The management of peripheral vascular complications associated with the use of percutaneous suture-mediated closure devices

Percutaneous endovascular management of Angio-Seal related vascular occlusion

BACKGROUND

The use of vascular closure devices (VCDs) to achieve quick and safe hemostasis after femoral arterial access is widely accepted. Major complications include bleeding and occlusion of the femoral artery due to device failure, which often necessitates vascular intervention. This manuscript details our peripheral percutaneous endovascular interventional (PEI) approach for the management of femoral artery occlusion resulting from Angio-Seal (Terumo, Somerset, New Jersey, USA) VCD deployment.

METHODS

Consecutive patients who developed occlusive complications after Angio-Seal deployment underwent PEI to overcome specific complications. Patients' clinical and procedural characteristics, along with their short- and long-term follow-up data, were analyzed.

RESULTS

The study cohort included 40 patients who experienced Angio-Seal occlusive complications between July 2013 and September 2023. The mean age of the patients was 74 ± 10 years and 55% were female. All the patients were treated with PEI, with an overall procedural success rate of 100%. The primary approach for PEI was directional atherectomy, which was used in 35 cases (88%), followed by balloon, while a cutting balloon was used in 5 patients (13%). Stenting served as the definitive therapy in only 7 patients (18%). No procedural complications or conversions to surgery were observed. During a median follow-up of 244 (IQR = 100-707) days, none of the patients required re-intervention related to Angio-Seal occlusion and salvage intervention.

CONCLUSION

In the management of Angi-Seal VCD-related femoral artery occlusion, the adjunctive use of directional atherectomy followed by balloon angioplasty was effective and safe, allowing re-establishment of flow with excellent long-term outcomes.

Avoiding peripheral nerve injury in arterial interventions

Although peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or by manual compression with incidence in literature ranging from as low as 0.04% for femoral access in a large retrospective study to 9% for brachial and axillary access. Given the increasing frequency of endovascular arterial procedures and the increasing use of nontraditional access points, it is important that the interventionalist have a working knowledge of peripheral nerve anatomy and function as it relates to relevant arterial access sites to avoid injury.

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.

Femoral Artery Closure Versus Surgical Cutdown for Endovascular Aortic Repair: A Single-Center Experience

BACKGROUND To compare the outcome and complication rates of femoral artery closure and surgical cutdown for endovascular aortic repair procedures (EVAR). MATERIAL AND METHODS Patients underwent either percutaneous femoral artery closure (PA group) or surgical cutdown (SC group) for EVAR between July 2011 and June 2016 and EVAR procedures were used for all cases. Data on outcomes and complications were collected and compared. RESULTS The SC group contained 55 patients and the PA group contained 60 patients and the technical success rates were 100.0% and 98.0%, respectively. The mean operation time, time to ambulation, and postoperative hospital stay were significantly shorter in the PA group (P<0.01). The estimated intraoperative blood loss and wound pain scores were significantly higher in the SC group (P<0.01). However, the PA procedure was more expensive (P<0.01). The overall incidence rate of complications was higher in the SC group (P=0.026). CONCLUSIONS The PA technique had a high success rate, shorter operation time and hospital stay, and fewer wound complications compared to SC. Thus, PA might be the preferred choice for selected EVAR procedures.

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.

Risk Factors for Groin Wound Infection After Femoral Artery Catheterization A Case-Control Study

Objective.

Groin wound infection (GWI) after femoral artery catheterization is unusual. However, several reports of GWI associated with the use of a Perclose device appear in the surgical literature.

Design.

A case-control study.

Setting.

We pooled 23 cases and 83 controls from a university hospital and a community medical center.

Patients.

A case was defined as a patient who developed a GWI after a femoral artery catheterization. At the university hospital, 3 controls were randomly selected from the at-risk population and matched to each case by time of procedure only (within 2 weeks). At the community medical center, 4 controls were selected and matched to each case by time of procedure (within 2 weeks), sex, and age (within 5 years).

Results.

We considered several covariates, including age, sex, body mass index, medical conditions, Perclose use, hematoma formation, and antithrombotic therapy. In a multivariate model, only hematoma formation (odds ratio, 68.8; 95% confidence interval, 12.1-391.4) and glycoprotein IIb/IIIa platelet inhibitor therapy (odds ratio, 6.1; 95% confidence interval, 1.1-33.6) were statistically significant predictors of GWI; Perclose use (odds ratio, 0.9; 95% confidence interval, 0.2-3.7) was not a statistically significant predictor of GWI. However, most of the hematomas (15/17) formed after procedures during which a Perclose device was used.

