suture technique

AIM

The aim of our study was to evaluate the safety and efficiency of the 'figure-of-eight' suture among children and young adults with congenital heart defects who underwent interventional procedures, in patients with structurally normal hearts who underwent electrophysiological study and in haemodynamically impaired children and newborns. We also reported a novel femoral haemostasis method in patients with a central catheter by modifying the 'figure-of-eight' suture around the catheter for haemorrhage control.

METHOD

Between 2015 and 2018, a total of 100 'figure-of-eight' sutures were performed in 90 patients (48 males, 42 females) where the median age was 12.5 years (minimum 3 days, maximum 22 years). The procedures were diagnostic angiography (n = 6), radiofrequency and/or cryoablation (n = 7) and interventional procedures (n = 87).

RESULT

Haemostasis was achieved in 89 of 90 patients. Haemostasis could not be achieved in one malnourished patient due to lack of subcutaneous tissue. There were no major complications. A bullous skin lesion and minor bleeding were the only complications seen in two patients. A central catheter was inserted in eight patients using the modified 'figure-of-eight' suture technique.

CONCLUSION

The 'figure-of-eight' suture is a safe and effective method for femoral venous haemostasis in patients who require large sheaths for procedures, in those using high-dose heparin and in haemodynamically unstable children who need cardiac catheterisation.

The efficacy of the figure-of-eight suture technique in the treatment of tunnel bleeding of the femoral artery route after percutaneous coronary intervention or angiography

Objective

To evaluate the efficacy of the figure-of-eight (FOE) suture technique in the treatment of tunnel bleeding after femoral artery puncture compared with manual compression (MC).

Methods

This prospective, randomized, controlled study enrolled patients that had received transfemoral coronary artery angiography or percutaneous coronary intervention and then developed tunnel bleeding. They were randomly assigned into two groups: FOE suture group (ES group) and manual compression group (MC group). Total treatment time, performance frequency, performance time, rate of deep vein thrombosis (DVT) and in-hospital time after the procedure were compared.

Results

A total of 152 patients were enrolled in the study (ES group, n = 63; MC group, n = 89). Compared with the MC group, the total treatment time (mean ± SD: ES 22.3 ± 5.4 h versus MC 26.8 ± 6.8 h), performance frequency (mean ± SD: ES 2.1 ± 0.7 versus MC 2.6 ± 1.1), performance time (mean ± SD: ES 8.9 ± 2.5 min versus MC 12.3 ± 4.1 min), in-hospital time after the procedure (mean ± SD: ES 3.5 ± 1.2 days versus MC 4.8 ± 2.1 days) and DVT rate (ES 0.0% versus MC 6.7%) were significantly lower in the ES group.

Conclusion

The FOE suture technique effectively treated tunnel bleeding after femoral artery puncture.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Update of Patient Selection and Therapeutic Strategy Using MitraClip

Patients with advanced heart failure often accompany severe function mitral regurgitation refractory to optimal medical therapy. Degenerative mitral regurgitation also develops due to various degeneration of mitral valve. Surgical intervention to the mitral valve might be effective in some cases, but it is challenging for the high-risk cases. Recently, percutaneous edge-to-edge mitral valve repair using the MitraClip system, which enables us to approach the mitral valve at relatively low risk, has developed. Two major prospective randomized control trials have been conducted to investigate the clinical advantage of MitraClip system over optimal medical therapy in patients with severe mitral regurgitation; both showed controversial conclusions. Now is a time to consider optimal patient selection and therapeutic strategy using MitraClip system.

Stitching your way to venous hemostasis

Venous compression using a purse string suture is a potential alternative to device suture of the venotomy or to the more extensively described Figure of 8 closure technique. The technique is likely to prove cost effective although the optimal methodology and overall risk remain to be determined. A general comment regarding the common femoral vein: it is a fragile structure. All venous closure techniques require special care not to obstruct, lacerate or sever the vein and operators should be vigilant for both bleeding and thrombosis.

A comparison of figure-of-8-suture versus manual compression for venous access closure after cardiac procedures: An updated meta-analysis

BACKGROUND

Manual compression (MC) is the current standard to achieve postprocedural hemostasis in patients who need venous vascular access closure after cardiovascular procedures. Figure-of-8 (F8) suture for venous access closure has been reported to be a safe and efficacious alternative to MC.

