Vascular Closure Devices

Factors related to insufficient hemostasis using the EXOSEAL vascular closure device with five-minutes compression for femoral artery punctures after neuro-endovascular therapy: A retrospective, single-center experience

OBJECTIVES

The aim was to identify the factors related to inadequate hemostasis with five minutes of manual compression using the EXOSEAL vascular closure device (VCD), and to evaluate the optimal time to hemostasis (TTH).

METHODS

A total of 119 consecutive patients who underwent neuro-endovascular therapy via common femoral arterial puncture between February 2019 and August 2021 were included. These patients underwent hemostasis using an EXOSEAL with manual compression for five minutes. In this retrospective study, the 119 patients were divided into two groups: (1) achieved hemostasis with five minutes (n = 76); and (2) required more than five minutes to achieve hemostasis (n = 43, Add group). In both groups, patient's characteristics, endovascular procedures, and closure procedures were assessed.

RESULTS

On univariable analysis, activated clotting time (ACT), multiple antiplatelets, closure with an under-sized EXOSEAL VCD (U-VCD), endovascular procedure, and use of a 7Fr. VCD were significantly associated with additional compression (p < 0.05). On multivariate logistic regression analysis, the following three factors were found to be associated with additional compression: pre-closure ACT (adjusted OR, 0.136; 95% CI, 1.017-1.056; p < 0.001); multiple antithrombotics (adjusted OR, 12.843; 95% CI, 3.458-47.693; p < 0.001); and closure with a U-VCD (adjusted OR, 5.653; 95% CI, 1.751-18.151; p = 0.004). On the receiver-operating characteristic curve analysis for prediction of the need for additional compression, the cutoff point for pre-closure ACT was calculated to be 268 s. In the Add group, mean TTH was 9.8 ± 1.5 min.

CONCLUSION

Multiple antiplatelets and closure with a U-VCD may increase the risk of insufficient hemostasis with five-minutes compression using an EXOSEAL VCD for femoral puncture sites if the pre-closure ACT is greater than 268 s. In these patients, mean TTH was 9.8 ± 1.5 min.

Supra-Aortic Arterial Injuries Following Central Venous Catheterization Managed with Percutaneous Closure Devices: A Comprehensive Literature Review of Current Evidence

BACKGROUND

Inadvertent supra-aortic arterial injuries during central venous catheterization can lead to devastating outcomes. These have been traditionally been managed with open repair or covered stent placement; only recently have percutaneous closure been incorporated into the management of these iatrogenic arterial injuries.

METHODS

We performed a MEDLINE literature search in the English language, using the PubMed web-based search engine across years 2000 to 2020. This report reviews 34 published case reports and series reporting 71 iatrogenic supra-aortic arterial injuries managed with percutaneous vascular closure devices.

RESULTS

In our review, the use of a closure device was successful in 87% of cases, even in some cases involving sheath sizes greater than 8F. The devices used in these situations caused minimal complications and offered a quick means to control bleeding. Thus, percutaneous closure devices are a helpful tool that offers an alternative to more invasive open surgical repair.

CONCLUSIONS

Vascular closure devices offer a minimally invasive and effective approach to the treatment of inadvertent supra-aortic arterial injury following CVC.

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.

Comparison of MynxGrip vascular closure device and manual compression for closure after femoral access angiography: a randomized controlled trial: the closure devices used in every day practice study, CLOSE-UP III trial

Background

Complications related to femoral artery access for coronary angiography (CAG) is a safety concern. Vascular closure devices (VCDs) have been developed to reduce the rate of complications after femoral artery access. We compared the safety and efficacy of the MynxGrip VCD versus manual compression (MC) after femoral access CAG in a randomized controlled trial.

Methods

The study was a randomized, single center, non-blinded, two-arm non-inferiority trial. The study was stopped prematurely because of low inclusion rate.

Results

We randomized 869 patients to closure with the MynxGrip VCD or MC and 865 entered analyses. The incidence of the primary endpoint of major adverse vascular events (MAVE) after 30 days was 1.2% in the MynxGrip group and 0% in the MC group (p = 0.06). The median time to hemostasis was 4 [3:5] minutes and 10 [7:11] minutes in the MynxGrip group and MC group, respectively (p < 0.0001). The corresponding median times to mobilization was 73 [65:87] minutes and 76 [70:88] minutes (p = 0.01).

Conclusions

MAVE was rare after closure of femoral arterial access by both the MynxGrip VCD and MC. We found a numerical difference in favour of MC but this did not reach statistical significance. Time to hemostasis was shorter in the MynxGrip group when compared to the MC group.

Trial registration

The study was approved by the local medical ethics committee and registered at clinicaltrials.org (ClinicalTrials identifier: NCT02237430 11/09/2014).

Hemorrhagic complications after endovascular interventions and the effectiveness of vascular closure devices

Aim. To identify the factors associated with hemorrhagic complications after endovascular interventions, as well as to assess the effectiveness of vascular closure devices.

Material and methods. The study included 423 patients after endo - vascular intervention with femoral arterial access: 118  — manual compression, 305  — hemostasis using vascular closure devices (VCDs). The development of following complications was recorded: retroperitoneal hematoma, false aneurysm, arteriovenous fistula, bleeding, thigh soft-tissue hematoma. Time to hemostasis, immobilization period, and length of stay were assessed.

Results. The complication rate was lower in VCD group compared to manual hemostasis (2,95 vs 11%, p=0,021). In VCD group, hemostasis characteristics significantly differed from the manual compression group: time to hemostasis — 3,1 vs 22,3 min (p=0,001), immobilization duration  — 4,1 vs 20 hours (p=0,001), length of stay  — 4 vs 8 days (p=0,001), respectively. The risk of complications increased with following factors: anticoagulant therapy, female sex, age >65 years, diabetes, body mass index >30 kg/m2 , vascular access calcification, introducer diameter >6 Fr, prior puncture. There were following independent predictors of complications: glycoprotein IIb/IIIa inhibitor therapy, superficial or deep femoral artery puncture.

Conclusion. VCDs significantly reduces the hemorrhagic complication rate and improves hemostasis parameters as compared to manual compression.