Conclusion.

Perclose use did not have any additional effect on GWI risk beyond the effect that hematoma formation had.

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.

Treatment of infected pseudoaneurysm of femoral artery after vascular closure device deployment: a practical solution

Like other invasive procedures, percutaneous coronary interventions are associated with complications. Most common access site for these procedures is common femoral artery. Complications such as groin and retroperitoneal hematoma can be encountered as well as pseudoaneurysms, arteriovenous fistulas, acute arterial occlusion, and infection. When infected pseudoaneurysm occurs, surgical treatment can be extremely difficult. We present a case of the patient in whom infected pseudoaneurysm of common femoral artery developed after percutaneous coronary intervention and was successfully treated by surgical excision and autoarterial graft insertion.

Arterial thrombosis after using Angio-Seal

Percutaneous closure systems of arterial puncture sites are being used more and more in modern endovascular practice. In this article, we report five cases of thrombotic complications following Angio-Seal deployment which required to be treated in our department between June 2004 and January 2006. We carried out a computerized literature review using "vascular closure" as a keyword and elected 106 articles published between 1992 and 2007. The analysis of this literature review showed that the rate of percutaneous closure complications was similar to the rate of manual compression complications, which is still the reference method. The complications associated with the use of these systems were more complex and more often required surgical repair. The severity and frequency of these complications differ based on the type of closure systems. The vascular surgeon in charge must have a good knowledge of these systems and of the complications each of them entails to be able to treat them in the most appropriate way.

Complications of uterine fibroid embolization

Uterine fibroid embolization (UFE) is an increasingly popular, minimally invasive treatment option for women with symptomatic fibroid disease. UFE therapy in qualified hands is an effective, well-tolerated procedure that offers relief of fibroid symptoms with a low risk of complications. In the acute postprocedural period, immediate complications may relate to vascular access, thromboembolic events, infection, and pain management. Reported major complications include but are not limited to pulmonary embolus, uterine ischemia, necrosis, sepsis, and death. Non-life-threatening complications include altered ovarian and sexual function, subcutaneous tissue necrosis, expulsion of fibroid tissue, and treatment failure. Awareness of the known complications of UFE may allow more rapid diagnosis and effective therapeutic responses to complications when they occur.

Retroperitoneal hematoma after percutaneous coronary intervention: prevalence, risk factors, management, outcomes, and predictors of mortality: a report from the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry

OBJECTIVES

This study sought to evaluate the prevalence, risk factors, outcomes, and predictors of mortality of retroperitoneal hematoma (RPH) following percutaneous coronary intervention.

BACKGROUND

Retroperitoneal hematoma is a serious complication of invasive cardiovascular procedures.

METHODS

The study sample included 112,340 consecutive patients undergoing percutaneous coronary intervention in a large, multicenter registry between October 2002 and December 2007. End points evaluated included the development of RPH and mortality.

RESULTS

Retroperitoneal hematoma occurred in 482 (0.4%) patients. Of these, 92.3% were treated medically and 7.7% underwent surgical repair. Female sex, body surface area <1.8 m(2), emergency procedure, history of chronic obstructive pulmonary disease, cardiogenic shock, pre-procedural IV heparin, pre-procedural glycoprotein IIb/IIIa inhibitors, adoption of sheath size >or=8-F, and use of vascular closure devices were independent predictors of RPH, whereas the use of bivalirudin was associated with a lower risk. The development of RPH was associated with a higher frequency of post-procedure myocardial infarction (5.81% vs. 1.67%, p < 0.0001), infection and/or sepsis (17.43% vs. 3.00%, p < 0.0001), and heart failure (8.00% vs. 1.63%, p < 0.0001). In-hospital mortality was significantly higher in patients who developed RPH than in patients who did not (6.64% vs. 1.07%, p < 0.0001). Among patients with RPH, independent predictors of death were history of myocardial infarction, cardiogenic shock, pre-procedural creatinine >or=1.5 mg/dl, and left ventricular ejection fraction <50%.

CONCLUSIONS

Retroperitoneal hematoma is an uncommon complication of contemporary percutaneous coronary intervention associated with high morbidity and mortality. The identification of risk factors for the development of RPH could lead to modification of procedure strategies aimed toward reducing its incidence.