METHODS

A systematic search was done using PubMed, Google Scholar, EMBASE, SCOPUS, and ClinicalTrials.gov without language restriction up until April 15, 2020 for studies comparing F8 suture versus MC. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated using a random effects model.

RESULTS

Time to achieve hemostasis was significantly reduced in the F8 arm [MD -21.04 min (95% CI: -35.66 to -6.42; P = .005)]. Access site bleeding was significantly lower in the F8 group [RR 0.35 (95% CI: 0.18 to 0.66; P = .001)] along with a lower incidence of hematoma formation [RR 0.42 (95% CI: 0.26 to 0.67; P = .0003)]. There was no significant difference in rates of fistula or pseudoaneurysm formation between the two groups. Overall access site complications were lower in the F8 arm [RR 0.38 (95% CI: 0.26 to 0.55; P < .00001)] and the effect was more pronounced for sheaths ≥10 Fr [RR 0.33 (95% CI: 0.18 to 0.60; P = .0003)]. There was lower postprocedural protamine use in the F8 group [RR 0.07 (95% CI: 0.01 to 0.36; P = .001)].

CONCLUSION

For large-bore venous access closure, the F8 suture results in a shortened time to achieve hemostasis along with a lower overall risk of access site complications and postprocedural protamine use.

Torque device suture technique to achieve hemostasis in large-bore venous access

Objectives

To describe and compare a novel technique using a torque device to manage figure‐of‐eight suture tension for venous access hemostasis in patients who have undergone atrial septal defect (ASD) or patent foramen ovale (PFO) closure.

Background

Large bore venous access has become increasingly important in transcatheter procedures, but management of hemostasis can be time‐consuming and/or resource intensive. As such, various techniques have sought to provide cost effective and safe alternatives to manual compression. We describe a modification of the figure‐of‐eight suture technique wherein we apply a torque device to manage variable suture tension instead of tying a knot and compare it to the standard figure‐of‐eight suture technique.

Methods

We performed a retrospective study of 40 consecutive patients who underwent ASD or PFO closure, 20 of whom underwent standard figure‐of‐eight technique and 20 of whom underwent figure‐of‐eight with torque device modification. Bleeding Academic Research Consortium definitions were used to categorize bleeding events.

Results

The groups were similar in age, gender, weight, aspirin use, platelet count, procedure time, hemoglobin, and international normalized ratio. Standard figure‐of‐eight suture had seven patients with bleeding, with six classified as BARC II and one as BARC I. Figure‐of‐eight plus torque device had three patients with bleeding, with two classified BARC II and one as BARC I. There were no incidences of hematoma in either group.

Conclusion

The torque device suture technique is a unique modification of the figure‐of‐eight suture technique to achieve venous hemostasis. In addition, the modification allows secure and variable suture tension as well as easy removal by nursing staff.

Transcaval Access for Large Bore Devices

PURPOSE OF REVIEW

Examine the latest data and techniques regarding transcaval access and closure.

RECENT FINDINGS

Transcaval access was proven to be a feasible and a translatable skill in a 100 patient open-label prospective study. No late complications from fistulas occurred and of all patients alive at 1 year, one fistula remained open. Transcaval is a viable access route for large bore devices. With adequate planning, bleeding and vascular complications are minimal. It should be integrated into the rubric of transcatheter large bore access.

Heparin reversal with protamine sulfate is not required in atrial fibrillation ablation with suture hemostasis

BACKGROUND

The utility of protamine sulfate for heparin reversal in catheter-based atrial fibrillation (AF) ablation is unclear when using the suture closure technique for vascular hemostasis.

OBJECTIVE

This study sought to address if protamine sulfate use for heparin reversal reduces vascular access complications in AF catheter ablation when suture techniques are used for postprocedural vascular hemostasis.

METHODS

This is a retrospective multicenter observational study of 294 consecutive patients who underwent catheter ablation for AF with subsequent vascular access hemostasis by means of a figure-of-eight suture or stopcock technique. A total of 156 patients received protamine for heparin reversal before sheath removal while 138 patients did not receive protamine. The two groups were compared for procedural activated clotting time (ACT), access site complications, and duration of hospital stay.

