Arterial Closure Devices Versus Manual Compression for Femoral Haemostasis in Interventional Radiological Procedures: A Systematic Review and Meta-Analysis

ESR Essentials: arterial vascular access and closure devices-practice recommendations by the Cardiovascular and Interventional Radiological Society of Europe

Vascular access is the initial, very important, step of endovascular procedures. Various access sites include the common femoral artery, brachial artery, radial artery, popliteal artery, and distal tibial vessels (pedal arteries). Successful arterial access requires advanced knowledge of anatomy, as well as proper training and experience. Today, vascular access should be obtained using real-time, ultrasound guidance to reduce access time, patient discomfort, and puncture-related complications including dissection, arteriovenous communication, and bleeding. Nevertheless, high-level evidence to support this recommendation in peripheral procedures is limited and level A data are mainly derived from randomized cardiac trials investigating only radial and femoral access. Vascular closure devices (VCDs) for femoral access can be broadly categorized as active closure devices, compression assist devices, and external/topical hemostasis devices. There is high-level evidence demonstrating that their use is related to less time for ambulation and increased patient satisfaction. However, available data failed to clearly demonstrate a benefit in complications compared to standard manual compression in peripheral endovascular arterial procedures, and thrombotic and infectious complications reported following VCD use remain an issue. Heterogeneity noted in the literature, caused by the vast variety of devices, access sites, sheath sizes, clinical scenarios, and procedures, poses difficulties in data analysis and future study design. As a result, an individualized VCD use is currently suggested for ≥ 5 Fr femoral artery access not only to reduce time to hemostasis and ambulation and to improve patient comfort, but also to reduce bleeding complications in cases of femoral access with increased bleeding risk, deranged coagulation, and large-bore access, though a high level of evidence to support this later recommendation is limited. KEY POINTS: US guidance is strongly recommended for femoral access and is mandatory to obtain more challenging access. The use of VCDs for femoral hemostasis is generally safe, effective, and currently supported by level I evidence. Proper training and correct VCD choice, based on the patient's individual characteristics, are imperative to optimize outcomes.

Passive Approximator Vascular Closure Device Use in Patients with Shallow Femoral Artery Depth Increases Puncture-site Complications in Neuroendovascular Treatment

OBJECTIVE

Puncture-site complications in interventional radiology sometimes cause severe conditions. Vascular closure devices play an important role in preventing puncture-site complications. Vascular closure devices are divided into 2 types, the directly suturing or clipping type (active approximators) and adherent sealant types (passive approximators). However, which types of vascular closure device are the safest and most effective for achieving hemostasis remains unclear. We analyzed the efficacy of each type of vascular closure device and risk factors for puncture-site complications.

METHODS

This study investigated 327 consecutive cases of neuroendovascular surgery using a transfemoral procedure during a 2-year study period. Passive approximators (Angioseal [St Jude Medical, Saint Paul, MN] and Exoseal [Cordis Corporation, Miami, FL]) were mainly used in the first half and active approximators (Perclose [Abbot Vascular, Santa Clara, CA]) in the second. We compared groups and estimated risk factors for puncture-site complications.

RESULTS

All procedures were successful. Comparing groups with and without puncture-site complications, use of passive approximators and ≥3 antithrombotic medications tended to be more frequent and distance from skin to femoral artery and body mass index tended to be lower in the group with complications without significance. The cutoff for femoral artery depth calculated from a receiver operating characteristic curve was 16.43 mm. Multivariate analysis revealed ≥3 antithrombotic medications (P = 0.002, OR 15.29, 95% CI 2.76-85.76) and passive approximator use in patients with femoral artery depth <16.43 mm (P < 0.001, OR 17.08, 95% CI 2.95-57.80) were significantly higher in the group with puncture-site complications.

CONCLUSIONS

Passive approximator use in patients with shallow femoral artery depth increases puncture-site complications in neuroendovascular treatment.

Dealing with complications in interventional radiology

It is widely accepted that most misadventures, which lead to harm have not occurred because of a single individual but rather due to a failure of process that results in healthcare workers making mistakes. This failure of process and the pervasiveness of adverse events is just as prevalent in Interventional Radiology (IR) as it is in other specialities. The true prevalence and prevailing aetiology of complications in IR are not exactly known as there is a paucity of investigative literature into this area; especially when compared with other more established disciplines such as Surgery. Some IR procedures have a higher risk profile than others. However, published data suggests that many adverse events in IR are preventable (55-84%) and frequently involve a device related complication such as improper usage or malfunction. This article aims to discuss factors that contribute to complications in IR along with tools and strategies for dealing with them to achieve optimal patient outcomes.

Off-Label Use of the 8-F Angio-Seal for Closure of Greater than 8-F Common Femoral Arterial Access: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the safety of >8-F access closures using 8-F Angio-Seal.

MATERIALS AND METHODS

An electronic search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines using Web of Science, Embase, Scopus, and PubMed databases from inception until January 17, 2022. Actionable and nonactionable bleeding events were defined in conjugation with the Bleeding Academic Research Consortium definition. Prevalence rates with corresponding 95% CIs were calculated using R software version 4.2.2. Eight articles, with 422 patients, were included in the analysis.

RESULTS

The overall groin adverse event rate was 5.92% (95% CI, 3.01-11.34). The most commonly reported adverse events were any bleeding (5.74%; 95% CI, 3.23-10.00) (nonactionable bleeding, 0.96% [95% CI, 0.10-8.30]; actionable bleeding, 2.30% [95% CI, 0.89-5.84]), pseudoaneurysm (1.18%; 95% CI, 0.49-2.81), and groin hematoma (1.28%; 95% CI, 0.23-6.79). The least commonly reported adverse events were device failure and vessel occlusion/stenosis, with rates 0.29% (95% CI, 0.01-7.41) and 0.45% (95% CI, 0.02-7.74), respectively. No studies recorded events regarding the following adverse events: mortality, infection, deep venous thrombosis, and retroperitoneal hematoma. Moreover, the results showed significant differences, based on the sheath size used, in actionable bleeding (P = .04) and the rate of need for surgical repair (P < .01).

CONCLUSIONS

Common femoral artery access of >8-F can be effectively closed with the Angio-Seal with comparable outcomes to those of <8 F; however, larger access approaching 14 F is associated with a significant increase in morbidity. Further safety is needed, especially for the larger access sizes.

Usefulness of Stanch Belt Plus in Postoperative Management after Endovascular Neurosurgery

Objective

We verified the usefulness of patient management using a balloon-pressurized belt (Stanch Belt Plus) to prevent puncture site hematomas, which can occur at a specific rate even with hemostatic devices after endovascular neurosurgery.

Methods

A total of 113 patients who underwent endovascular surgery with a femoral puncture from April 2019 to September 2020 were divided into two groups: 31 cases using a traditional compression belt and 82 cases using a newly introduced balloon-pressurized belt during this period. The clinical data were analyzed retrospectively. The chi-square test and Mann-Whitney U test were used to test for significant differences.