ULSOSEAL Technique: A Unique Technique to Achieve Hemostasis Using ExoSeal in High-Risk Patients after Common Femoral Artery Puncture

This study aimed to assess the safety and feasibility of the ULtrasound-guided uSe Of exoSEAL technique (ULSOSEAL technique) in patients at a high risk of complications following the use of ExoSeal. ExoSeal is a novel, completely extravascular hemostatic device that can treat punctures of the common femoral artery; however, it is not preferable for use in cases that require hemostasis of complex puncture sites. From November 2019 to August 2020, the ULSOSEAL technique was performed in 35 patients with implanted stents (6 patients, 17%), severe calcification (32 patients, 91%), and plaque (7 patients, 20%) around the puncture site; the presence of these conditions is usually undesirable when using ExoSeal. The antegrade approach was used in 22 patients (71%). The size of the ExoSeal used was 5 Fr (13 patients, 37%), 6 Fr (21 patients, 60%), and 7 Fr (1 patient, 2%). Technical success was achieved in 34 patients (97%), while ExoSeal malfunction occurred in 1 patient. There was no incidence of vessel occlusion, pseudoaneurysm, arteriovenous fistula, infection, and secondary bleeding. One patient developed a hematoma (>5 cm in size); however, it occurred before the use of ExoSeal due to side leakage from the inserted sheath. The ULSOSEAL technique was safe and feasible for hemostasis in patients who were considered unsuitable for the ExoSeal device.

Perclose ProGlide embolization as a complication: case report and review of literature

Background: Vascular closure devices have replaced mechanical compression for closure of femoral access sites after endovascular procedures. Case: We present an 87-year old male with symptomatic infrarenal aortic aneurysm measuring 4.8 cm presenting for elective endovascular repair of the aortic aneurysm. A Perclose ProGlide Suture-Mediated Closure was used for closure. The closure was complicated by a separation of the ProGlide device resulting in the migration of the footplate to the descending aorta. Correction required snare retrieval via radial access, and the patient recovered without complications. Discussion: We highlight an important complication of the Perclose ProGlide Suture-Mediated Closure device that is rare but important to know when performing endovascular closures with this device.

Results from the prospective, multicenter AMBULATE-CAP trial: Reduced use of urinary catheters and protamine with hemostasis via the Mid-Bore Venous Vascular Closure System (VASCADE® MVP) following multi-access cardiac ablation procedures

INTRODUCTION

Manual compression (MC), historically the most common method to achieve hemostasis after percutaneous vascular procedures, is time consuming, requires prolonged bedrest, and is uncomfortable for patients and clinicians. Recent studies demonstrate the efficacy and safety of vascular closure devices and suggest shorter times to hemostasis and patient ambulation compared with MC. The current study evaluated the feasibility of the VASCADE® venous vascular closure system (VVCS) while allowing for urinary catheter (UC) elimination, and elimination of protamine and/or same calendar day discharge (SCDD).

METHODS AND RESULTS

In this prospective, multicenter trial, patients were enrolled and assigned to the following groups: no UC, no protamine, and/or SCDD (no co-enrollment in no protamine and SCDD). After completing the catheter-based cardiac procedure, access sites were closed using the VVCS. Outcomes included final hemostasis (all sites) without major access site-related complications at 30 days, rates of access site closure-related complications, device success, and study group success. All 168 patients had hemostasis without major access site-related complications through 30 days. In the no UC group, 160 out of 164 (97.6%) patients did not receive a UC. Additionally, 39 out of 41 (95.1%) patients received heparin without protamine reversal and no access site bleeding-related ambulation delays, and 18 out of 18 (100%) patients were discharged on the same day. There were no major access site closure-related complications, few minor complications, and adverse events were generally mild and well managed.

CONCLUSION

The VVCS was effective for achieving hemostasis following catheter-based procedures; access site closure-related complications and adverse events were well managed.

The MANTA Vascular Closure Device for Percutaneous Femoral Vessel Cannulation in Minimally Invasive Surgical Mitral Valve Repair

A 65-year-old Caucasian male was referred to our institution with severe mitral regurgitation due to posterior mitral leaflet prolapse. The patient underwent minimally invasive surgical mitral valve repair. Here we present the application of a new vascular closure device (MANTA) for percutaneous arterial access and closure.

Complication rates associated with antegrade use of vascular closure devices: a systematic review and pooled analysis

BACKGROUND

Vascular closure devices (VCDs) have become a mainstay in endovascular interventions in recent years. On-label use only allows for retrograde interventions originating at the common femoral artery (CFA). However, off-label use in antegrade and/or superficial femoral artery (SFA) access has become more common in the treatment of peripheral arterial disease. Despite this, there is a paucity of comparative literature assessing individual VCD safety profiles and relative complication risks of CFA vs SFA applications.

METHODS

MEDLINE and EMBASE systematic searches were performed from inception to October 2019 to identify studies assessing VCD use in antegrade CFA and SFA interventions. Abstract selection and data extraction were performed by two independent reviewers. Primary outcomes included bleeding-related complications, vessel occlusion or stenosis, embolization, pseudoaneurysm formation, or arteriovenous fistula formation.

RESULTS

Twenty-four unique studies with 4124 vascular closure events via six unique VCDs were included (Angioseal, Exoseal, Femoseal, Glubran 2, Mynx, Starclose; 3698 CFA, 426 SFA). Pooled occurrence of all complications across closure devices used in the CFA and SFA ranged from 0.9% (Mynx) to 7.4% (Starclose) and 0% (Perclose) to 10.1% (Starclose), respectively, depending on VCD type. Clinically meaningful differences were identified between devices with a trend toward significance (P = .08 CFA, P = .07 SFA). Individual devices demonstrated a range of bleeding complication rates from 0.4% (Mynx) to 7.2% (Femoseal) for the CFA site and from 0% (Perclose) to 6.4% (Starclose) for the SFA site (P = .01 and P = .03, respectively). Significant heterogeneity between studies precludes definitive characterization of the device as cause for variations in bleeding complication rates. Pooled complication rates did not differ between the CFA and SFA arms (4.6% vs 5.8%, P = .56). Bleeding complication rates also did not differ between the CFA and SFA arms (3.6% vs 3.6%, P = .98).

CONCLUSIONS

Clinically meaningful differences in overall pooled complications were identified between VCDs with a trend toward significance. Significant differences between VCDs exist with respect to bleeding risk. However, this must be interpreted with caution as these differences could be secondary to interstudy heterogeneity. Finally, no difference was identified between antegrade SFA and CFA VCD use with respect to overall complication and bleeding risks.

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.

Das moderne befund- und patientenadaptierte Management von peripheren Pseudoaneurysmen nach arteriellem Zugang

Pseudoaneurysmen (PSA) zählen zusammen mit den Hämatomen zu den häufigsten Komplikationen nach kathetergestützten Eingriffen.