RESULTS

Baseline demographic characteristics were comparable in both groups. Despite higher ACT before venous sheath removal in patients not receiving protamine (288.0 ± 44.3 vs 153.9 ± 32.0 seconds; P < .001), there was no significant difference in groin complications, postoperative thromboembolic events, or duration of hospital stay between the two groups. Suture failure requiring manual compression was rarely observed in this cohort (0.34%).

CONCLUSION

With modern vascular access and sheath management techniques, for patients undergoing catheter ablation for AF, simple suture closure techniques can obviate the need for protamine administration to safely achieve hemostasis after removal of vascular sheaths.

Efficacy and Safety of Subcutaneous Fellow's Stitch Using "Fisherman's Knot" Technique to Achieve Large Caliber (> 10 French) Venous Hemostasis

Background

Among patients undergoing intervention involving venous access, various techniques have been implemented to achieve hemostasis in order to reduce local access site complications, to decrease length of stay and to facilitate early ambulation. We aimed to assess the efficacy and safety of fellow’s stitch using “fisherman’s knot” (figure of Z (FoZ)) technique when compared with conventional manual compression for immediate closure of large venous sheath (> 10 French (Fr)).

Methods

Between November 2012 and March 2019, 949 patients underwent various interventions which involved venous access requiring hemostasis. All the patients were anticoagulated with heparin during the procedure. In a sequential allocation, fellow’s stitch using “fisherman’s knot” (group I: n = 384) and conventional manual compression (group II: n = 365) were used in achieving hemostasis at right/left femoral venous access site following sheath removal (> 12 Fr). A 0-Vicryl suture was used to make one deep stitch just distal to entry of sheath and one superficial stitch just proximal to entry site, thereby creating an FoZ. A fisherman’s knot was then tied, and knot was pushed down while sheath was removed. In cases where immediate hemostasis was not achieved, it was compressed for 2 min to achieve it.

Results

The mean age of 949 patients was 13.1 ± 8.2 years where male (n = 574; 65%) outnumbered female (n = 375; 35%). In group I, hemostasis was achieved immediately after tying the knot in 343 (89.3%) patients, while within ≤ 2 min of light pressure in 41 (10.7%) patients. Five (1.3%) patients had failure of stitch as suture snapped during knotting, and hemostasis was achieved by manual compression as per protocol in group I. The median time to hemostasis (1.1 vs. 14.3 min, P < 0.001), ambulation (3.3 vs. 18.9 h, P < 0.01) and hospital stay (24.6 vs. 36.8 h, P < 0.001) was significantly shorter in group I compared to group II. The minor vascular access site complications in form of hematoma (n = 6 (1.6%) vs. n = 1 (0.2%); P < 0.001), and thrombosis at femoral vein (n = 4 (1.1%) vs. n = 0 (0%); P < 0.001) were significantly higher in group II when compared to group I. The differences regarding re-bleeding and formation of arterio-venous fistula between both the groups were statistically insignificant.

Conclusion

The fellow’s stitch using “fisherman’s knot” or “FoZ” suture is a simple, efficacious and safe technique to achieve an immediate hemostasis after removal of larger venous sheath (> 10 Fr).

Tetra-PEG Based Hydrogel Sealants for In Vivo Visceral Hemostasis

Medical sealant devices for in vivo hemostasis are far from satisfactory in the aged society. A major challenge is effective integration of quick hemorrhage control of the increased anticoagulated patients, high safety, and facile accessibility. Here, a well-defined ammonolysis-based Tetra-PEG hydrogel sealant is developed with rapid gelation speed, strong tissue adhesion, and high mechanical strength. Introduction of cyclized succinyl ester groups into a hydrogel matrix endows the sealant with fast degradable and controllably dissolvable properties. The hydrogel possesses outstanding hemostatic capabilities even under the anticoagulated conditions while displaying excellent biocompatibility and feasibility. These results reveal that the optimized hydrogel may be a facile, effective, and safe sealant for hemorrhage control in vivo.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Efficacy and safety of figure-of-eight suture versus manual pressure for venous access closure: a systematic review and meta-analysis

BACKGROUND

Vascular hemostasis after venous access in cardiovascular procedures remains a challenge. Figure-of-eight (FoE) emerged as an alternative technique to manual pressure. However, its feasibility and safety is unknown.

METHODS

A comprehensive search in clinicalTrials.gov, PubMed, Web of Science, EBSCO Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from inception to December 1, 2018, was performed. A meta-analysis was performed using random effects model to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI).