Results

There were no significant differences in treatment procedures or frequency of hemostatic device use, but the balloon-pressurized belt group had a significantly lower incidence of hematomas (2.4% vs 12.9%, p <0.05) and a significantly lower incidence of moderate or higher lumbago (22.0% vs 41.9%, p <0.05). The incidence of epidermal detachment tended to be low; however, no significant difference was observed (3.7% vs. 12.9%, n.s.).

Conclusion

Patient management with the newly introduced balloon-pressurized belt may decrease the occurrence of groin hematoma and lumbago among complications after endovascular neurosurgery.

Safety and effectiveness of vascular closure devices in interventional radiological procedures

BACKGROUND

Although it is well known that vascular closure devices (VCD) are commonly used in therapeutic interventional radiological procedures, standard use in diagnostic procedures is not as well studied.

PURPOSE

The aim of this study was to determine the real-world safety and effectiveness of the VCD in both diagnostic and therapeutic interventional radiological procedures.

MATERIALS AND METHODS

A retrospective, single center study included all patients where VCDs were used for either a diagnostic or therapeutic interventional procedure. Various demographic and clinical risk factors were recorded and examined for any significant association with successful deployment and complications.

RESULTS

A total of 2072 patients were included. VCDs were successfully deployed in 95.2% of the patients with 4.8% of perioperative complications, which included minor oozing from the puncture site, small hematoma less than or equal to 5 cm, large hematoma greater than 5 cm, pain, and loss of vascular access. Therapeutic (vascular interventional radiology (VIR) and neuro-interventional radiology (NIR)) procedures (OR 3.03, 95% CI 1.51-6.09, p = 0.002), use of Angioseal (OR 5.26, 95% CI 3.13-8.33), p < 0.001), and no use of antiplatelet medications (OR 0.47, 95% CI 0.22-0.97, p = 0.041) were independently associated with successful deployment of VCDs when controlled for other risk factors. Smoking (OR 3.50, 95% CI 2.00-6.05, p = <0.001), use of antiplatelet (OR 2.01, 95% CI 1.04-3.87, p = 0.037) and use of heparin (OR 1.78, 95% CI 1.10-2.86, p = 0.018) were independently associated with higher complication rates.

CONCLUSION

VCD's were successfully deployed in 95.2% of the patients with 4.8% of perioperative minor complications.

Comparison of plug-based versus suture-based vascular closure for large-bore arterial access: a collaborative meta-analysis of observational and randomized studies

BACKGROUND

Large-bore arteriotomies can be percutaneously closed with suture-based or plug-based vascular closure device (VCD) strategies. The efficacy of both techniques remains controversial.

AIMS

We conducted a meta-analysis of comparative studies between both VCD strategies, focusing on the most commonly applied VCDs (MANTA and ProGlide).

METHODS

We searched MEDLINE, the Cochrane Central Register of Controlled Trials and Google scholar for observational studies (OS) and randomized controlled trials (RCT) comparing vascular closure with the MANTA-based and the ProGlide-based technique. The principal endpoint of this analysis was access-site related vascular complications. Both study types were analyzed separately.

RESULTS

Access-site related vascular complications were less frequent after vascular closure with the MANTA technique in the analysis of OS (RR 0.61 [95%CI 0.43-0.89], p = 0.01, I2 = 0%), but more frequent in the analysis of RCT data (RR 1.70 [95%CI 1.16-2.51], p = 0.01, I2 = 0%). Both data sets provided no significant difference between the VCD techniques in terms of overall bleeding events (OS: RR 0.57 [95%CI 0.32-1.02], p = 0.06, I2 = 70%; and RCT: RR 1.37 [95%CI 0.82-2.28], p = 0.23, I2 = 30%). RCT data showed that endovascular stenting or vascular surgery due to VCD failure occurred more often after MANTA application (RR 3.53 [95%CI 1.07-11.33], p = 0.04, I2 = 0%).

CONCLUSIONS

While OS point to favorable outcomes for large-bore vascular closure with the MANTA-based technique, RCT data show that this strategy is associated with more access-site related vascular complications as well as endovascular stenting or vascular surgery due to device failure compared with the ProGlide-based technique.

Costs and budget impact of collagen-based vascular closure device versus manual compression following peripheral endovascular procedures

OBJECTIVES

To evaluate the annual costs and budget impact of using a vascular closure device to achieve haemostasis following femoral access endovascular procedures in England, compared with manual compression.

METHODS

A budget impact model was developed in Microsoft® Excel, based on the estimated number of peripheral endovascular procedures eligible for day-case management performed annually by the National Health Service in England. The clinical effectiveness of vascular closure devices was captured based on the requirement for inpatient stays and the incidence of complications. Data for endovascular procedures, time to haemostasis, length of hospital stay, and complications were collected from public sources and the published literature. There were no patients involved in this study. Model outcomes are reported as estimated number of bed days and annual costs to the National Health Service for all peripheral endovascular procedures in England, and the average cost per procedure. The robustness of the model was tested in a sensitivity analysis.

RESULTS

The model estimated savings for the National Health Service of up to £4.5 million annually if vascular closure devices were used in every procedure instead of manual compression. The model estimated an average cost saving of £176 per procedure for vascular closure devices over manual compression, primarily due to fewer inpatient stays. The sensitivity analysis demonstrated that the proportion of day-case procedures for vascular closure devices and manual compression was a key driver of costs and savings.

CONCLUSIONS

The use of vascular closure devices for achieving haemostasis after peripheral endovascular procedures may be associated with lower resource use and cost burden, compared with manual compression, based on shorter time to haemostasis and ambulation and an increased likelihood of a day-case procedure.

An alarm device for mechanical compression device displacement at femoral artery puncture sites

OBJECTIVE

To develop an alarm device for the mechanical compression device displacement (MCD), and further evaluate its effectiveness in clinical use.

MATERIAL AND METHODS

The alarm device is mainly composed of buzzer, indicator light, magnetic sheet. This is a prospective randomized and controlled study. Four hundred patients who met the inclusion/exclusion criteria were included and randomly assigned to two groups (MCD group vs alarm + MCD group). The primary outcome measures were the sensitivity and specificity of the alarm device to detect MCD displacement, time to hemostasis (TTH), time to ambulation (TTA), time to hospital discharge (TTHD), hospital costs (HC), complication rates, and patient satisfaction.

RESULTS

The sensitivity and specificity of the alarm device in detecting MCD displacement were 94.44% and 88.46%, respectively. The study group achieved shorter TTH (p = .034), shorter TTA (p = .021), lower complication rates (p = .025), and better patients' satisfaction (p < .001) compared to the control group. However, no significant difference was observed in TTHD (p = .361) and HC (p = .583).

CONCLUSION

The alarm device is highly sensitive in detecting MCD displacement, while achieving better clinical outcomes compared with artificial monitoring.

The Use of Vascular Closure Devices for Brachial Artery Access: A Systematic Review and Meta-Analysis

PURPOSE

To estimate the rates of technical success and adverse events of vascular closure devices (VCDs) in the brachial artery and compare the rates of adverse events with manual compression.

MATERIALS AND METHODS

MEDLINE and Embase were searched for observational studies examining VCDs in the brachial artery. Meta-analyses were performed using random effects for the following outcomes: (a) technical success, (b) hematoma at the access site, (c) pseudoaneurysm, (d) local neurological adverse events, and (e) total number of adverse events. A pairwise meta-analysis compared VCD with manual compression for the outcomes of hematoma and the total number of adverse events.

