The frequency of vascular complications associated with the use of vascular closure devices varies by indication for cardiac catheterization

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

Backgrounds

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

Methods

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

Results

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

Conclusions

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

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.

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.

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.

Usefulness of a Nonsuture Closure Device in Patients Undergoing Diagnostic Coronary and Peripheral Angiography

Vascular access site complications can follow diagnostic coronary and peripheral angiography. We compared the complication rates of the Catalyst vascular closure device, with the complication rates after manual compression in patients undergoing diagnostic angiographic procedures via femoral access. We studied 1,470 predominantly male patients undergoing diagnostic coronary and peripheral angiography. Catalyst closure devices were used in 436 (29.7%) patients and manual compression was used in 1,034 (70.3%) patients. The former were allowed to ambulate after 2 hours, while the latter were allowed to ambulate after 6 hours. Major complications occurred in 4 (0.9%) patients who had a Catalyst device and in 14 (1.4%) patients who had manual compression (odds ratio [OR]: 0.67, 95% confidence interval [CI]: 0.22-2.1, p  = 0.49). Any complications occurred in 51 (11.7%) patients who had a Catalyst closure device and in 64 (6.2%) patients who had manual compression (OR: 2, CI: 1.4-3, p  < 0.01). After adjustment for other variables and for a propensity score reflecting the probability to receive the closure device, the association of major complications with the use of the closure device remained not significant (OR: 0.54, 95% CI: 0.17-1.7, p  = 0.29), while the association of any complications with the use of the Catalyst device remained significant (OR: 1.9, 95% CI: 1.3-2.9, p  < 0.01). The Catalyst device was not associated with an increased risk of major groin complications but was associated with an increased risk of any complications compared with manual compression. Patients receiving the closure device ambulated sooner.

Mechanical Thrombectomy in Patients with Acute Ischemic Stroke and Lower NIHSS Scores: Recanalization Rates, Periprocedural Complications, and Clinical Outcome

BACKGROUND AND PURPOSE

Mechanical thrombectomy, in addition to intravenous thrombolysis, has become standard in acute ischemic stroke treatment in patients with large-vessel occlusion in the anterior circulation. However, previous randomized controlled stroke trials were not focused on patients with mild-to-moderate symptoms. Thus, there are limited data for patient selection, prediction of clinical outcome, and occurrence of complications in this patient population. The purpose of this analysis was to assess clinical and interventional data in patients treated with mechanical thrombectomy in case of ischemic stroke with mild-to-moderate symptoms.

MATERIALS AND METHODS

We performed a retrospective analysis of a prospectively collected stroke data base. Inclusion criteria were anterior circulation ischemic stroke treated with mechanical thrombectomy at our institution between September 2010 and October 2015 with an NIHSS score of ≤8.

RESULTS

Of 484 patients, we identified 33 (6.8%) with the following characteristics: median NIHSS = 5 (interquartile range, 4-7), median onset-to-groin puncture time = 320 minutes (interquartile range, 237-528 minutes). Recanalization (TICI = 2b-3) was achieved in 26 (78.7%) patients. Two cases of symptomatic intracranial hemorrhage were observed. Favorable (mRS 0-2) and moderate (mRS 0-3) clinical outcome at 90 days was achieved in 21 (63.6%) and 30 (90.9%) patients, respectively.

CONCLUSIONS

The clinical outcome of patients undergoing mechanical thrombectomy for acute ischemic stroke with mild stroke due to large-vessel occlusion appears to be predominately favorable, even in a prolonged time window. However, although infrequent, angiographic complications could impair clinical outcome. Future randomized controlled trials should assess the benefit compared with the best medical treatment.

Evaluation of a structured training program for arterial femoral sheath removal after percutaneous arterial catheter procedures by assistant personnel