RESULTS

Seven studies were eligible and included 1978 patients, of whom 982 patients received the FoE suture, while 996 received manual pressure. There was no difference in the risk of access site pseudoaneurysm (RR 0.48, 95%CI 0.13 to 1.73, p = 0.26) and fistula (RR 0.90, 95%CI 0.22 to 3.75, p = 0.89) between the two techniques. Compared with manual pressure, FoE was associated with lower risk of access site complications (RR 0.37, 95%CI 0.24 to 0.58, 0.65, p < 0.0001) including bleeding (RR 0.30, 95%CI 0.18 to 0.50, p < 0.00001) and hematoma (RR 0.41, 95%CI 0.25 to 0.68, 0.83, p = 0.0005). Time to hemostasis was significantly lower in FoE group compared with manual pressure (MD - 21.04 min, 95%CI - 35.66 to - 6.42, p = 0.005).

CONCLUSIONS

The results of our meta-analysis showed that there was no difference in the risk of access site pseudoaneurysm and fistula between FoE and manual pressure. FoE was associated with lower risk of access site hematoma and bleeding compared with manual pressure. Our results reiterate the safety and feasibility of FoE suture for venous access closure.

Transcatheter Closure of Atrial Septal Defects: Comparable Experience and Outcomes Between Developing and Developed Countries

Atrial septal defect (ASD) is one of the most common congenital heart defects. Transcatheter device closure of ASDs is safe and effective with most of the reported data being described from developed countries. To evaluate the short and mid-term results and experience of device closure of ASDs at a tertiary center in a developing country and compare it to that from developed countries. Retrospective study based on data collection from all patients who have undergone transcatheter percutaneous device closure for ASD from January 2005 until December 2017 at the Children's Heart Center at the American University of Beirut, Medical Center, Lebanon. During the study period, a total of 254 cardiac catheterizations were performed for device closure of ASDs. The mean age of the patients was 18 ± 17.9 years with 37% being less than 6 years of age. Females were 54%. Defect size ranged from 7 to 37 mm and device size ranged from 8 to 40 mm. The procedure was executed with a success rate of 96%. Five patients had device embolization (2%); in one patient the device was snared and for the remainder the devices were removed surgically. None of the study patients had thrombus formation, neurological complications, bacterial endocarditis, or cardiac erosions. There was no mortality. Device closure of ASDs at our tertiary center in a developing country has an effective and safe profile with excellent results and low complications rates, which compare favorably to those reported from centers in developed countries.

Figure-of-eight sutures for hemostasis result in shorter lab recovery time after ablation for atrial fibrillation

BACKGROUND

Ablation for atrial fibrillation (AF) requires multiple venous sheaths and anticoagulation with heparin, both risk factors for bleeding complications. Manual compression (MC) with heparin reversal is the standard method to achieve venous hemostasis postablation; however, temporary figure-of-eight sutures (F8S) are an alternative. While this technique has been shown to be safe and effective, little is known about its effect on postprocedural recovery time.

METHODS

In this retrospective cohort study, consecutive patients who underwent AF radiofrequency ablation over a 23-month period were reviewed for type of hemostasis (manual compression or figure-of-eight suture), demographics, periprocedural anticoagulation, groin complications, and procedural duration.

RESULTS

A total of 104 patients were included (42 in the MC group and 62 in the F8S group). The two groups were similar for mean age, gender, weight, oral anticoagulant use, and procedural heparin dosing. Access site complications were 4.76% versus 3.23% (P = 0.68). Time from procedure end to sheath removal was lower in the F8S group (16.2 ± 8.47 vs 4.25 ± 4.14 min, P < 0.0001). Overall time from procedure end to hemostasis was 36.1 ± 10.1 min in the MC group versus 7.9 ± 5.6 in the F8S group (P < 0.0001). Times to extubation and transport out of the lab were both significantly lower in the F8S group (34.1 ± 14.6 vs 13.5 ± 5.4 min, and 44 ± 14.6 vs 21.9 ± 6.7 min, respectively, P < 0.0001).

CONCLUSION

Figure-of-eight sutures provided efficient hemostasis following AF ablation, with significantly reduced postprocedure recovery time including time to hemostasis, extubation, and transport out of the lab.