Ischemic complications of percutaneous femoral artery catheterization

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

Immediate removal of femoral-sheath following protamine administration in patients undergoing intracoronary paclitaxel-eluting-stent implantation

BACKGROUND

Immediate sheath-removal using post-procedural reversal of heparin with protamine reduces groin complications, shortens bed rest and hospital stay after percutaneous coronary intervention (PCI) with bare-metal stents. No data are available with newer and possibly more thrombogenic paclitaxel-eluting stents (PES).

AIM

We assessed the safety and efficacy of post-procedural protamine administration after successful coronary PES implantation in elective PCI and in patients with acute coronary syndromes (ACS).

METHODS

A consecutive series of 291 patients received 0.5 mg of protamine per 100 units of heparin whenever the post-procedural ACT was > 180 seconds, followed by immediate removal of the sheath (protamine group). Outcomes were compared to a historic control group comprising 291 consecutive patients, who also underwent PCI with PES, but without reversal of anticoagulation by protamine (non protamine group). The incidence of post-procedural vascular complications and bleeding complications, as well as hospital stay, were compared; as were the incidence of major cardiac events at 24 h, 30 days and 6 months.

RESULTS

The post-procedural bleeding complications were significantly higher in the non-protamine group. Vascular complications were also more frequent in patients who were not treated with protamine. Hospitalisation length was significantly lower in the protamine group than in the non-protamine group (13.6 +/- 7 h versus 20.41 +/- 3.9 h; p < 0.001). The protamine-group patients also had a significantly reduced bed rest (10.3 h +/- 5.6 h versus 18 h +/- 3.5 h; p < 0.001). During hospitalisation, after PES implantation, no deaths or acute stent thrombosis were observed in either group. The overall incidence of thrombosis and major adverse cardiac events at follow-up were similar in the two groups.

CONCLUSIONS

Immediate heparin neutralisation by protamine after successful PES implantation appears to be safe and feasible, also in patients with ACS. Use of protamine and early sheath removal after PCI confers early deambulation and may significantly limit healthcare cost, reduce vascular complications, bedrest, delayed discharge and patient discomfort.

The safety and efficacy of the Angio-Seal closure device in diagnostic and interventional neuroangiography setting: a single-center experience with 1,443 closures

INTRODUCTION

We evaluated the safety and efficacy of the Angio-Seal closure device used to close arterial puncture sites in patients who had undergone diagnostic cerebral angiography and neurointerventional procedures.

METHODS

A total of 1,443 Angio-Seal devices were placed in 1,099 patients in the Interventional Neuroradiology Unit between May 2005 and August 2006. Of these, 670 were interventional and 745 were diagnostic cerebral angiographic procedures. In 28 patients bilateral puncture of the femoral arteries was performed for endovascular treatment. In 167 patients 286 repeat diagnostic procedures were performed and 30 interventional procedures were followed by re-closure with an Angio-Seal device at the time of repeat puncture.

RESULTS

The procedural success rate for antegrade closures was 99.7% for all procedures. The device failed in 5 of 745 diagnostic procedures (0.7%). Major complication occurred in one patient only (0.13%) in the diagnostic group. No minor complications were observed in this group. In the interventional group, the major complication rate was 1.4% (10 of 698 closures) and the minor complication rate was 2.4% (17 of 698 closures). However, in the subgroup of patients with cerebral aneurysms who received heparin in combination with antiplatelet agents after the procedure, the major complication rate was 5.3%, but in the carotid/vertebral stenting group it was 0.8%.

CONCLUSION

Our experience in a relatively large series of patients shows that the use of the Angio-Seal STS vascular closure device is safe and effective in patients undergoing cerebral diagnostic angiography and neurointerventional procedures with an acceptable rate of complications, although the complication rate was higher in the group of patients who received heparin and/or antiplatelet medication.

Acute Leg Ischemia: The Dark Side of a Percutaneous Femoral Artery Closure Device

The use of femoral artery closure devices to obtain hemostasis after percutaneous catheterization has become widespread because of their proven feasibility in combination with patient-related advantages. Since 2002 more than 6,500 patients have undergone either diagnostic angiography or therapeutic intervention via the femoral route with an Angioseal closure device in our hospital. We were faced with six cases of limb-threatening complications, which are described here. Most (5/6) complications were of obstructive origin due to traumatic dissection or occlusion of the artery mainly caused by malpositioning of the device. Recommendations are made in order to prevent or successfully overcome this certainly increasing problem in the vascular field.