After cardiac catheterization procedures, arterial closure can be achieved by manual compression (MC), using external mechanical compression devices, or by applying vascular closure devices (VCDs) with comparable vascular access site-related complication rates. The aim of the present study was to assess vascular access site-related complications during the implementation of structured sheath removal and MC by paramedics after catheterization procedures. After an observational phase of 3 months to assess the baseline complication rate, a structured 4-level training program was implemented to train assistant personnel, in this case paramedics, in the management of sheath removal by MC. Access site-related complication rates after sheath removal were assessed prospectively and MC by paramedics compared with MC by physicians and application of VCDs. To account for imbalances in procedure- and patient-related risk factors of access-site complications, propensity score-based matching analysis was performed (ClinicalTrials.gov identifier NCT00825331). All consecutive percutaneous transfemoral arterial cardiac catheterization procedures were prospectively assessed over a period of 8 months (n = 3,503). MC was performed in 2,315 cases, of which 180 were performed by paramedics and 2,135 by physicians; VCDs were applied in 1,188 procedures. Rates of access site-related complications were significantly lower for paramedics compared with physicians (p = 0.03) and similar between paramedics and VCDs (p = 0.77). In conclusion a structured program for paramedics to be trained in sheath removal after percutaneous cardiac catheterization procedures can be readily implemented during clinical routine with low in-hospital complication rates.

Using vascular closure devices following out-of-hospital cardiac arrest?

OBJECTIVES AND BACKGROUND

Despite a generally broad use of vascular closure devices (VCDs), it remains unclear whether they can also be used in victims from out-of-hospital cardiac arrest (OHCA) treated with mild therapeutic hypothermia (MTH).

METHODS

All victims from OHCA who received immediate coronary angiography after OHCA between January 1(st) 2008 and December 31(st) 2013 were included in this study. The operator decided to either use a VCD (Angio-Seal™) or manual compression for femoral artery puncture. The decision to induce MTH was based on the clinical circumstances.

RESULTS

76 patients were included in this study, 46 (60.5%) men and 30 (39.5%) women with a mean age of 64.2 ± 12.8 years. VCDs were used in 26 patients (34.2%), and 48 patients (63.2%) were treated with MTH. While there were significantly more overall vascular complications in the group of patients treated with MTH (12.5% versus 0.0%; p=0.05), vascular complications were similar between patients with VCD or manual compression, regardless of whether or not they were treated with MTH.

CONCLUSION

In our study, the overall rate of vascular complications related to coronary angiography was higher in patients treated with mild therapeutic hypothermia, but was not affected by the application of a vascular closure device. Therefore, our data suggest that the use of VCDs in victims from OHCA might be feasible and safe in patients treated with MTH as well, at least if the decision to use them is individually carefully determined.

Large-scale experience with an anchorless vascular closure device in a real-life clinical setting

AIMS

This study was designed to evaluate safety and effectiveness of the vascular closure device Exoseal (Cordis) for hemostatic control following cardiac catheterization in a real-life clinical setting.

METHODS AND RESULTS

This prospective, single-center study enrolled n = 2,031 consecutive patients who underwent coronary angiography via the femoral artery ± PCI (n = 801). Patients were excluded if they had radial access, percutaneous repair of structural heart disease, or if they had severe peripheral artery disease. If clinical abnormalities were discovered at the access site, color Doppler ultrasound was performed. The composite primary endpoint was defined as bleeding/vascular complications and device failure, and it was experienced by 5.4 % (n = 110) of patients. The most frequent complications were pseudoaneurysm (2.9 %, n = 58) and access-site hematoma >6 cm (1.8 %, n = 37). The overall device failure rate was 0.7 % (n = 14). Multiple logistic regression analysis demonstrated that the strongest independent predictors of bleeding/vascular complications and/or device failure were procedure duration (OR 2.1, CI 1.4-3.2), PCI (OR 2.7, CI 1.7-4.2), GP IIb/IIIa inhibitors (OR 2.9, CI 1.5-5.7), and age (OR 2.2, CI 1.4-3.5).

CONCLUSIONS

These results indicate that Exoseal was safe in a broad collective of patients. However, lengthy procedures, PCIs, the use of GP IIb/IIIa inhibitors, and elderly patients require special attention.

Routine use of ultrasound-guided access reduces access site-related complications after lower extremity percutaneous revascularization

OBJECTIVE

We sought to elucidate the risks for access site-related complications (ASCs) after percutaneous lower extremity revascularization and to evaluate the benefit of routine ultrasound-guided access (RUS) in decreasing ASCs.

METHODS

We reviewed all consecutive percutaneous revascularizations (percutaneous transluminal angioplasty or stent) performed for lower extremity atherosclerosis at our institution from 2002 to 2012. RUS began in September 2007. Primary outcome was any ASC (bleeding, groin or retroperitoneal hematoma, vessel rupture, or thrombosis). Multivariable logistic regression was used to determine predictors of ASC.