Closure of Large Percutaneous Femoral Venous Access Using a Modified "Figure-of-Eight" Suture

Recent advances in different percutaneous treatments made insertion of large-caliber sheaths in the femoral veins more common. Venous punctures are historically managed by initial manual compression with subsequent application of a compression bandage and bed rest. We describe a modified "figure-of-eight" suture technique for minimizing the risk of accidental puncture of the vein while grabbing the subcutaneous tissue. We examined the safety and feasibility of this technique combined with early mobilization in a real-world setting. We performed a retrospective analysis on 56 consecutive patients undergoing percutaneous mitral valve repair using large femoral venous access. The patient population was heterogeneous and bleeding risk characteristics were common. Bleeding Academic Research Consortium Consensus (BARC)-classifiable bleeding complications occurred in eight patients (14%), BARC of two events or more in five patients (8.9%), and BARC of three or more event in only one patient (1.8%), which is a comparable success rate to large venous access closure with suture-mediated closure devices. No BARC Type 3b or BARC Type 5 bleeding occurred. During routine clinical follow-up, no groin-related problems were reported in all patients. Closure of large femoral venous access using a modified temporary subcutaneous figure-of-eight suture in combination of a light compression bandage and bed rest for 2 to 4 hours provides a safe and low-cost alternative to closure devices for early mobilization.

Catheter-Based Embolectomy for Acute Pulmonary Embolism: Devices, Technical Considerations, Risks, and Benefits

A significant number of patients with high-risk pulmonary embolism have contraindications to thrombolytic therapy. Catheter-based therapy may be helpful and consists of a multitude of catheters and techniques, some old and some new. Although there are few data supporting the use of any of these techniques, there has been a recent rise in interest and use of catheter-based pulmonary embolectomy. This text describes the contemporary devices used in pulmonary embolism treatment, discusses their challenges, and proposes some future directions.

Safety and Feasibility of Subcutaneous Purse-String Suture of the Femoral Vein After Electrophysiological Procedures on Uninterrupted Oral Anticoagulation

The aim of this study was to compare safety and feasibility of a subcutaneous purse-string suture (PSS) with manual compression (MC) to gain hemostasis in patients after multiple femoral venous punctures undergoing electrophysiological procedures on uninterrupted oral anticoagulation (OAK). A total of 784 patients who underwent catheter ablation for atrial fibrillation (n = 564) or (a)typical atrial flutter (n = 220) were assessed. Four hundred sixty-two patients received PSS (58.9%) and 322 patients (41.1%) received MC to gain hemostasis. All patients were on uninterrupted full-dose OAK. During the procedure, weight-adapted heparin was applied. Venous sheath diameter were 8Fr (n = 2)/11.5Fr (n = 1) for left atrial or 8Fr (n = 1)/6Fr (n = 2) for right atrial procedures. No protamine was administered at the end of the procedure. After PSS, patients' had 6 hours of bed rest compared with 10 hours after MC (sheath removal after 4 hours followed by a bandage for 6 hours). PSS was removed the following day. All patients underwent duplex sonography of the access site the following day. Using the PSS, hemostasis was achieved in 453 of 462 patients (98%). MC leads to hemostasis in all 322 patients. No difference was found between the 2 approaches regarding hematomas (<5 cm or >5 cm), arterio-venous fistulas, or pseudoaneurysms. No major complication such as ipsilateral leg ischemia, the need of vascular surgery, or deep vein thrombosis occurred. In conclusion, PSS is a safe and effective way to gain immediate hemostasis after multiple punctures of the femoral vein in patients undergoing catheter ablation on OAK. PSS avoids MC and leads to shorter patient immobilization.

Transcatheter Treatment of Severe Tricuspid Regurgitation With the Edge-to-Edge MitraClip Technique

BACKGROUND

Current surgical and medical treatment options for severe tricuspid regurgitation (TR) are limited, and additional interventional approaches are required. In the present observational study, the safety and feasibility of transcatheter repair of chronic severe TR with the MitraClip system were evaluated. In addition, the effects on clinical symptoms were assessed.

METHODS

Patients with heart failure symptoms and severe TR on optimal medical treatment were treated with the MitraClip system. Safety, defined as periprocedural adverse events such as death, myocardial infarction, stroke, or cardiac tamponade, and feasibility, defined as successful implantation of 1 or more MitraClip devices and reduction of TR by at least 1 grade, were evaluated before discharge and after 30 days. In addition, functional outcome, defined as changes in New York Heart Assocation class and 6-minute walking distance, were assessed.