Incidence of Vascular Injuries after Use of the Angio-Seal Closure Device following Endovascular Procedures in a Single Center

INTRODUCTION

Percutaneous closure devices have been used to obtain rapid hemostasis and early mobilization of the patient after arterial catheterization. However, we observed challenging problems with the sealing procedure that require further surgical intervention. The present report is a retrospective analysis of the patterns of injury and the final outcome of four cases of femoral artery injury following the use of Angio-Seal.

METHODS

During the last 24 months, in a group of 175 patients (131 men, 44 women; median age 68.4 years, range 47-81 years) underwent percutaneous closure after diagnostic (n = 53) or therapeutic (n = 122) endovascular procedures. Among them we observed four patients (three men, one woman; median age 65.2 +/- 10.8 years, range 47-75 years) who developed severe limiting claudication and required vascular repair of an iatrogenic vascular injury following deployment of the Angio-Seal. They had a femoral thrombosis due to narrowing/severe intimal dissection.

RESULTS

All patients required operative intervention with removal of the device. We performed femoropopliteal thrombectomy and common femoral endarterectomy with patch angioplasty (n = 2), resection of the femoral bifurcation and reimplantation of the deep femoral artery (n = 1), and femoral bifurcation endarterectomy with direct arterial suture (n = 1). The median hospital stay was 6.5 +/- 3.8 days (range 4-12 days). Limb salvage was achieved in all of the surviving patients at a mean follow-up of 7 months (range 1-12 months).

CONCLUSIONS

Vascular injuries are uncommon after use of the hemostasis closure device. When they occur, however, they are likely to require challenging surgical correction.

Safety and efficacy of staple-mediated femoral arteriotomy closure: Results from a randomized multicenter study

BACKGROUND

Mechanical closure of percutaneous femoral arteriotomies following catheter based procedures remains problematic.

METHODS

The EVS closure device is the first to utilize a staple to effect arteriotomy closure and was compared to manual compression following sheath removal in a 362 patient randomized (2:1 to device) multicenter trial. As pre-specified, one half of the patients underwent coronary intervention.

RESULTS

Time to hemostasis was significantly reduced in the EVS group for both diagnostic (3.3 +/- 2.6 vs. 19.3 +/- 5.7 minutes; p < 0.001) and interventional procedures (5.5 +/- 5.1 vs. 22.3 +/- 9.9 minutes; p < 0.0001). Time to ambulation was similarly reduced in the EVS group following diagnostic (2.4 +/- 3.3 vs. 6.0 +/- 5.2 hours; p < 0.001) and interventional procedures (3.4 +/- 4.5 vs. 7.6 +/- 7.0 hours; p < 0.001). The incidence of major complications was similar between the EVS and manual compression groups at discharge (0.4% vs. 1.7%; p = NS) and at 30 day follow-up (0.4% vs. 2.5%; p = NS).

CONCLUSION

Compared to manual compression, the EVS device provides a safe and effective method of femoral artery closure.

Infectious complications of percutaneous vascular closure devices

OBJECTIVE

To describe the infectious complications of percutaneous vascular closure devices (PVCDs) on the basis of our institutional experience with PVCDs and the published medical literature.

PATIENTS AND METHODS

We retrospectively reviewed all cases of PVCD-related Infection seen at the Mayo Clinic in Rochester, Minn, between January 1, 2000, and December 31, 2003, and searched the English language medical literature for all previously published reports.

RESULTS

We identified 46 cases in the medical literature and 6 cases from our Institutional database. The median age of patients was 63 years (range, 40-79 years). Diabetes mellitus and obesity were the most common comorbidities. The median Incubation period from device Insertion to presentation with access-site infection was 8 days (range, 2-29 days). The most common presenting symptoms were pain, erythema, fever, swelling, and purulent drainage at the access site. Mycotic pseudoaneurysm (22 cases) was the most common complication. Staphylococcus aureus was responsible for most (75%) of the Infections. All patients underwent surgical debridement, and 54% required reconstructive procedures. The median duration of antibiotic treatment was 28 days (range, 7-42 days). The mortality rate was 6% (3 patients).

CONCLUSIONS

Infection associated with PVCD placement is uncommon but is an extremely serious complication. Morbidity is high, and aggressive medical and surgical interventions are required to achieve cure.