RESULTS

Of 1,761 eligible records, 16 studies including 510 access sites were included. Primary procedures performed were peripheral arterial disease interventions, percutaneous coronary intervention, and endovascular thrombectomy for ischemic stroke. The technical success rate was 93% (95% CI, 87%-96%; I² = 47%). Data on the following adverse events were obtained via meta-analysis: (a) hematoma, 9% (5%-15%; I² = 54%); (b) stenosis or occlusion at access site, 3% (1%-14%; I² = 51%); (c) infection, 0% (0%-5%; I² = 0%); (d) pseudoaneurysm, 4% (1%-13%; I² = 61%); (e) local neurological adverse events, 5% (2%-13%; I² = 54%); and (f) total number of adverse events, 15% (10%-22%; I² = 51%). Angio-Seal success rate was 96% (93%-98%; I² = 0%), whereas the ExoSeal success rate was 93% (69%-99%; I² = 61%). When comparing VCD and manual compression, there was no difference in hematoma formation (relative risk, 0.75; 95% CI, 0.35-1.63; I² = 0%; P = .47) or the total number of adverse events (relative risk, 0.75; 95% CI, 0.35-1.58; I² = 76%; P = .45).

CONCLUSIONS

Despite being off-label, studies suggest that VCDs in the brachial artery have a high technical success rate. There was no significant difference in adverse events between VCDs and manual compression in the brachial artery.

The emerging role of adopting protamine for reducing the risk of bleeding complications during the percutaneous coronary intervention: A meta-analysis

BACKGROUND

The safety and the benefits of reducing the risk of bleeding complications via protamine administration during the percutaneous coronary intervention (PCI) remains unclear. This study aimed to systematically assessed the efficacy and safety of using protamine in PCI.

METHOD

Potential academic studies were identified from PubMed, Cochrane Library, EMBASE, and Web of Science. The time range we retrieved from was that from the inception of electronic databases to March 31, 2022. Gray studies were identified from the references of included literature reports. Stata version 12.0 statistical software (StataCorp LP) was used to analyze the pooled data.

RESULTS

A total of seven studies were involved in our study. The overall participants of the protamine group were 4983, whereas it was 1953 in the nonprotamine group. This meta-analysis indicated that protamine was preferable for PCI as its lower value of major bleeding (odds ratio [OR] = 0.489, 95% confidence interval [CI]: 0.362-0.661, p < .001) and minor bleeding (OR = 0.281, 95% CI: 0.123-0.643, p = .003). Additionally, the protamine did not tend to be related a higher incidence of mortality (p = .143), myocardial infarction (p = .990), and stent thrombosis (p = .698).

CONCLUSIONS

Based on available evidence, use of protamine may reduce the risk of bleeding complications without increasing the risk of mortality, myocardial infarction, and stent thrombosis. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.

Midterm results of kissing stent reconstruction of the aortoiliac bifurcation

Purpose

One subset of peripheral arterial disease is aortoiliac occlusive diseases (AIOD). AIOD is the term for all arterial lesions between the infrarenal distal aorta and common femoral artery. Implantation of kissing stents (KS) with covered stents (CS), bare-metal stents (BMS) is one of the endovascular treatment (ET) modalities for AIOD involving aortic bifurcation. In this study, we report the outcomes of the KS technique in infrarenal AIOD.

Methods

Between January 2014 and September 2017, 31 patients who underwent ET were treated with KS technique either with balloon-expandable BMS or balloon-expandable CS. Technical details, clinical success, complications, and patency at follow-up were documented.

Results

The majority of patients were male (77.4%), and the median age was 62 years (range, 45-78 years). All patients were classified according to the TASC II criteria. Eight patients (25.8%) were classified as TASC B. Fifteen patients (48.4%) were classified as TASC C, and 8 patients (25.8%) were classified as TASC D. These 23 patients were classified as complex AIOD group. BMS was used in 17 patients (54.8%), and CS was used in 14 patients (45.2%). Technical and clinical success was achieved in 100% of treated cases. The median follow-up was 24 months (range, 24-34 months). Primary patency rates at 12, 18, and 24 months after ET were 100%, 96.8%, and 90.3%, respectively.

Conclusion

We found that the KS technique has satisfying 24-month results, even in complex AIOD lesions, with high technical success and acceptable midterm patency. Key Words: Aorta, Arterial occlusive diseases, Endovascular procedures, Iliac artery, Stents.

Contemporary post-marketing adverse events and modes of failure related to VASCADE Vascular Closure System: The utility of the MAUDE database

OBJECTIVES

To analyze post-marketing surveillance data from the United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for the VASCADE Vascular Closure System (Cardiva Medical Inc., Santa Clara, CA).

BACKGROUND

The VASCADE Vascular Closure System is a closure device for femoral arterial and venous access-site closure that was approved by the FDA in 2013. However, post-marketing data and experience on the most commonly reported complications and modes of failure associated with the VASCADE Vascular Closure System are limited.

METHODS

Post-marketing surveillance data from the FDA MAUDE database from October 2013 through March 2020 were analyzed, yielding 201 reports.

RESULTS

Of the 201 reports of major complications involving VASCADE devices, 156 reports involved either injury (145) or death (11) related to the device. Of the 145 injury reports, bleeding was the most common adverse outcome described (85), followed by pseudoaneurysm (29) and pulselessness of an extremity (21). The device malfunction incidents (41 reports) were reported in three main categories, with deployment failure being the most commonly reported complication.

CONCLUSIONS

Our analysis of the MAUDE database demonstrates that in contemporary post-marketing practice, physicians should be well-trained and educated to use the VASCADE closure device because improper utilization is a common cause of device failure, and complications with the VASCADE device can have profound clinical implications.

Access Site Complications of Peripheral Endovascular Procedures: A Large, Prospective Registry on Predictors and Consequences

PURPOSE

The purpose of this study was to investigate predictors and consequences of acute vascular access site complications (ASCs) related to peripheral endovascular diagnostic or interventional procedures. Despite improvement of puncture techniques, access site-related morbidity and mortality is still considerable.

MATERIALS AND METHODS

A total of 5263 participants who underwent 5385 endovascular procedures at a single center were consecutively included in this prospective, observational study. Primary outcomes were ASCs defined as composite of puncture site hematoma, pseudoaneurysm, arteriovenous fistula, and overt puncture site bleeding on the first day after procedure.

RESULTS

ASCs occurred in 16.6% of peripheral endovascular procedures (78.6% hematomas, 18.9% pseudoaneurysms, 1.4% arteriovenous fistulas, 1.1% overt bleedings). Independent predictors were advanced age [odds ratio (OR) per 10 years: 1.12, p=0.004], female sex (OR men, 0.77; p=0.001), lysis (OR 3.56; p<0.001), periprocedural heparin (OR 5000 IU, 1.96; p=0.001; OR >5000 IU, 3.56; p=0.02), time to access (OR per 10 seconds, 1.01; p<0.001), sheath size (OR per French, 1.59; p<0.001), brachial artery access (OR vs retrograde transfemoral, 4.58; p<0.001), and compression only (OR Angio-Seal, 0.57, p=0.02; ProGlide, 0.36, p<0.001; FemoSeal, 0.57, p<0.001). Treatment was required in 20.2% and prolonged hospitalization in 17.7% of ASC. Three participants died from access site-related bleeding.