RESULTS

We included 64 consecutive patients (mean age 76.6±10 years) deemed unsuitable for surgery who underwent MitraClip treatment for chronic, severe TR for compassionate use. Functional TR was present in 88%; in addition, 22 patients were also treated with the MitraClip system for mitral regurgitation as a combined procedure. The degree of TR was severe or massive in 88% of patients before the procedure. The MitraClip device was successfully implanted in the tricuspid valve in 97% of the cases. After the procedure, TR was reduced by at least 1 grade in 91% of the patients, thereof 4% that were reduced from massive to severe. In 13% of patients, TR remained severe after the procedure. Significant reductions in effective regurgitant orifice area (0.9±0.3cm² versus 0.4±0.2cm²; P<0.001), vena contracta width (1.1±0.5 cm versus 0.6±0.3 cm; P=0.001), and regurgitant volume (57.2±12.8 mL/beat versus 30.8±6.9 mL/beat; P<0.001) were observed. No intraprocedural deaths, cardiac tamponade, emergency surgery, stroke, myocardial infarction, or major vascular complications occurred. Three (5%) in-hospital deaths occurred. New York Heart Association class was significantly improved (P<0.001), and 6-minute walking distance increased significantly (165.9±102.5 m versus 193.5±115.9 m; P=0.007).

CONCLUSIONS

Transcatheter treatment of TR with the MitraClip system seems to be safe and feasible in this cohort of preselected patients. Initial efficacy analysis showed encouraging reduction of TR, which may potentially result in improved clinical outcomes.

Figure-of-eight suture for venous hemostasis in fully anticoagulated patients after atrial fibrillation catheter ablation

Introduction

Limited data exists for types of venous closure and its associated complications in patients after atrial fibrillation (AF) catheter ablation. We evaluated the subcutaneous figure-of-eight closure (FO8) for achieving venous hemostasis after AF catheter ablation compared to manual pressure.

Methods

284 consecutive patients that underwent AF catheter ablation by two operators were included. All patients received continuous therapeutic warfarin or interrupted novel oral anticoagulants (NOAC) and heparin (ACT300-400 s) without reversal. Patients were divided into two groups: 1) sheaths were left in place and pulled once ACT < 180 s, with hemostasis being achieved with manual pressure (MP); and 2) a subcutaneous FO8 suture closed the venous access site immediately after the ablation on each groin site and sheaths were removed immediately after the ablation despite full anticoagulation with heparin and warfarin or interrupted NOAC. Sutures were removed after four hours, and the patients laid flat for an additional two hours.

Results

The MP group (n = 105) was similar to the FO8 group (n = 179). Time in bed was 573 ± 80 min for MP group vs. 373 ± 49 min for FO8 group (p < 0.0001). Eleven hematomas were seen in the MP group compared to seven in the FO8 group (P = 0.041).

Conclusions

In fully anticoagulated patients undergoing AF catheter ablation, excellent hemostasis was achieved with figure-of-eight sutures, with no major vascular complications, a lower hematoma rate, and a significantly shorter flat-time-in-bed compared to manual pressure.

Subcutaneous Double "Purse String Suture"-A Safe Method for Femoral Vein Access Site Closure after Leadless Pacemaker Implantation

BACKGROUND

Leadless cardiac pacemaker (LCP) requires large-caliber venous sheaths for device placement. Sheath sizes for these procedures vary from 18- to 23-French (F). The most common complications are hematomas, pseudoaneurysms, and arteriovenous fistulas. Complete and secure closure of the venous access is an important step at the end of such a procedure.

METHODS

We performed a retrospective analysis of all patients who had undergone LCP implantation at our institution. Patients and procedural characteristics as well as groin complications at 30 days and 3 months were evaluated. After sheath removal venous access sites were closed performing a so-called "purse-string" suture (PSS).

RESULTS

Seventy-seven patients received an LCP at our institution. In 27 (35%) of these patients a heparin bolus was given at the beginning of the procedure. Anticoagulation therapy with phenprocoumon was present in 32 (40%) of patients. In 76 (98.7%) patients, the LCP was implanted without complications. In one (1.3%) patient a perforation occurred during implantation, which required surgical intervention. Access site complications occurred in three (3.9%) patients, two (2.6%) groin hematomas, and one (1.3%) arteriovenous fistula. The hematomas disappeared completely after 3 weeks, and the fistula was not detectable by ultrasound anymore after 4 weeks.