Ziel und Methode Die narrative kompakte Kurzübersicht umreißt sowohl die Entstehung und Charakteristika von Pseudoaneurysmen sowie die Optionen der Diagnostik und Therapie als auch deren mögliche Komplikationen.

Ergebnisse Ätiopathogenese: Durch den nicht verschlossenen Stichkanal der Punktion kommt es zum kontinuierlichen Blutausstrom aus dem Gefäß, der im umliegenden Gewebe eine Pseudoaneurysmahöhle formt. Diese wird nicht wie beim wahren Aneurysma durch eine Gefäßwand begrenzt, sondern nur durch die umliegenden Gewebestrukturen eingedämmt. Dies ist aber meist nicht suffizient und es kommt zu einer raschen Ausbreitung und diffusen Einblutungen. Dadurch können umliegende Strukturen wie Nerven und Venen durch das expandierende Pseudoaneurysma komprimiert werden, woraus sich irreversible Schäden entwickeln können. Diagnostik: Die Duplexsonografie steht dominierend absolut im Vordergrund. Die CT-A, MR-A und DSA bleiben speziellen Fragestellungen oder klinischen Fallkonstellationen (z. B. Begleiterkrankungen etc.) vorbehalten – eine DSA ist stets mit Interventionsbereitschaft zu verbinden. Therapie: Mit der manuellen Kompression und der darauffolgenden Anlage eines Druckverbandes, einer ultraschallgestützten Kompression, der Thrombininjektion und der operativen Sanierung stehen mehrere Verfahren zur Auswahl. Die ultraschallgestützte Kompression sollte dabei immer sofort eingesetzt werden, da sie höchst effizient und ubiquitär verfügbar ist. Additiv zur Kompression kann die Thrombininjektion bei PSA ohne Nerven-/Gewebeirritation mit eingesetzt werden und bietet noch bessere Verschlussraten, ist jedoch anspruchsvoller in der Anwendung. Die operative Ausschaltung ist die effektivste Methode, bietet aber neben dem größten Aufwand die meisten Begleitkomplikationen wie Wundheilungsstörung bei mazeriertem Gewebe und den längsten Krankenhausaufenthalt. Alternative Verfahren zu den genannten haben sich bisher nicht durchsetzen können.

Schlussfolgerung Das diagnostische und therapeutische Management von Pseudoaneurysmen stellt eine Herausforderung im interdisziplinären befund- und patientenadaptierten Vorgehen dar, das den erfahren Gefäßmediziner erfordert.

Risk of Ipsilateral Deep Vein Thrombosis After Use of AngioSeal Closure Device in Aneurysmal Subarachnoid Hemorrhage Patients

BACKGROUND

Deep vein thrombosis (DVT) is a known complication in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study investigated the association between use of the AngioSeal (St. Jude Medical, Minnetonka, MN) vascular closure device and the risk of ipsilateral and any DVT event after angiography in patients with aSAH.

METHODS

We conducted a review of our institutional cerebral angiography database for the years 2005-2018 to identify all adult patients who underwent angiography for aSAH. We compared the incidence of DVT (occurring within 14 days) between aSAH patients who underwent manual compression versus the AngioSeal closure device.

RESULTS

A total of 459 aSAH patients underwent angiography; 262 underwent manual compression (57.1%) and 197 received AngioSeal (42.9%). There was a 3.4% rate of ipsilateral DVT in the manual compression group and 7.6% in the AngioSeal closure device group (χ2 test, P = 0.04). Similarly, the rate of any DVT was 8.8% for manual compression and 16.8% for patients who received AngioSeal (χ2 test, P = 0.01). On multivariate analysis, AngioSeal remained a significant independent predictor of ipsilateral DVT (odds ratio 2.4, P = 0.04) and any DVT (odds ratio 2.3, P = 0.01).

CONCLUSIONS

In aSAH patients undergoing cerebral angiographic procedures with access through the femoral artery, the use of AngioSeal closure device was found to be associated with a significantly increased risk of ipsilateral DVT within 14 days.

Differences of bleedings after percutaneous coronary intervention using femoral closure and radial compression devices

Bleedings represent most relevant complications being correlated with significant rates of adverse clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). To reduce bleeding and improve prognosis various types of vascular closure devices (VCD) are frequently applied. This study aims to compare directly one specific femoral closure (FC) to one specific radial compression (RC) device in patients after PCI focusing on overall and access-site bleedings as well as major adverse cardiac events (MACE).This single-center, prospective, and observational study included consecutive patients either treated by the FC (StarClose SE) or RC (TR Band) device following PCI. The primary outcome was bleeding; the secondary outcomes were MACE at 30 days of follow-up.Two hundred patients in each group were enrolled following PCI. Access-site bleeding was significantly higher in the FC (43%) compared to the RC (30%) group (P = .001). Most common type of access-site bleeding consisted of hematomas. Of these, small and large hematomas were significantly higher in the FC group (P < .05). No significant differences of MACE were observed in both groups. In multivariable logistic regression models no consistent significant association of any risk factor with bleeding complications was identified.Despite the use of VCD, transfemoral arterial access is still associated with a higher rates of access site bleeding consisting mostly of hematomas compared to trans-radial access, whereas no differences of MACE were observed between FC and RC patients at 30 days follow-up.

Extravascular compared to Intravascular Femoral Closure is Associated with Less Bleeding and Similar MACE after Percutaneous Coronary Intervention

Background: Various types of vascular closure devices (VCDs) are frequently utilized in patients undergoing percutaneous coronary intervention (PCI) in order to prevent arterial access site bleeding, which represents one of the most relevant complications associated with adverse clinical outcomes. This study aims to compare directly two mechanistically different types of femoral closure (FC) devices in patients undergoing PCI. Methods: This single-center, prospective, observational study includes consecutively patients either treated by the extravascular StarClose SE® (Abbott, Illinois, U.S.A.) or the intravascular AngioSeal™ FC (St. Jude Medical, Inc., St. Paul, MN, U.S.A.) after PCI. The primary endpoint was bleeding complications, the secondary endpoint was major adverse cardiac events (MACE) at 30 days of follow-up. Results: 200 patients in each group (StarClose SE® and AngioSeal™) were enrolled following PCI. The rates of overall and non-access site bleedings were significantly higher in the AngioSeal™ group (56%; 6%) compared to the StarClose SE® group (43.5%; 0.5%) (p = 0.012; 0.003). Additionally, complicated access site bleedings were also significantly higher in the AngioSeal™ group (p = 0.011). No significant differences of MACE were observed in both groups. However, there was a higher rate of unsuccessful implantation of the StarClose SE® (n=12, excluded from the study). Conclusions: In case of successful implantation, FC by the AngioSeal™ is associated with the higher rate of both access and non-access site bleedings, but similar rates of MACE at 30 days compared to the StarClose SE® device.