CONCLUSION

ASCs after peripheral endovascular procedures are associated with advanced age, female sex, periprocedural antithrombotic medication, brachial artery access, postinterventional bleeding, and nonuse of vascular closure devices.

A novel double clip-based vascular closure device in antegrade and retrograde femoral punctures: A single-center experience in peripheral non-cardiac procedures

BACKGROUND

This retrospective study investigates the efficacy and safety of the novel Celt ACD^® vascular closure device (VCD) following antegrade and retrograde common femoral artery (CFA) punctures for the treatment of peripheral artery disease in a challenging patient collective (e.g. calcifications, obesity, and anticoagulation).

METHODS

A total of 208 VCDs (i.e. 100 antegrade and 108 retrograde) were deployed between October 2019 and December 2020 in a tertiary referral interventional radiology department. Fifty-two devices were undersized in relation to the introducer sheath (up to 2 Fr). Technical success and VCD related complications were evaluated in the immediate post procedure period and the following 24 h clinically. In 68% of cases, additional duplex ultrasound was performed prior to discharge.

RESULTS

The overall technical success rate was 97%. Technical failures following antegrade approach were due to a too acute access angle (⩾60°), rendering it impossible to pass the applicator tip through the sheath lumen. A subgroup analysis of technical success pinpoints severe calcification as another key limiting factor in VCD use (p = 0.004). Comparing equally sized with undersized device selection (p = 0.196), direction of approach (p = 0.265), and body mass index (p = 0.184) proved to be insignificant. Five (2%, 5/208) major complications occurred: Four antegrade (i.e. one false aneurysm, one vessel laceration with retroperitoneal hemorrhage, two device migrations; 4%, 4/100) and one following retrograde access (i.e. >6 cm hematoma, 1%, 1/108)). Complications were successfully managed with manual compression or interventional procedures.

CONCLUSIONS

The novel clip-based VCD proved to be effective with a low VCD related complication rate.

Ultrasound-guided puncture reduces bleeding-associated complications, regardless of calcified plaque, after endovascular treatment of femoropopliteal lesions, especially using the antegrade procedure: A single-center study

Background

A common complication of endovascular treatment for femoropopliteal lesions is bleeding at the vascular access site. Although risk factors of bleeding-associated complications at the approach site have been reported, the results have been inconclusive. Hence, this study aimed to assess the predictors of bleeding-associated complications at the approach site in patients undergoing endovascular treatment for femoropopliteal lesions.

Methods

This retrospective, single-center, observational study included consecutive patients who underwent endovascular treatment (n = 366, 75% male, 72.4±9.9 year) for peripheral arterial disease with claudication and critical limb ischemia in our hospital from January 2010 to December 2017. We divided the patients into bleeding and non-bleeding groups, depending on whether bleeding-associated complications occurred at the approach site. Bleeding-associated complications were defined according to the Bleeding Academic Research Consortium criteria types 2, 3, and 5.

Results

Altogether, 366 endovascular treatment procedures and 404 arterial accesses were performed for femoropopliteal lesions in 335 peripheral arterial disease patients with claudication and 69 critical limb ischemia patients. We recorded 35 postprocedural bleeding-associated complications at the approach site (9%), all of which were hematomas. The predictors of increased bleeding-associated complications were age ≥ 80 years (bleeding vs. non-bleeding group, 43% vs. 25%, p<0.05) and antegrade cannulation of the common femoral artery (48% vs. 69%, p<0.05). Ultrasound-guided puncture reduced bleeding-associated complications (odds ratio, 0.28; 95% confidence interval, 0.004–0.21; p<0.05). In contrast, there was no significant difference in puncture site calcification between the groups (bleeding vs. non-bleeding groups, 29% vs. 21%, p = 0.29).

Conclusion

Ultrasound-guided puncture is associated with a decrease in bleeding-associated complications at the approach site, regardless of the presence of calcified plaque. It is particularly effective and should be more actively used in patients aged ≥80 years and for antegrade cannulation of the common femoral artery.

Mid-term Clinical Outcomes of Immediate Protamine Use Following Elective Percutaneous Coronary Interventions

Bleeding complication has been considered as a serious problem in current percutaneous coronary interventions (PCI). Fortunately, several groups have already reported the effectiveness of protamine use just after PCI to immediately remove any arterial sheath. However, there is a concern that protamine reversal may increase non-occlusive thrombus and, in turn, lead to mid-term cardiovascular events such as target vessel revascularization (TVR) or stent thrombosis. Thus, the purpose of this study was to evaluate whether protamine use following elective PCI was associated with mid-term clinical outcomes. In total, 472 patients were included in this study; subsequently, they were divided into protamine group (n = 142) and non-protamine group (n = 330). The primary endpoint was the composite of ischemia-driven TVR and stent thrombosis. The median follow-up period was determined to be at 562 days. In total, 32 primary endpoints were observed during the study period, and the incidence of primary endpoints tended to be greater in the protamine group than in the non-protamine group (P = 0.056). However, the lesion length, the degree of calcification, and the prevalence of hemodialysis were significantly determined greater in the protamine group than in the non-protamine group. In the multivariate Cox proportional hazards model, the use of protamine (versus non-protamine: hazard ratio 0.542 and 95% confidence interval 0.217-1.355, P = 0.191) was deemed not to be associated with the primary endpoint after controlling legion length, calcification, and hemodialysis. In conclusion, immediate protamine use following elective PCI did not increase mid-term ischemia-driven TVR or stent thrombosis. However, immediate protamine use after PCI should be discussed further for the safety of the patient.

A novel femoral artery compression device (butterfly compress) versus manual compression for hemostasis after femoral artery puncture: a randomized comparison

Objective: This study aimed to investigate the hemostatic efficacy of a novel femoral artery compression device in patients undergoing an interventional procedure through femoral artery puncture.Material and methods: Patients enrolled in this trial were randomly assigned 1:1 to the novel femoral artery compression device (NFACD) or the manual compression (MC) group. The primary endpoints were time to hemostasis (TTH), time to ambulation (TTA), any other complications, such as the occurrence of hematoma, bleeding, pseudoaneurysm and arteriovenous fistula at the puncture site, and time to hospital discharge.Results: A total of 617 patients were included in this study (NFACD, n = 308 versus MC, n = 309) from May 2017 to September 2019, and the baseline characteristics of the groups were similar. We found that the TTH and TTA were significantly shorter in the NFACD group than in the MC group (4.4 ± 11.6 min vs. 20.1 ± 22.5 min; p < 0.001; 8.9 ± 14.2 h vs. 16.3 ± 27.5 h; p = 0.002). There were few other complications in either group. In addition, there was no significant difference in time to hospital discharge between the NFACD group and the MC group.Conclusion: The novel femoral artery compression device is effective in achieving hemostasis in patients undergoing femoral artery puncture and is associated with a marked shortening of the TTH and TTA.