CONCLUSION

Use of subcutaneous absorbable double PSS closure after removal of large-caliber venous sheaths is a safe technique to achieve immediate postprocedural hemostasis. Especially for sheath sizes with an inner diameter of 23F, this technique creates a very secure and also cosmetically appealing closure.

How to perform transcaval access and closure for transcatheter aortic valve implantation

Transcaval, or caval-aortic, access is a promising approach for fully percutaneous transcatheter aortic valve implantation in patients without good conventional access options. This tutorial review provides step-by-step guidance to planning and executing the procedure, along with approaches to remedy complications.

Feasibility and clinical benefit of a suture-mediated closure device for femoral vein access after percutaneous edge-to-edge mitral valve repair

AIMS

We assessed feasibility, efficacy and safety of a suture-mediated closure device, Perclose Proglide (Abbott Vascular Devices, Santa Clara, CA, USA), for closure of the femoral vein access after percutaneous MitraClip (Abbott Vascular Devices) implantation.

METHODS AND RESULTS

Venous access of 80 consecutive patients undergoing percutaneous mitral valve repair using the MitraClip device was managed either by manual compression, "figure eight" suture and compression bandage for 12 hours, or by applying the Proglide device for haemostasis after the procedure (40 patients each group). Patients with Proglide closure showed complete immediate haemostasis in 92.5% (37/40) and were immobilised with a compression bandage for only four hours. In the Proglide group, one arteriovenous fistula was observed and had to be treated by vascular surgery. The overall duration of stay on an intensive care unit was significantly reduced in the Proglide group (59.4±48.9 hours vs. 84.6±59.5 hours, p<0.005).

CONCLUSIONS

Using a suture-mediated closure device for the femoral vein after percutaneous MitraClip implantation is feasible and safe. This allows earlier patient mobilisation and may reduce post-interventional duration of stay on an intensive care unit.

Awake extracorporeal membrane oxygenation for very high-risk coronary angioplasty

High-risk angioplasty has been defined as an intervention on an unprotected left main (LM) coronary artery or "last patent coronary conduit" in the context of moderate to severe left ventricular (LV) dysfunction. We report a case of a patient with severe LV dysfunction, severe aortic valve stenosis, and an occluded right coronary artery requiring elective intervention on a heavily calcified subtotally occluded LM coronary artery while the patient was awake with extracorporeal membrane oxygenation (ECMO) support. Given the added benefit of percutaneous closure, we believe that ECMO support with only conscious sedation is a viable mode of hemodynamic support in high-risk cases.

Antegrade approach for TAVR with total occlusion of the descending aorta

The antegrade approach for aortic valve interventions is well known but has not been widely used for transcatheter aortic valve replacement (TAVR) procedures. We encountered a patient with no possibility of retrograde access due to a totally occluded abdominal aorta who had a failed attempt at apical TAVR. We describe antegrade TAVR despite occlusion of the abdominal aorta, with the arterial limb of the requisite veno-arterial loop created using bilateral arm access, a novel version of the previously described antegrade approach.

Clinically manifest thromboembolic complications of femoral vein catheterization for continuous renal replacement therapy

PURPOSE

The safety of femoral vein (FV) catheterization for continuous renal replacement therapy is uncertain. We sought to determine the incidence of clinically manifest venous thromboembolism (VTE) in such patients.

METHODS

We retrospectively studied patients with femoral high flow catheters (≥ 13F) (December 2005 to February 2011). Discharge diagnostic codes were independently screened for VTE. The incidence of VTE was also independently similarly assessed in a control cohort of patients ventilated for more than 2 days (January 2011 to December 2011) in the same intensive care unit (ICU).

RESULTS

We studied 380 patients. Their mean age was 61 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation III score was 84; average duration of continuous renal replacement therapy was 74 hours, and 232 patients (61%) survived to hospital discharge with an average length of hospital stay of 22 days. Only 5 patients (1.3%) had clinically manifest VTE after FV catheterization. In the control cohort of 514 ICU patients, the incidence of VTE was 4.4% (P < .05 compared with FV group).

CONCLUSION

The incidence of clinically manifest VTE after FV catheterization with high flow catheters is low and lower to that seen in general ICU patients.