Transcatheter aortic valve implantation via the superficial femoral artery: An underused access route?

Common femoral arterial (CFA) access is the most commonly used access route for transcatheter aortic valve implantation (TAVI). In majority of cases, it is easily accessible percutaneously without requiring surgical cut down. However, in patients with high body mass index (BMI) or central obesity, it can be more than 8-10 cm below the skin making the procedure more technically demanding and satisfactory hemostasis more difficult to achieve. The superficial femoral artery (SFA) lies only a few centimeters distal to the CFA with little compromise on vessel caliber, yet can allow more suitable access in certain patients with a high BMI. We describe three cases in which SFA access was successfully used as the primary delivery route for TAVI.

Safety and Effectiveness of Suture-mediated Arterial Closure Device in Hepatocellular Carcinoma Patients Who Underwent Drug-Eluting Beads Transarterial Chemoembolization

BACKGROUND

The number of transarterial percutaneous procedures has risen over the years, consequently reducing puncture site related complications has become a necessity. To this end, the use of arterial closure devices has been growing progressively and their benefits have become a focus of research. The purpose of this study is to assess the safety and effectiveness of a suture-mediated closure device, Perclose ProGlide^® (Abbott Vascular, Redwood City, CA), in patients with liver disease and hepatocellular carcinoma who underwent transarterial liver chemoembolization with drug-eluting beads.

MATERIALS AND METHODS

A cohort of 253 hepatocellular carcinoma patients who underwent 449 procedures of transarterial liver chemoembolization with drug-eluting beads using the Perclose Proglide device was prospectively studied. The main endpoints evaluated were the technical success of the device, defined as complete hemostasis achieved within 3 min after the closure, and the incidence of puncture-site complications. The secondary endpoints evaluated were the correlation between epidemiological factors, coagulation profile and degree of liver disease, and the occurrence of complications.

RESULTS

Technical success was achieved in 96% of the cases. Among patients who underwent repeated procedures using the same vascular access, this rate was 95.3%. Puncture-site complications were observed in 7 procedures (1.56%); 4 (0.89%) were due to hemorrhage, 2 (0.44%) hematomas and 2 (0.44%) pseudoaneurysms; 2 (0.44%) due to limb ischemia; and 1 (0.22%) due to arterial dissection. Among them, 3 cases required intervention. The statistical analysis of demographic characteristics, Child-Pugh classification, and coagulation status did not show a significant correlation with the occurrence of complications. Of the 449 procedures, only 4 (0.89%) needed hospitalization due to puncture-site complications.

CONCLUSIONS

The use of Perclose Proglide is safe and effective in patients with liver disease and hepatocellular carcinoma who underwent transarterial liver chemoembolization with drug-eluting beads.

Development, preclinical evaluation and validation of a novel quick vascular closure device for transluminal, cardiac and radiological arterial catheterization

Following percutaneous coronary intervention, vascular closure devices (VCDs) are increasingly used to reduce time to ambulation, enhance patient comfort, and reduce potential complications compared with traditional manual compression. Newer techniques include complicated, more or less automated suture devices, local application of pads or the use of metal clips and staples. These techniques often have the disadvantage of being time consuming, expensive or not efficient enough. The VCD failure rate in association with vascular complications of 2.0-9.5%, depending on the type of VCD, is still not acceptable. Therefore, the aim of this study is to develop a self-expanding quick vascular closure device (QVCD) made from a bioabsorbable elastic polymer that can be easily applied through the placed introducer sheath. Bioabsorbable block-co-polymers were synthesized and the chemical and mechanical degradation were determined by in vitro tests. The best fitting polymer was selected for further investigation and for microinjection moulding. After comprehensive haemocompatibility analyses in vitro, QVCDs were implanted in arterial vessels following arteriotomy for different time points in sheep to investigate the healing process. The in vivo tests proved that the new QVCD can be safely placed in the arteriotomy hole through the existing sheath instantly sealing the vessel. The degradation time of 14 days found in vitro was sufficient for vessel healing. After 4 weeks, the remaining QVCD material was covered by neointima. Overall, our experiments showed the safety and feasibility of applying this novel QVCD through an existing arterial sheath and hence encourage future work with larger calibers.

MynxGrip vascular closure device use in pediatric neurointerventional procedures

OBJECTIVE The aim of this paper was assess the efficacy and safety of using the MynxGrip arterial closure device in pediatric neuroendovascular procedures where the use of closure devices remains off-label despite their validation and widespread use in adults. METHODS A retrospective review of all pediatric patients who underwent diagnostic or interventional neuroendovascular procedures at the authors' institution was performed. MynxGrip use was predicated by an adequate depth of subcutaneous tissue and common femoral artery (CFA) diameter. Patients remained on supine bedrest for 2 hours after diagnostic procedures and for 3 hours after therapeutic procedures. Patient demographics, procedural details, hemostasis status, and complications were recorded. RESULTS Over 36 months, 83 MynxGrip devices were deployed in 53 patients (23 male and 30 female patients; mean age 14 years) who underwent neuroendovascular procedures. The right-side CFA was the main point of access for most procedures. The mean CFA diameter was 6.24 mm and ranged from 4 mm to 8.5 mm. Diagnostic angiography comprised 46% of the procedures. A single device failure occurred without any sequelae; the device was extracted, and hemostasis was achieved by manual compression with the placement of a Safeguard compression device. No other immediate or delayed major complications were recorded. CONCLUSIONS MynxGrip can be used safely in the pediatric population for effective hemostasis and has the advantage of earlier mobilization.

FemoSeal® Device Use for Femoral Artery Closure by Different Techniques

BACKGROUND

Common femoral artery is still the most frequently used site for vascular access, mostly for peripheral arterial interventions, and its puncture remains a significant source of patient's morbidity. Manual compression (MC) has been the gold standard for hemostasis after femoral catheterization until recently, but only in the last few years, vascular closure devices (VCDs) are replacing MC due to their rapid development. Nowadays, vascular surgeons (VSs) are also becoming familiar with VCDs. The purpose of this study was to investigate FemoSeal^® arterial closure system use in terms of safety and efficacy in patients undergoing transfemoral peripheral procedure and evaluate the complication risk factors.