RESULTS

A total of 1371 punctures were performed on 877 patients (43% women; median age, 69 [interquartile range, 60-78] years) for claudication (29%), critical limb ischemia (59%), or bypass graft stenosis (12%) with 4F to 8F sheaths. There were 72 ASCs (5%): 52 instances of bleeding or groin hematoma, nine pseudoaneurysms, eight retroperitoneal hematomas, two artery lacerations, and one thrombosis. ASCs were less frequent when RUS was used (4% vs 7%; P = .02). Multivariable predictors of ASC were age >75 years (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.7; P = .03), congestive heart failure (OR, 1.9; 95% CI, 1.1-1.3; P = .02), preoperative warfarin use (OR, 2.0; 95% CI, 1.1-3.5; P = .02), and RUS (OR, 0.4; 95% CI, 0.2-0.7; P < .01). Vascular closure devices (VCDs) were not associated with lower rates of ASCs (OR, 1.1; 95% CI, 0.6-1.9; P = .79). RUS lowered ASCs in those >75 years (5% vs 12%; P < .01) but not in those taking warfarin preoperatively (10% vs 13%; P = .47). RUS did not decrease VCD failure (6% vs 4%; P = .79).

CONCLUSIONS

We were able to decrease the rate of ASCs during lower extremity revascularization with the implementation of RUS. VCDs did not affect ASCs. Particular care should be taken with patients >75 years old, those with congestive heart failure, and those taking warfarin.

Detailed analysis of puncture site vascular complications in Japanese Registry of Neuroendovascular Therapy (JR-NET) and JR-NET2

A subgroup analysis of access site complications in the Japanese Registry of Neuroendovascular Therapy (JR-NET) and JR-NET2, which were retrospective registry studies, was performed. Puncture site vascular complications occurred in 195 (0.63%, mean age: 69.2) of all 31,836 patients. Most of these complications resulted from surgery in main hospitals (186 patients, 0.67%, P < 0.001) and scheduled surgery (167 patients, 0.73%, P < 0.001). Carotid artery stenting (81 patients, 1.04%, p < 0.001), extracranial percutaneous transluminal angioplasty (PTA) (15 patients, 1.02%, p < 0.001), and intracranial PTA (10 patients, 0.81%, p < 0.05) were associated with significantly higher incidence of complications. The incidence of puncture site vascular complications was correlated with the number of antiplatelet drugs (p < 0.001) and intraoperative heparinization (p < 0.05).

Practices and complications of vascular closure devices and manual compression in patients undergoing elective transfemoral coronary procedures

Femoral arterial puncture is the most common access method for coronary angiography and percutaneous coronary interventions (PCIs). Access complications, although infrequent, affect morbidity, mortality, costs, and length of hospital stay. Vascular closure devices (VCDs) are used for rapid hemostasis and early ambulation, but there is no consensus on whether VCDs are superior to manual compression (MC). A retrospective review and nested case-control study of consecutive patients undergoing elective transfemoral coronary angiography and PCI over 3 years was performed. Hemostasis strategy was performed according to the operators' discretion. Vascular complications were defined as groin bleeding (hematoma, hemoglobin decrease ≥3 g/dl, transfusion, retroperitoneal bleeding, or arterial perforation), pseudoaneurysm, arteriovenous fistula formation, obstruction, or infection. Patients with postprocedure femoral vascular access complications were compared to randomly selected patients without complication. Data were available for 9,108 procedures, of which PCI was performed in 3,172 (34.8%). MC was performed in 2,581 (28.3%) and VCDs (4 different types) were deployed in 6,527 procedures (71.7%). Significant complications occurred in 74 procedures (0.81%), with 32 (1.24%) complications with MC and 42 (0.64%) with VCD (p = 0.004). VCD deployment failed in 80 procedures (1.23%), of which 8 (10%) had vascular complications. VCD use was a predictor of fewer complications (odds ratio 0.52, 95% confidence interval 0.33 to 0.83). In the case-control analysis, older age and use of large (7Fr to 8Fr) femoral sheaths were independent predictors of complications. In conclusion, the retrospective analysis of contemporary hemostasis strategies and outcomes in elective coronary procedures identified a low rate of complications (0.81%), with superior results after VCD deployment. Careful selection of hemostasis strategy and closure device may further decrease complication rates.