Analysis of Puncture Site-related Complications in Japanese Registry of Neuroendovascular Therapy (JR-NET)3

A subgroup analysis of puncture site-related complications listed in the Japanese Registry of NeuroEndovascular Therapy 3, based on retrospective studies, was performed. Puncture site-related complications occurred in 315 (0.73%, average age: 65.2) of 36,708 patients out of all 43,303 registered cases. Carotid artery stenting (CAS, 95 patients, 1.1%, P <0.01) and extracranial percutaneous transluminal angioplasty (PTA, 21 patients, 1.4%, P <0.01) were associated with significantly higher incidence of puncture site-related complications. The incidence of complications correlated with the number of antiplatelet drugs (P <0.001). Although 40% of the puncture complications were treated conservatively, 13% were treated endovascularly and 5% underwent open surgery.

Single Angio-Seal vascular closure device for transfemoral access exceeding 8F

BACKGROUND

This was a retrospective single-center evaluation for off-label use of a single Angio-Seal-VIP 8F vascular closure device (VCD) (Terumo Interventional Systems, Somerset, NJ, USA) for retrograde transfemoral arterial access exceeding 8F.

METHODS

Between 2010 and 2018, in 32 consecutive patients (3 females; mean age 67±9; range 46-86 years) retrograde femoral access was performed in 48 groins for aortoiliac stent or stent graft implantations using 9-14F sheaths. For vascular closure, one single Angio-Seal™-VIP 8F was used. Procedural success, closure-related complications, and risk factors were retrospectively evaluated using patient characteristics, duplex-ultrasound, and contrast-enhanced computed tomography angiography (CTA). Receiver-operating-characteristics were used for statistical analysis.

RESULTS

Technical success for deployment of VCD was 100%. Visual inspection and duplex-ultrasound confirmed immediate hemostasis in 100%. Postinterventional CTA depicted major vascular access site complications in 6.3% (3/48 groins) requiring surgical treatment. A subgroup of 13 patients underwent surgical cut-down one day after VCD deployment as part of a two-staged complex endovascular aortic aneurysm repair procedure, allowing for visual assessment of prior used undersized Angio-Seal^TM. Patient's height (p=0.028) and severe access site calcifications (p=0.028) proved as predictors for one vessel occlusion and two pseudoaneurysms. Low body-mass-index (BMI) showed a non-significant trend. Sheath-size, common femoral artery depth, or body weight were not indicative for occurrence of complications.

CONCLUSIONS

In selected cases, without availability of appropriate VCDs, a single Angio-Seal^TM-VIP 8F served as a feasible option to achieve sufficient hemostasis of transfemoral access exceeding 8F without relevant bleeding complications. Very low BMI, tall body-height, and severe atherosclerosis were identified to predispose to access site complications.

Risk Factors for Puncture Site Complications Using the Angio-Seal Closure Device in Endovascular Therapy: A Single-center Analysis

OBJECTIVE

To retrospectively analyze the complication rates and risk factors associated with the use of the Angio-Seal vascular closure device during neuroendovascular therapy.

METHODS

In this study, we enrolled 283 patients who underwent Angio-Seal hemostasis between December 2005 and June 2019 at our institute. We retrospectively analyzed the major and minor complication rates and risk factors between the complication and no-complication groups using the medical charts of patients for whom the device was used.

RESULTS

Of the 283 patients, 5 had major complications (1.8%) and 18 had minor complications (6.3%). There were no significant differences between the complication (n = 23) and no-complication (n = 260) groups regarding the baseline characteristics or operation procedures. Among the major complications, superficial femoral artery puncture, 8Fr device, Angio-Seal Evolution, post-carotid artery stenting, dual antiplatelet therapy, and delirium were considered risk factors.

CONCLUSION

The Angio-Seal is a safe and useful hemostatic device. However, puncture site complications need to be considered when the device is used for contraindicated patients or for those with delirium who cannot rest following the procedure.

An update on the use of an arterial closure device following femoral arterial puncture in children

BACKGROUND

The use of arterial closure devices in achieving femoral hemostasis has been well documented in adults but insufficiently studied in the pediatric population. An earlier study from our institution of 40 Angio-Seal devices in 38 patients concluded that the arterial closure device is safe in children with only a single minor complication. Ongoing experience with this device at our institution, however, suggests a higher rate of complication.

OBJECTIVE

To retrospectively evaluate the safety and efficacy of the Angio-Seal in a pediatric population.

MATERIALS AND METHODS

A retrospective analysis reviewed all cases in which the Angio-Seal was deployed from June 2011 to September 2017. Peri-procedural documentation was reviewed for pre-procedure labs, clinical effectiveness in achieving hemostasis and complications related to the use of this device. Logistic regression analysis was also used to evaluate the relationship between patient demographic, vessel size and indication for angiography, and the presence or absence of complications.

RESULTS

During the study period, 48 additional Angio-Seal devices were deployed in 41 consecutive patients. Five patients were excluded for being older than 18 years. The mean age of the patients was 13.3 years (range: 4-18 years) with 18 patients female. The mean common femoral artery diameter was 5.98 mm in short axis diameter (range: 4-9 mm). Complications were present in 6/43 cases (14%) including 3 minor and 3 major complications that included additional procedures. No significant relationship was identified between vessel size, age and the indication for angiography, and the rate of complication on logistic regression analysis.

CONCLUSION

While percutaneous arterial closure devices can be efficacious for achieving hemostasis, our experience demonstrates a higher rate of complications in children, contrary to a previous report. The deployment of such devices should be performed with prejudice in this population.

FemoSeal® vascular closure device for antegrade common femoral artery access: Safety and technical notes

PURPOSE

To retrospectively assess the efficacy and safety of FemoSeal^® vascular closure device to achieve hemostasis following antegrade common femoral artery puncture after lower limb revascularization using vascular sheaths from 5 to 8 Fr.

METHODS

We reviewed the hemostatic outcome achieved with FemoSeal in 103 consecutive patients (mean age: 69 ± 8 years, 71 males) that undergone to 111 antegrade common femoral artery accesses for percutaneous lower limbs revascularization using 5- to 8-Fr vascular sheaths. We used FemoSeal in an unselected population, without exclusion criteria. The primary outcome was the technical success, meant as achieving complete hemostasis without immediate complications.

RESULTS

Hemostasis was achieved in all 111 puncture sites (100% technical success). We observed eight (7%) puncture site minor complications (hematomas), none of which affecting the patients' outcome or requiring further therapies or increasing the hospital stay. There were no statistically significant differences between the variables potentially related to the occurrence of complications (age, international normalized ratio, platelet count, partial thromboplastin time ratio, body mass index, and common femoral arteries calcification grade) in patients with and without complications. Complications group mean body mass index was 26.4 ± 2.8 kg/m² versus non-complications group 26.6 ± 4.4 kg/m², p = 0.92. Mean international normalized ratio and partial thromboplastin time ratio were 1.05 ± 0.01 and 1.05 ± 0.14 versus 1.13 ± 0.2 (p = 0.39) and 1.12 ± 0.23 (p = 0.53), respectively. Common femoral arteries calcification grade was the same (mean: 1, p = 1). Platelet count was 202 × 10³/mL ± 66.7 versus 226 × 10³/mL ± 91.2, p = 0.55. Mean age was 72.3 ± 10 years versus 72.8 ± 8 years, p = 0.86.