METHODS

A retrospective analysis to compare 2 different specialists and technique with systematic implantation of FemoSeal^® VCD was performed in a cohort of vascular patients treated by endovascular procedure with femoral artery access site over a 2-year period and sheaths ranged from 6F to 8F. All the patients were on antiplatelet therapy and received heparin during the procedure. The FemoSeal^® was deployed in common femoral arteries. All patients were examined for access site complication by VS in both groups 20-24 hrs after VCD deployment and 1 and 6 weeks after the procedure with clinical visit and ultrasound duplex scan. Complications, as minor and major hematomas, pseudoaneurysm formation, vessel occlusion or dissection, and infection were recorded.

RESULTS

During the study period, 130 FemoSeal^® were deployed in 114 patients, 102 FemoSeal^® in VS group, and 28 in interventionalist group. Mean age was 57 ± 24 years. There was no significant difference between the 2 groups in terms of comorbidities. Patient follow-up ranged from 1 to 15 months. All but 3 of the FemoSeal^® devices were successfully deployed (all 3 cases in group 2). Mobilization time was 6 ± 4 hrs following interventions, and the discharge time ranged from 6 hrs to 7 days after procedure. Early discharge (within 6 hrs) was obtained in 23% of group 1 and in 0 cases of group 2 (P = 0.008). Delayed discharge was obtained in 74% of group 1 (67 pts) and in 70% of group 2 (18 pts) on postoperative day 1 (P = 0.47). Technical success was achieved in 99% of group 1 and in 93% of group 2 (P = 0.87). There were no perioperative deaths. There were no significant differences in terms of minor bleeding complications (P = 0.21) or infections or transfusion needing (P 0.06) in both groups. FemoSeal^®-related complications occurred in 6 patients (1 in group 1 and 5 in group 2; P = 0.0017). All complications occurred following therapeutic intervention with 6F sheath introducer. Complication rate resulted significatively higher in group 2 in terms of pseudoaneurysm development (P < 0.0001) and transfusion needing (P = 0.03) in a subgroup analysis on peripheral arterial disease (Rutherford 3-5). Only chronic limb ischemia was found to be independent predictor of complications due to VCD use.

CONCLUSIONS

Our data suggest that when simple guidelines are observed, the device is safe, effective, and easy to deploy and allows for early ambulation and discharge. However, appropriate randomized clinical trials could clarify the correct guideline to minimize the complication rates.

Use of vascular closure devices for endovascular interventions requiring a direct puncture of PETE grafts

Abstract. Background: Effectiveness of vascular closure devices during endovascular procedures requiring a direct puncture of a vascular prosthesis placed in the inguinal region is unknown. Patients and methods: The retrospective analysis included 134 patients with a history of polyethylene terephthalate (PETE) graft implantation in the inguinal region. In 20 (15 %) patients, haemostasis was achieved with manual compression, in 21 (16 %) with the StarClose™, and in 93 (69 %) with the AngioSeal™ device. Results: The incidence of vascular complications in the manual compression group was higher (at a threshold of statistical significance) than in the device closure group (45.0 vs. 24.5 %, p = 0.059). The difference was considered statistically significant when manual compression was compared with the AngioSeal™ closure group (45.0 vs. 13.9 %, p < 0.01). The vascular complication rate in the StarClose™ group was significantly higher than in the AngioSeal™ group (71.4 vs. 13.9 %, p < 0.000001). While haematomas were the only vascular complications observed after application of AngioSeal™, both haematomas and pseudoaneurysms were found in the StarClose™ group. Conclusions: The AngioSeal™ vascular closure device provides better local haemostasis than the StarClose™ device or manual compression during endovascular interventions requiring a direct puncture of PETE grafts

Percutaneous cannulation for cardiopulmonary bypass in minimally invasive surgery is associated with reduced groin complications

OBJECTIVES

Femoral cutdown is standard in most centres if groin cannulation is used for cardiopulmonary bypass in minimally invasive cardiac surgery (MICS). Arterial closure devices (ACDs) allow placement of larger cannulas percutaneously, but its benefit in MICS is unclear. We assessed our results with percutaneous groin cannulation using ACDs in comparison with conventional surgical access in patients undergoing MICS.

METHODS

We reviewed 445 consecutive patients having undergone MICS between October 2010 and March 2015. Of those, 92 (21%) were performed with conventional surgical access to the groin vessels and 353 (79%) with the use of ACDs.

RESULTS

Operative risk was higher in the ACD group [logistic EuroSCORE 7.9% (SD: 8.1) vs 10.6% (SD: 12.3); P = 0.010]. The use of ACDs significantly reduced operation time [193 min (SD: 43.8) vs 173 min (SD: 47.1); P < 0.001] and hospital stay [Cutdown: median 9 days (8, 14); ACD: median 9 days (7, 12), P = 0.040] without affecting the time to full mobilization. The incidence of any complication was significantly lower in the ACD group (2.3% vs 8.7%; P = 0.007). Complications with conventional cannulation consisted of lymphatic fistulae (n = 4), wound infections (n = 2), stenosis (n = 1) and haematoma (n = 1). In the ACD group, there were local dissections (n = 2) and stenoses (n = 3). There was 1 haematoma in both groups. There were 2 vascular injuries in the ACD group (n = 2), leading to conversion to surgical access.

CONCLUSIONS

Percutaneous groin cannulation using ACDs for establishing cardiopulmonary bypass in minimally invasive valve surgery significantly reduces groin complications, operation time and hospital stay. However, the remaining complications are mainly of vascular nature versus wound infection and lymph fistulae with cutdown.

The CLOSER trial: a multi-center study on the clinical safety and effectiveness of CloserTM VSS, a novel resorbable transfemoral vascular access sealing system

OBJECTIVES

To evaluate the safety and effectiveness of the Closer Vascular Sealing System (VSS) against prespecified performance goals (PGs) in sealing femoral arterial access following 5-7 Fr procedures.

BACKGROUND

Inconsistent safety profiles, costs and learning curves of earlier generation vascular closure devices have limited their widespread use following transfemoral procedures.

METHODS

In this prospective single-arm, multi-center trial, we compared the clinical outcomes in patients undergoing 5-7 Fr transfemoral diagnostic or interventional procedures and access sites managed with Closer VSS against pre-specified PGs. The primary endpoints were time to hemostasis (TTH) and 30-day access site closure-related major complications; secondary endpoints included time to ambulation (TTA), time to discharge eligibility (TTDE), time to discharge (TTD), 30-day access site minor complications, procedure and device success.