The use of closure devices

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

Percutaneous arterial closure in peripheral vascular disease: a prospective randomized evaluation of the Perclose device

BACKGROUND

Patients with peripheral vascular disease have been excluded from initial studies of percutaneous suture-mediated closure devices (SMCD) despite representing a significant proportion of those requiring endovascular intervention. We sought to determine whether these devices could be safely used in patients with peripheral vascular disease.

METHODS

Patients were stratified into two groups and five subgroups on the basis of indication for arteriography, and they were prospectively randomized at the end of the procedure to receive either the SMCD or manual compression. Ankle-brachial index was determined and duplex ultrasound scanning of the accessed femoral artery was performed, before and after the procedure. Ultrasound data included peak systolic velocity, minimum intraluminal vessel diameter, and presence or absence of calcified plaque. Time to hemostasis, ambulation, and discharge were recorded, and major or minor complications were noted.

RESULTS

Of 102 patients included in the study, 52 patients were randomized to receive the SMCD. There was no difference in ankle-brachial index, minimum intraluminal vessel diameter, or peak systolic velocity in the accessed vessel after closure with SMCD or manual compression. Time to hemostasis, ambulation, and discharge was significantly less in the SMCD group (P =.001). Presence of calcified plaque was not associated with complications (P =.146). In the SMCD group, hemostasis was achieved with 49 of 52 devices (94.2%). There were six complications (5.9%), two of which were major and required operative intervention. All complications were hemorrhagic and not occlusive. There was no difference in overall complication rate between SMCD (7.7%) and manual compression (4.0%) groups (P =.678). No infection was noted in any of the 102 patients.

CONCLUSIONS

Suture-mediated percutaneous arterial closure can be safely performed in patients with peripheral vascular disease, even in the presence of calcified plaque. This closure technique enables shorter time to hemostasis, ambulation, and hospital discharge. There are observed differences in minor, but not major, complication rates for MC versus percutaneous arterial closure in patients with peripheral vascular disease, but these differences did not achieve statistical significance in this small series.

Status of Femoral Closure Devices

Both sealing and suturing closure devices have been shown to shorten hemostasis time, reduce the discomfort of manual or mechanical compression, and allow for earlier ambulation after cardiac catheterization and percutaneous coronary interventions without increasing vascular complications compared with conventional compression techniques. Several studies now report a reduction in vascular complications for percutaneous coronary intervention patients treated with closure devices compared with manual compression with pronounced benefit seen in patients receiving glycoprotein IIb/IIIa receptor inhibitors. Adoption of a simple predeployment femoral angiogram is now standard practice for use of a closure device. In an attempt to develop devices that are safer and more "user friendly," considerable modifications and improvements have been made in newer generation devices. Ultimately, the acceptance of femoral closure devices will depend on which device provides a simple approach with reliable hemostasis and a cost that can justify their incorporation into routine practice.

Femoral endarteritis associated with percutaneous suture closure: new technology, challenging complications

OBJECTIVE

Use of percutaneous suture closure devices after catheter-based interventions is increasing. We recently have seen several severe femoral arterial wall infections after use of such devices. The purpose of this study was to examine the incidence, comorbid associations, and management of femoral arterial infections associated with percutaneous suture closure devices.

METHODS

We retrospectively reviewed all infectious complications that occurred after 2223 consecutive cardiac catheterization procedures performed over 12 months in a university-affiliated community teaching hospital. Outcome variables included demographics, procedural details, infection, type of arterial reconstruction required, mortality, and limb loss.

RESULTS

During this study, 822 patients received percutaneous suture devices. Infection developed in 6 patients (0.7%). The incidence of diabetes in the population undergoing percutaneous suture closure was 219 of 822 patients (26.6%). Three comorbid conditions, noted in multiple patients with infectious complications, included diabetes mellitus, obesity, and placement of a percutaneous suture closure device within the past 6 months. Invasive femoral endarteritis developed in 4 patients. Gram-positive cocci predominated in 4 patients. In 1 patient with polymicrobial infection catastrophic complications developed, including multiple anastomotic ruptures and hemorrhage. A new method of repair that incorporated double-thickness everted saphenous vein was used in 2 patients, and safe arterial closure was achieved. There was 1 late fatality on postoperative day 36. Limb salvage was achieved in all patients.