CONCLUSION

The low rate (7%) and grading of the adverse events, combined with the high technical success rate (100%), in an unselected group of patients treated in daily routine, suggest high safety and efficacy of FemoSeal vascular closure device in antegrade common femoral artery puncture site hemostasis when using vascular sheaths ranging from 5 to 8 Fr. Therefore, FemoSeal could be considered as a first-line hemostasis strategy in such cases.

Access site pseudoaneurysms after endovascular intervention for peripheral arterial diseases

Purpose

Pseudoaneurysms after percutaneous vascular access are common and potentially fatal if left untreated. The aim of this study was to determine the incidence and risk factors associated with access site pseudoaneurysms after endovascular intervention for peripheral arterial disease (PAD) under a routine postintervention ultrasound (US) surveillance protocol.

Methods

A total of 254 PAD interventions were performed in a single center between January 2015 and November 2016, and puncture site duplex US surveillance was routinely performed within 48 hours of the procedure. Clinical, procedural and follow-up US data were analyzed.

Results

The overall incidence of pseudoaneurysm was 2.75% (6 cases in the femoral artery and 1 in the brachial artery). There was no difference between retrograde and antegrade approach, but there was a higher rate of pseudoaneurysm formation after manual compression compared to arterial closure device (ACD) use (4.3% vs. 0.87%). Manual compression was more commonly used for antegrade punctures (79.0%) and ACD for retrograde punctures (67.7%). Calcification was more frequently found in antegrade approach cases (46.8% vs. 16.9% for retrograde cases) and manual compression was preferred in its presence. All pseudoaneurysms were treated successfully at the time of diagnosis by US-guided compression repair and there were no cases of rupture.

Conclusion

Pseudoaneurysm rates after therapeutic endovascular intervention for PAD were comparable to other cardiologic or interventional radiologic procedures despite the higher possibility of having a diseased access vessel. Routine US surveillance of access sites allowed for early diagnosis and noninvasive treatment of pseudoaneurysms, preventing potentially fatal complications.

Aspiration Thrombectomy-Assisted Endovascular Retrieval of an Embolized Angio-Seal Device Causing Claudication

The Angio-Seal vascular closure device is used to reduce time to hemostasis after femoral artery puncture. Although rare, complications associated with Angio-Seal are significant, including infection, pseudoaneurysm formation, symptomatic femoral artery stenosis, and separation and embolization, leading to limb-threatening ischemia. This report describes Angio-Seal polymer anchor embolization to the tibioperoneal trunk successfully retrieved using the 8-French Indigo Aspiration System.

Transvenous Treatment of Carotid Aneurysms Through Transseptal Access

BACKGROUND

Transseptal puncture has been widely used by cardiologists to reach the left side of the heart through a transvenous access. Rarely, it also can be used to pass into the supra-aortic arteries from the venous side when conventional transarterial access pathways (transfemoral, transradial/brachial routes, or direct carotid puncture) are likely to fail.

CASE DESCRIPTION

We report 2 cases of transvenous femoral access followed by transseptal access to aorta to treat dissecting carotid artery aneurysms at the level of the skull base with flow diverters. In one case, multiple cervical arterial bypass operations and in the other a rare anomaly of the aortic arch precluded endovascular treatment through conventional routes.

CONCLUSIONS

Transvenous-transseptal access enabled treatment of both cases easily and without complications. On follow-up computed tomography angiograms, both flow diverters were patent, there were no residual aneurysms, and no neurologic or cardiac adverse events in either patient.

Are complication rates lower with 4-Fr versus 6-Fr transfemoral arterial access - prospective audit at a single interventional radiology centre

Background

Femoral arterial access constitutes the first step in a significant proportion of interventional endovascular procedures. Whilst existing reports describe sheath size as an independent risk factor for bleeding complications in radial arterial access for coronary intervention, the influence of sheath size on overall complication rates and morbidity following femoral arterial access is not well described. This prospective single centre study reports our experience of vascular sheath size, patient and procedural factors in influencing complication rates following femoral arterial access. From April 2010 to May 2013, data was collected prospectively for all femoral arterial access procedures performed in the Interventional Radiology department of a tertiary hospital. For vascular sheath size <6-Fr, haemostasis was achieved by manual compression. For 6-Fr sheath size, a closure device was used in the absence of any contraindication.

Results

Of the 320 femoral access cases with eligible inclusion criteria, 52.5% had 4-Fr whilst 47.5% had 6-Fr vascular sheaths inserted. Overall post procedure complications rates were significantly higher following 6-Fr sheath (17/152 (11.2%)) versus 4-Fr systems (3/168 (1.8%)) (p=0.0007) mostly comprising self-limiting hematoma. There was no significant difference in major complications that required escalation of treatment.

Conclusion

No significant difference has been demonstrated between the use of either sheath systems for major complications. The practical limitations of a smaller system, combined with existing body of evidence, may not justify the routine use of 4-Fr sheath systems as the primary sheath size for all endovascular procedures.

Safety and efficacy of using vascular closure devices for hemostasis on sheath removal after a transfemoral artery percutaneous coronary intervention

AIM

To determine the efficacy of vascular closure devices (VCDs) for hemostasis following transfemoral percutaneous coronary interventions (PCIs).

METHODS

This two-group pre-post-test observational study with purposive sampling enrolled 73 patients between January, 2014 and February, 2015. The patients were allocated to either the intervention (vascular closure devices group, n = 34) or the control group (manual compression [MC] group, n = 39). Questionnaires were used to assess their demographic and clinical characteristics, vascular complications, visual analogue scale score for pain, and discomfort levels. Pain and discomfort were measured before and after the PCI.

RESULTS

Vascular complications were observed in 15 (44.1%) VCD patients and 13 (33.3%) MC patients, with no significant between-group difference. However, the VCD patients had a higher relative risk of bruising, hematomas, and need for further treatment. After the PCI, the pain scores and discomfort levels increased significantly in both groups, but the VCD patients had more successful hemostasis, less pain, and less physical and psychological discomfort (lower-limb numbness, shoulder pain, restlessness, and worrying about walking ability, being unable to lift heavy objects in the future, and taking time off from work).

CONCLUSION

The VCDs seem to be superior to the MCs, providing more successful hemostasis, less pain and discomfort, and earlier ambulation after a transfemoral PCI. These findings aid clinical nurses in understanding the risk of vascular complications, discomfort, and pain that are associated with VCD use for improving the quality of clinical care and help clinicians in determining the appropriate hemostatic method for patients undergoing a transfemoral PCI, particularly in the Chinese population.