RESULTS

A total of 220 subjects (49.5% interventional) were enrolled. The mean TTH was 1.78 ± 7.81 min in the intention to treat and 0.98 ± 3.71 min in the per protocol cohort. Median TTH was 0 min with immediate hemostasis achieved in 80.5% of subjects, mean TTA was 2.50 ± 1.05 hr, and mean TTDE was 2.83 ± 1.54 hr. Thirty-day follow-up was completed on 219 subjects. There were no access site closure-related major complications, minor complication rate was 0.0% for diagnostic and 2.75% for interventional procedures.

CONCLUSIONS

In patients undergoing 5-7 Fr transfemoral diagnostic and interventional procedures, the CLOSER Trial met both its primary effectiveness and safety PGs. Immediate hemostasis was achieved in the majority of patients without major complication.

Avaliação técnica do dispositivo de fechamento vascular Exoseal-Cordis®

Contexto

Os dispositivos de oclusão vascular (DOV) permitem rápida remoção da bainha introdutora de um acesso arterial, reduzindo o tempo de hemostasia, a restrição do paciente ao leito e as complicações no sítio de punção.

Objetivos

Avaliar a eficácia e possíveis complicações do uso de dispositivo de oclusão arterial comparado com a compressão manual.

Métodos

Estudo longitudinal prospectivo randomizado com 20 pacientes no período de dezembro de 2014 a julho de 2015 em Maringá (PR). Foram divididos em dois grupos: aqueles que utilizaram DOV (grupo DOV) e aqueles submetido apenas a compressão manual (grupo CM). Realizaram-se exames de ultrassom Doppler para avaliar a espessura pele-artéria pré e pós-procedimento e verificou-se o tempo de compressão e de deambulação. Os dados foram analisados pelo Programa Statistical Analysis Software.

Resultados

Um total de 60% dos pacientes eram do sexo masculino e a média de idade de ambos os grupos foi de aproximadamente 60 anos. Não houve diferença na espessura pele-artéria entre os grupos. O tempo de compressão no grupo DOV foi de 2 minutos e no grupo CM foi de 21±2,11 minutos (p = 0,0005), e o tempo para retorno de movimentos no membro inferior puncionado foi de 2,35±0,75 horas no grupo DOV e de 6 horas no grupo CM (p = 0,0005). Não houve complicações.

Conclusões

Neste estudo a hemostasia por compressão manual foi tão efetiva quanto o uso de DOV, embora o tempo de compressão e o tempo para retorno às atividades sejam menores nos pacientes submetidos ao uso do dispositivo.

Manual Compression versus Vascular Closing Device for Closing Access Puncture Site in Femoral Left-Heart Catheterization and Percutaneous Coronary Interventions: A Retrospective Cross-Sectional Comparison of Costs and Effects in Inpatient Care

OBJECTIVES

To compare complication rates, length of hospital stay, and resulting costs between the use of manual compression and a vascular closing device (VCD) in both diagnostic and interventional catheterization in a German university hospital setting.

METHODS

A stratified analysis according to risk profiles was used to compare the risk of complications in a retrospective cross-sectional single-center study. Differences in costs and length of hospital stay were calculated using the recycled predictions method, based on regression coefficients from generalized linear models with gamma distribution. All models were adjusted for propensity score and possible confounders, such as age, sex, and comorbidities. The analysis was performed separately for diagnostic and interventional catheterization.

RESULTS

The unadjusted relative risk (RR) of complications was not significantly different in diagnostic catheterization when a VCD was used (RR = 0.70; 95% confidence interval [CI] 0.22-2.16) but significantly lower in interventional catheterization (RR = 0.44; 95% CI 0.21-0.93). Costs were on average €275 lower in the diagnostic group (95% CI -€478.0 to -€64.9; P = 0.006) and around €373 lower in the interventional group (95% CI -€630.0 to -€104.2; P = 0.014) when a VCD was used. The adjusted estimated average length of stay did not differ significantly between the use of a VCD and manual compression in both types of catheterization.

CONCLUSIONS

In interventional catheterization, VCDs significantly reduced unadjusted complication rates, as well as costs. A significant reduction in costs also supports their usage in diagnostic catheterization on a larger scale.

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.

Angiographic Analysis of Vascular Integrity After Percutaneous Closure Using Prostar XL Device During Transcatheter Aortic Valve Implantation

Introduction:

Percutaneous closure devices are commonly used to achieve hemostasis during endovascular procedures including transcatheter aortic valve implantation (TAVI). The aim of our study was to investigate the quality of the percutaneous femoral arterial closure by Prostar XL device using a systematic peroperative angiographic control at the end of TAVI procedure.

Materials and Methods:

Two hundred seventeen consecutive patients (mean age: 84 [6.5]; 112 women and 105 men) undergoing TAVI with percutaneous transfemoral access were prospectively registered in our center. Preoperative computed tomography scan was performed, and mean femoral vessel diameter was 7.9 (0.9) mm. At the end of TAVI intervention, the hemostasis was systematically achieved using the percutaneous closure device Prostar XL, without selection of patients based on anatomical criteria. An angiography with front and oblique views was performed to evaluate the quality and the safety of the closure device. Success of the percutaneous closure was defined as the absence of hemorrhage and the restitution of the arterial anatomy. Complications related to the percutaneous closure were classified as stenosis, dissection at the puncture site, suture failure, misplacement, or persistent bleeding.

Results:

Twenty-three (10.6%) patients had complications related to arterial percutaneous closure—14 (60.8%) stenosis, 6 (26.1%) persistent bleeding, and 1 (4.3%) dissection. These lesions were accessible to endovascular treatment via a crossover procedure. One (4.3%) suture failure and 1 (4.3%) misplacement of the device, with a puncture site created above the femoral arch, were reported. The patient developed a retroperitoneal hematoma postoperatively and required transfusion of 2 units of red blood cells associated with a cutdown to remove hematoma and to repair the common femoral artery.

Conclusion:

Angiography after arterial percutaneous closure using Prostar XL device during TAVI allows detection and endovascular treatment of vascular complications and is associated with low rate of conversion to open surgery.