Safety of Reversing Anticoagulation by Protamine Following Elective Transfemoral Percutaneous Coronary Intervention in the Drug-Eluting Stent Era

Bleeding complications following percutaneous coronary interventions (PCI) have been closely associated with morbidity and mortality. Although radial arteries have been widely used in current PCI, including primary PCI, transfemoral PCI remains necessary for complex PCI. The purpose of this study was to compare the incidence of complications following elective transfemoral PCI between manual compression with and without protamine. We identified 249 consecutive patients who underwent elective transfemoral PCI from hospital records, and divided them into two groups: patients who used protamine for manual compression (the protamine group; n = 205) and patients who did not (the non-protamine group, n = 44). Complications including acute thrombosis, bleeding requiring blood transfusion, transient hypotension, skin rash, and death within 30 days were compared between groups. The baseline clinical and procedural characteristics were comparable between the protamine and non-protamine groups. The incidences of all complications were not different between the protamine (5.9%) and the non-protamine groups (9.1%) (P = 0.43). While more than 90% of the patients received drug-eluting stent implantation, there was no acute thrombus in either group. The incidence of bleeding requiring blood transfusion was significantly lower in the protamine group (0.5%) than in the non-protamine group (6.8%) (P = 0.002). Multivariate logistic regression analysis revealed the inverse association between protamine use and bleeding requiring blood transfusion (odds ratio 0.08, 95% confidence interval 0.01-0.84, P = 0.04). In conclusion, the use of protamine for manual compression following elective transfemoral PCI was safe and was associated with less bleeding complications.

Closure of large bore 9 F arterial puncture sites with the AngioSeal STS device in acute stroke patients after intravenous recombinant tissue plasminogen activator (rt-PA)

Purpose

This retrospective analysis was performed to evaluate whether large bore 9 F puncture sites can be safely closed with the 8 F AngioSeal STS device after endovascular stroke procedures in patients who did or did not receive recombinant tissue plasminogen activator (rt-PA).

Methods

Out of 161 consecutive endovascular stroke procedures we identified 72 patients who met the inclusion criteria, of whom 46 received rt-PA before the endovascular procedure and 26 did not. All groin complications such as major haemorrhage, failure of the device to close the puncture site, delayed haemorrhage, acute lower extremity ischaemia or necessary vascular surgery as well as infections were recorded.

Results

Only one patient had delayed groin haemorrhage after closure of the 9 F puncture site with the AngioSeal STS device. There was no significant difference in complications between patients with or without rt-PA treatment.

Conclusion

The 8 F AngioSeal STS seems to be safe and efficient to close 9 F femoral artery puncture sites, even under active rt-PA thrombolysis.

Usefulness of an access-site hemostasis device in neuroendovascular treatment

BACKGROUND

We examined the safety and efficacy of the access-site hemostasis device Angio-Seal™ STS Plus (AS; St. Jude Medical,St. Paul, MN, USA) compared with the method of hemostasis by manual compression (MC) in neuroendovascular therapy.

METHOD

We conducted a prospective multicenter registration study enrolling 229 patients who were scheduled to undergo endovascular treatment.

RESULTS

Of the 119 and 110 cases assigned to the AS and MC groups, 118 (99.2%) and 105 (95.5%) achieved successful hemostasis, respectively. Six AS patients and 38 MC patients had access-site hematoma (5% vs 34.5%, P < 0.001). Hemostasis time was significantly shorter in the AS group than in the MC group (4.4 min vs 150.7 min, P < 0.001). Puncture-site hematoma was significantly larger in the AS group than the MC group (5.5 cm vs 2.9 cm, P < 0.05). Patients in the AS group had a significantly shorter hospital stay than those in the MC group (8.7 days vs 13.3 days, P < 0.001); they also had a significantly shorter time before they could start to walk (23.9 h vs 52.2 h, P < 0.001). No serious adverse events were noted in either group. Minor adverse events included four cases from the AS group and two cases from the MC group.

CONCLUSIONS

Use of an access-site hemostatic device resulted in quick and reliable access-site hemostasis in neuroendovascular therapy. When using AS, it is necessary to be careful when there is a possibility of a hematoma, as the hematomas, though significantly less frequent than in MC, were significantly bigger in that group.

Single-center comparison of the efficacy and complications of arterial vascular closure devices in interventional radiology

Introduction

Vascular closure devices (VCDs) are commonly used to achieve hemostasis of arterial access sites, but there is little comparative data on the variety of VCDs currently in clinical use. We reviewed the VCD experience at our institution to determine the safest and most effective VCD.

Materials and Methods

Retrospective analysis of 907 consecutive arterial procedures in interventional radiology from June 2012 to June 2014 was performed. Five VCDs were used: Angio-Seal (n = 478), FISH (n = 56), Mynx (n = 56), Perclose (n = 61), and Starclose (n = 68). Patients who underwent manual compression (n = 188) without use of VCDs were also studied as a comparison group. Patient demographics and pre-procedural laboratory parameters were recorded. The technical success rate for achievement of hemostasis and complication rates were noted.

Results

Complete hemostasis rate (aka technical success rate) was 93.5% for Angio-Seal, 83.9% for FISH, 53.6% for Mynx, 73.7% for Perclose, 76.5% for Starclose, and 91.5% for manual compression. The differences among the devices were statistically significant (p<0.001). Fourteen major complications (1.5%) were encountered: nine with Angio-Seal (1.9%), one with Mynx (1.8%), one with Starclose (1.5%), and three with manual compression (1.6%); these differences were not statistically significant. Of the demographic and laboratory parameters studied, none were significantly correlated with hemostasis failure or development of complications.

Conclusions

In our single-center institutional experience, Angio-Seal is the device with the best technical success rate. Major complications of VCDs were rare, with no statistically significant difference between devices.

Use of a vascular closure device during percutaneous arterial access in a dog with impaired hemostasis

OBJECTIVE

To report the use of a vascular closure device (VCD) to provide rapid arterial hemostasis following percutaneous femoral arterial catheterization and diagnostic angiography in a thrombocytopenic and coagulopathic dog.

CASE SUMMARY

A 6-year-old female spayed Kai Ken Tora dog presented after vehicular trauma. The dog was diagnosed with traumatic pneumothorax, degloving wounds of the right antebrachium, subcutaneous hemorrhage within the axillary tissues of the left thoracic limb, and anemia and thrombocytopenia secondary to acute hemorrhage. Treatment included therapeutic thoracocentesis and open wound management of the right thoracic limb as well as packed RBC and fresh frozen plasma transfusions. Diagnostic angiography of the left brachial artery was performed via percutaneous femoral arterial access to investigate the source of a persistent axillary hematoma. The arterial access site was closed using an extraluminal VCD and hemostasis was immediate with normal femoral arterial blood flow documented by Doppler ultrasound.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes use of a VCD for arterial closure following percutaneous access in a dog with impaired hemostasis; to the authors' knowledge, this is the first clinical report of a VCD used in a veterinary species.

A Retrospective Analysis of Surgical Femoral Artery Closure Techniques: Conventional versus Purse Suture Technique

BACKGROUND

Different techniques have been reported for the exploration and repair of femoral artery (FA) in patients who undergo minimally invasive cardiac surgery (MICS) and endovascular aortic surgery. We used a modified approach alternative to the conventional technique (group CT) since May 2013, which specifies a shorter groin incision and diamond-shaped hemostatic purse sutures for arteriotomy closure without the requirement of cross-clamping (group PT [purse suture technique]) and evaluated early outcomes and the complication profiles of the 2 techniques for femoral access.

METHODS

In our clinic, between May 2011 and December 2015, 503 FA cannulations were performed on 345 patients who underwent MICS (n = 109, mean age 64.1 ± 17.6 years, female/male ratio 71/38), endovascular abdominal aneurysm repair (n = 158, mean age 71.3 ± 10.2 years, female/male ratio 63/95), thoracal endovascular aneurysm repair (n = 50, mean age 65.0 ± 15.3 years, female/male ratio 15/35), and transaortic valve implantation (n = 28, mean age 80.8 ± 5.9 years, female/male ratio 13/15). A total of 295 FAs were exposed via mini incision and were repaired with the PT. We compared the duration of femoral closure (FC), wound infection, and vascular complications including bleeding hematoma, thromboembolic and ischemic events, pseudoaneurysm, seroma, surgical reintervention rates, delayed hospital stay for groin complications, and existence of postoperative local luminal narrowing (LLN) at the intervention site over 25% for both groups.

RESULTS

FC time (CT 14.9 ± 3.16 min, PT 6.5 ± 1.12 min, P < 0.0001), bleeding hematoma frequency (CT 6.2%, PT 1.7%, P = 0.01), and prolonged hospital stay for groin complications (CT 14.9%, PT 3.4%, P < 0.0001) were significantly lower in the PT group. Rate of technical success (CT 80.3%, PT 87.4%, P = 0.03) and event-free patient (CT 66.1%, PT 77.5%, P = 0.03) were significantly better in the PT group. There were no differences between groups in terms of ischemic events, wound infection rates, development of pseudoaneurysm and seroma, surgical reintervention rates, and LLN of FA over 25% at 6-month duplex evaluation.

CONCLUSIONS

The comparison of the 2 approaches revealed the advantages of the PT in terms of bleeding hematoma and shortening in FC time and the length of hospital stay. We suggest performing a smaller skin incision for FA access and utilizing purse sutures, which allows completing the procedure without cross-clamping, thus providing a favorable approach and excellent comfort for the surgeon.

An Analysis of Complications of Brachial and Axillary Artery Punctures

To examine the complications of brachial and axillary artery punctures and the precautionary measures taken to lower their incidences. Retrospective analysis of 266 cases of brachial and axillary artery punctures was performed for angiography or angioplasty between January 2009 and December 2013 at the Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University. Complications and their causes were assessed. Among all brachial artery punctures (n = 140), there were complications in 3.6 per cent of cases, including local hematoma in 1.4 per cent, pseudoaneurysm in 0.7 per cent, acute arterial thrombosis in 0.7 per cent, and median nerve injury in 0.7 per cent. Among all axillary artery punctures (n = 126), there were complications in 10.3 per cent of cases, including local hematoma in 4.8 per cent, pseudoaneurysm in 0.8 per cent, acute arterial thrombosis in 0.8 per cent, acute venous thrombosis in 0.8 per cent, and nerve injury in 3.2 per cent. The incidence of complications was significantly lower in brachial axillary artery puncture compared with axillary artery puncture (P < 0.05). The main factors associated with complications might be patient's vascular condition, perioperative medication, anatomical features of the artery, puncture site, successful rate of first-attempt puncture, and bandage strength. Incidence of complications of brachial and axillary artery punctures could be lowered by strengthening the choice of indications, improving the perioperative managements, being fully aware of the anatomical characteristics of the brachial and axillary arteries, and applying the standardized techniques of puncture and compression hemostasis.

Death Due to an Unusual Angio-Seal-Related Complication: Case Report and Literature Review

Angio-SealTM is a vascular closure device (VCD) that can be applied to the femoral artery following cardiac catheterization to achieve hemostasis. Although it has been demonstrated to be superior to conventional manual pressure and to reduce time to hemostasis and patient ambulation, the use of this VCD is not without its complications. In this report, we describe the case of a 55-year-old man who died due to an extremely rare event that occurred several hours after the deployment of an Angio-SealTM VCD: acute complete transverse laceration of the femoral artery that occurred because of the particular fragility of the vessel due to an unrecognized and asymptomatic arteriosclerotic disease. Few data are available in the literature about the incidence of such events, and much more remains to be done to determine how to prevent and manage its occurrence.

Comparison of a collagen plug arterial closure device with manual compression after endovascular interventions for peripheral artery disease

OBJECTIVE

Arterial closure devices (ACDs) seem to be safe and effective to obtain hemostasis for cardiac interventions and diagnostic vascular procedures. However, only limited evidence is presented on therapeutic interventions in patients with peripheral atherosclerotic disease. We compared ischemic and hemorrhagic complications of an ACD vs manual compression (MC) after puncture of the femoral artery for endovascular lower extremity procedures.

METHODS

The records of all subsequent endovascular interventions for peripheral artery disease performed in a large teaching hospital, from January 2012 to April 2014, were retrospectively reviewed. The primary outcome was an ischemic complication requiring reintervention. Secondary outcomes were hematoma (needing conservative or invasive intervention) and infection (needing intervention or antibiotics). Multivariate analysis was performed to identify predictors for any complication.

RESULTS

The Angio-Seal (St. Jude Medical, Minnetonka, Minn) closure device was used in 244 of 463 endovascular interventions (54%). Five patients (2%) who received an ACD needed emergency surgery for ischemic complications vs none in the MC group (P = .06). Hematomas occurred in 22 patients (9%) after ACD vs in six (3%) after MC (adjusted odds ratio [OR], 3.4; 95% confidence interval [CI], 1.4-8.9; P = .015). There were no infections in either group. ACD (OR, 3.8; 95% CI, 1.5-9.7) and current smoking (OR, 2.6; 95% CI, 1.01-6.7) were independent predictors for any complication.

CONCLUSIONS

This study demonstrates that ACD use in patients with peripheral artery disease can lead to serious adverse events resulting in increased morbidity. Therefore, the potential benefits of an ACD over MC should be carefully weighed.

Transradial access for visceral endovascular interventions in morbidly obese patients: safety and feasibility

PURPOSE

Transradial access (TRA) has been shown to lower morbidity and bleeding complications compared to transfemoral access in percutaneous coronary interventions. Morbid obesity, commonly defined as a body mass index (BMI) ≥40 kg/m2, has been shown to be a risk factor for access site complications irrespective of access site. This study evaluates the safety and feasibility of performing visceral endovascular interventions in morbidly obese patients via TRA.

METHODS

Procedural details, technical success, and 30-day major and minor access site, bleeding, and neurological adverse events were prospectively recorded in a database of 1057 procedures performed via the radial artery. From this database we identified 22 visceral interventions performed with TRA in 17 morbidly obese patients (age: 53 ± 11 years, female: 71%) with a median BMI of 42.7 kg/m2.

RESULTS

Interventions included radio-embolization (n = 7, 31.8%), chemo-embolization (n = 6, 27.3%), uterine fibroid embolization (n = 4, 18.2%), renal embolization (n = 2, 9.1%), hepatic embolization (n = 1, 4.5%), lumbar artery embolization (n = 1, 4.5%), and renal angioplasty (n = 1, 4.5%). The technical success was 100%. There were no major or minor adverse access site, bleeding, or neurological complications at 30 days.

CONCLUSIONS

This study suggests visceral endovascular interventions performed in morbidly obese patients are safe and feasible.