A multicenter randomized trial comparing the effectiveness and safety of a novel vascular closure device to manual compression in anticoagulated patients undergoing percutaneous transfemoral procedures: The CELT ACD trial

OBJECTIVES

This study compared the performance of Celt ACD^® , a novel stainless steel based vascular closure device versus manual compression (MC) for femoral arteriotomy site hemostasis in patients undergoing percutaneous coronary procedures.

BACKGROUND

Optimal access site management after percutaneous transfemoral procedures remains controversial.

METHODS

Patients enrolled in this multicenter, randomized open label trial underwent 6-F diagnostic or interventional procedures and were assigned 2:1 to Celt ACD^® versus MC. All patients were on full anticoagulation. The primary efficacy end point was time to hemostasis (TTH) and the primary safety end points were 30-day incidence of major procedural and access site related complications.

RESULTS

The trial allocated 207 patients to Celt ACD^® (n = 148) versus MC (n = 59) at 5 investigational sites. Baseline characteristics of the two groups were similar. Median TTH was 0 (Interquartile range (IQR): 0, 0.33) in the Celt ACD^® compared to 8 min (IQR: 0, 20; P < 0.0001) in the MC group. Procedural success was 99.3% in the Celt ACD^® versus 98.1% in the MC group (P = NS). There was a single major adverse event due to device maldeployment and embolization with successful percutaneous retrieval. The 30-day major complication rate was 0.7% in the Celt ACD^® and 0% in the MC group (P = NS).

CONCLUSIONS

After 6-F percutaneous invasive procedures in fully anticoagulated patients, TTH was significantly reduced in patients assigned to Celt ACD^® compared to patients managed with MC. The 30-day rates of vascular complications were similarly low in both groups. (CELT ACD Trial; NCT01600482) © 2017 Wiley Periodicals, Inc.

Arterial access-site complications after use of a vascular closure device related to puncture height

Background

To analyze differences of access-site complications related to the height of femoral arterial puncture and the use of a vascular closure device (VCD) following percutaneous coronary intervention (PCI).

Methods

A subgroup of the FERARI study being treated by femoral arterial access and valuable inguinal angiography before implantation of a VCD were included. Inguinal angiographies were systematically reviewed by two independent cardiologists to determine the correct height of femoral arterial puncture. Bleeding complications were documented within 30 days after PCI and were categorized according to BARC, TIMI, GUSTO and FERARI classifications.

Results

Femoral access point imaging was available in 95 patients compared to 105 patients without. The common femoral artery (CFA) was the most accessed artery in 41%, followed by the femoral arterial bifurcation (39%) and lower access sites distally from the femoral arterial bifurcation (low puncture: 20%). No differences were observed regarding indication of PCI, procedural data and anticoagulation therapies in relation to the heights of femoral arterial access (p > 0.05). Despite using VCD, arterial puncture at the CFA resulted in numerically highest numbers of overall bleedings (62%) compared to femoral arterial bifurcation (41%) (p = 0.059). 58% of bleedings occurred after arterial puncture below the femoral bifurcation (low puncture). Though no significant differences of bleedings regarding classifications of BARC, GUSTO, TIMI and FERARI as well as other vascular endpoints were observed regarding puncture height.

Conclusions

The present analysis demonstrates no significant differences of bleeding complications in relation to the height of femoral arterial puncture and subsequent use of a VCD.

Successful Retrieval of an Embolized Vascular Closure Device (Angio-Seal®) After Peripheral Angioplasty

A 55-year-old male with peripheral arterial disease underwent angioplasty of the right lower limb arteries via antegrade femoral access. Angio-Seal^® closure device was used to treat the puncture site, whereby the intravascular sealing anchor accidentally embolized into the malleolar region of the right posterior tibial artery. Successful retrieval of the anchor was accomplished by a SpiderFX embolic protection device. This technique may be a useful approach to retrieve embolized foreign bodies via endovascular access.

Poorly recognized age-related downward deviation of the inguinal ligament

Objective:

To determine factors affecting actual inguinal ligament course in live human subjects.

Introduction and hypothesis:

Although the expected inguinal ligament course is supposedly a straight line extending from anterior superior iliac spine to pubic tubercle, the actual inguinal ligament course is frequently depicted a priori by a downward bowing dotted line. There are no studies in a live subject supporting this assumption. We hypothesized this assumption is indeed valid and is related to among other factors a lifelong effect of gravity and lax abdominal musculature on the inguinal ligament course.

Methods:

We retrospectively reviewed 54 consecutive computed tomography scans of the abdomen and pelvis randomly distributed across all age groups. Actual inguinal ligament course was visualized by reconstructing images using Terracon software. Vertical distance from the lowest point of actual inguinal ligament course to the expected inguinal ligament course was measured. We used multiple linear regression analysis to study the correlation between degree of inguinal ligament deviation and several variables.

Results:

Actual inguinal ligament course was below the expected inguinal ligament course in 52 of 54 patients. The mean deviation was 8.2 ± 5.9 mm. Advanced age was significantly associated with greater downward bowing of the inguinal ligament (p = 0.001).

Conclusion:

Actual inguinal ligament course is often well below the expected inguinal ligament course; this downward bowing of the inguinal ligament is especially pronounced with advancing age. Operators need to be mindful as this downward bowing can lead to supra-inguinal sticks causing vascular complications.

Femoral arterial closure using ProGlide® is more efficacious and cost-effective when ambulating early following cardiac catheterization

OBJECTIVE

This was a prospective, single-center study evaluating the efficacy and cost-effectiveness of early ambulation (within 30 min) following femoral artery closure with the ProGlide® suture-mediated vascular closure device (PD) in patients undergoing diagnostic cardiac catheterization compared with manual compression.

BACKGROUND

It is unclear whether early ambulation with ProGlide is safe or is associated with patient satisfaction and cost savings as compared with manual compression (MC).

METHODS AND RESULTS

Inclusion criteria were met in 170 patients (85 PD and 85 MC patients). Patients ambulated 20 ft. within 30 min (PD) or after the requisite 4 h recumbent time (MC) if feasible. Primary endpoint was time-to-ambulation (TTA) following device closure. We also directly compared the safety of closure, times-to-hemostasis (TTH), -ambulation (TTA) and -discharge (TTD) with MC and, using a fully allocated cost model, performed cost analysis for both strategies. Multivariate analysis was used to determine predictors of patient satisfaction. The primary endpoint of safe, early ambulation was achieved following closure (mean of 27.1 ± 14.9 min; 95% confidence interval [CI] 25.2-30.2). Predictors of patient satisfaction in the PD group were absence of pain during closure, decreased TTA, and drastic reductions in TTD; the latter contributed indirectly to significant cost savings in the PD group (1250.3 ± 146.4 vs. 2248.1 ± 910.2 dollars, respectively; P < 0.001) and incremental cost savings by strategy also favored closure over MC ($84,807).

CONCLUSIONS

ProGlide is safe and effective for femoral artery closure in patients who ambulate within 30 min after cardiac catheterization; translating into improved patient satisfaction and substantial cost savings.

Off-label use of the Angioseal vascular closure device for femoral arteriotomy: retrospective analysis of safety and efficacy

Background

Angioseal, an arteriotomy closure device (ACD), functions as a collagen plug that physically closes arteriotomy sites and can simultaneously induce platelet activation and aggregation. When used ‘on-label’, the safety and efficacy profile of Angioseal is superior compared with those of other ACDs. However, Angioseal is sometimes deployed in less than ideal situations. Therefore, we sought to assess the safety and efficacy of ‘off-label’ Angioseal use in patients undergoing femoral arteriotomies.

Methods

We performed a retrospective review of all femoral arterial angiograms executed at our institution between 2008 and 2014. Patients whose femoral punctures did not fit the criteria for on-label Angioseal use were included, and were dichotomized based on vascular closure (off-label Angioseal vs manual compression).

Results

Of the 521 patients (1023 angiograms) reviewed, 303 (58.2%) patients had off-label Angioseal groin punctures. Mean patient age was 46.2±14.0 years, and 113 were men. 234 patients (77%) had off-label Angioseal deployment while 69 (22%) individuals received manual pressure, serving as controls. Demographic and procedural variables were nearly identical between the two groups but the Angioseal group comprised mostly patients that underwent neurointerventional procedures and thus received intraprocedural heparinization (41%) more often than the manual compression group (19%). The overall rate of major complications associated with off-label Angioseal deployment was low (<0.85%), and clinical complications were not independently associated with Angioseal use (OR 0.76 (95% CI 0.06 to 8.86); p=0.69).

Conclusions

Off-label use of Angioseal was found to be safe and was not associated with an increased complication rate in our cohort.

Central Pseudo-Aneurysm Formation Following Arterial Closure with a StarClose SE Device: When a StarClose Doesn't Completely Close

BACKGROUND

Vascular closure devices (VCDs) are frequently used for hemostasis with endovascular procedures by employing sutures or plug devices (using collagen or hydrogel) or through the use of a metal clip made of nickel and titanium, such as the StarClose SE device. In comparison to manual compression (MC), VCDs are associated with earlier time to discharge and ambulation, improved patient comfort, and better cost-effectiveness.

CASE REPORT

A 77-year-old man with history of ischemic cardiomyopathy with non-ST segment elevation myocardial infarction (NSTEMI) underwent diagnostic cardiac catheterization with deployment of a StarClose SE vascular closure device for hemostasis. Upon repeat access 4 days later for coronary intervention, retrograde sheath angiography revealed a pseudo-aneurysm emanating from the center of the StarClose clip.

CONCLUSIONS

A review of the literature shows VCDs to be non-inferior to MC, with an overall high success rate. Major and minor complications rates are comparable to those with MC, and pseudo-aneurysm is an infrequent complication.

Simplified swift and safe vascular closure device deployment without a local arteriogram: Single center experience in 2074 consecutive patients

Objective

Vascular closure devices (VCDs), such as the Angio-Seal, a three-component hemostatic plug, have greatly facilitated the routine clinical practice in the catheterization laboratory. The manufacturer recommends a local angiogram before Angio-Seal deployment. However, from the outset, we employed a simplified routine of deploying this VCD, i.e. without use of local angiography.

Methods

The Angio-Seal was employed without a preceding femoral arteriogram over 8 years in 2074 consecutive patients, 72% presenting with acute coronary syndromes and subjected to coronary angiography (n = 1032) or PCI n = 1042) via a transfemoral approach with use of heparin and dual antiplatelet therapy.

Results

Deployment of the VCD was successful in 99.4%. Complete hemostasis was obtained in 98% of cases. In 14 patients, Angio-Seal deployment failed. Mean time for placement of Angio-Seal was <1 min, to-hemostasis 1 min, and to-mobilization 3 h. Only 3 (0.15%) patients had a major complication with vessel occlusion that required emergent vascular surgery with a successful outcome. Two patients developed a local pseudoaneurysm treated with ultrasonography-guided compression. Six small and 4 large inguinal hematomas (one requiring blood transfusion) and 5 cases of retroperitoneal bleeding (one requiring blood transfusion) were recorded.

Conclusion

Deployment of Angio-Seal without use of local angiography was efficacious and safe, characterized by a high success rate of deployment and hemostasis with few correctable complications in a large patient cohort undergoing transfemoral catheterization for PCI and non-PCI procedures under anticoagulation and antiplatelet drug therapy. VCD reduced the time-to-hemostasis and time-to-mobilization and minimized the incidence of complications.

Comparison of Angioseal and Manual Compression in Patients Undergoing Transfemoral Coronary and Peripheral Vascular Interventional Procedures

Vascular closure devices (VCDs) were introduced in the early 1990s with the goal of limiting the time, labor, bed rest, and patient discomfort associated with manual compression (MC) for hemostasis after cardiovascular interventions. However, its advantage over MC has not been extensively studied after interventional procedures. The aim of this study was to do prospective, randomized study comparing the safety and efficacy of the Angio-Seal (AS) to that of MC in patients undergoing transfemoral coronary and peripheral vascular interventional procedure. A prospective, randomized trial was undertaken on consecutive series of patients admitted to King Fahd Hospital of the University for transfemoral coronary and peripheral vascular interventional procedures over 1 year. The study was designed to compare the hemostasis time in minutes and the incidence of vascular complications in patients receiving AS with those undergoing MC. All patients were on antiplatelets and received heparin during the procedure. During the study period, 160 patients were included, 80 in each group. There was a significant difference in mean time to hemostasis in minutes (15.83 ± 1.63 minutes for MC and 0.42 ± 0.04 minutes for the AS; p < 0.001), time to ambulation in minutes (280 ± 15 for MC and 120 for AS; p = 0.04) and in minor complications (33.8% in MC vs. AS 5%; p < 0.001). However, the major complication rate did not significantly differ between the two groups (0% in AS vs. 2.5% in MC; p = 0.15). AS was found to achieve rapid closure of the femoral access site safely in patients undergoing coronary and peripheral vascular interventional procedures under antiplatelets and systemic heparinization.