CONCLUSIONS

Femoral endarteritis complicating percutaneous suture closure is a challenging new problem for vascular surgeons and can result in catastrophic complications. Customary techniques that use saphenous vein patch or interposition grafting are not adequate in all circumstances. Successful outcome requires operative exploration in patients with suspected infection. Removal of the percutaneous suture closure device and debridement to normal arterial wall is recommended in all patients with suspected femoral endarteritis, based on positive intraoperative Gram stains or abnormal appearance of the adjacent femoral artery. Early success with an autologous bolstered repair is reported. Caution is advised when considering the use of a percutaneous suture closure device in patients with comorbid conditions including diabetes, obesity, and previously implanted devices.

[Complications with femoral access in cardiac cathetization. Impact of previous systematic femoral angiography and hemostasis with VasoSeal-ES collagen plug]

INTRODUCTION AND OBJECTIVES

Most cardiac catheterizations are performed via femoral artery access, and hemostatic devices are commonly used. We evaluate the relationship between the strategy used for femoral arteriography and the use of VasoSeal-ES, and local vascular complications.

PATIENTS AND METHOD

Prospective study of 540 consecutive catheterizations with systematic femoral artery and sheath angiography. VasoSeal-ES was used in 427 patients. Predictors of local vascular complications such as patient-related factors, anatomy and hemostasis were analyzed. Variables related to failure of the collagen plug were also studied.

RESULTS

Punctures of the common femoral artery occurred in 35.9% of all patients (16% in the deep femoral artery and its ostium). Spasm was evident in 18% (ranging from 58.1% in the deep femoral artery to 5.2% in the common femoral artery). Puncture at the site of ramification was seen in 11.3%. Angiographically significant atheroma was seen in 17.8%. The femoral head was a valid landmark for the common femoral artery in only 63.9% of the pateints. Risk factors for local vascular complications were punctures of the common femoral artery, female sex and failure of VasoSeal-ES to achieve hemostasis (15.8% in the first two months of use, 5.2% in the last months of the study). Complications involving superficial and deep femoral arteries occurred in 6.7% and 1.2% of the patients, respectively, in contrast to 0.6% involving the common femoral artery. Variables related to collagen plug failure were patient-related factors, weight less than 55 kg, operator-related factors and the learning curve.

CONCLUSIONS

Systematic femoral angiography provides data that aids the choice of the best hemostasis procedure to reduce local vascular complications. Punctures of the common femoral artery were more frequent than expected, and were associated with a higher complication rate. VasoSeal-ES is a safe and useful method of hemostasis, and its infrequent failures were associated with high complication rates that were substantially reduced with experience.

Complications of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure: a case-controlled study

PURPOSE

To evaluate the incidence and types of complications encountered with use of a percutaneous suture-mediated closure device versus manual compression for arteriotomy closure in a retrospective case-controlled study.

MATERIALS AND METHODS

The authors identified 100 consecutive patients, 15 men and 85 women 21-85 years of age (mean, 50 years), between December 2000 and July 2001 in whom the Closer percutaneous suture-mediated closure device was used during 65 uterine artery embolization (UAE) procedures, 11 hepatic chemoembolization procedures, nine diagnostic angiography procedures, seven peripheral vascular interventions, six visceral arterial interventions, and two thrombolysis procedures. An age-, sex-, and procedure-matched control population was identified in which manual compression was performed. Procedure reports and clinical charts were reviewed for the presence of puncture-site complications, as categorized according to Society of Interventional Radiology reporting standards, and for risk factors and comorbid conditions (hypertension, diabetes, stroke, smoking, and coronary artery disease). Follow-up visits and imaging studies were reviewed for patients with complications.

RESULTS

In the Closer group, there were seven device failures, four minor complications, and three major complications. Minor complications included two groin hematomas and two cases of persistent pain at the arteriotomy site. Three major complications consisted of two cases of external iliac artery dissection, one with distal embolization, and one case of common femoral artery (CFA) occlusion and distal embolization. All major complications occurred in women undergoing UAE. One patient required thromboendarterectomy and patch angioplasty to repair the CFA occlusion, as well as amputation of a gangrenous toe. In the manual-compression group, there was one minor complication (a groin hematoma) and no major complications. There were significantly more complications in the Closer group than in the manual compression group (P =.02).

CONCLUSIONS

Significantly more complications were associated with use of a percutaneous suture-mediated closure device than with manual compression for arteriotomy-site hemostasis. Major complications and associated morbidity may be seen with use of percutaneous suture-mediated closure devices. In particular, an unexpectedly high frequency of device-related complications was demonstrated in young women undergoing UAE.

Restick following initial Angioseal use

The Angioseal hemostatic device is currently in widespread use for arterial closure after both diagnostic and interventional procedures. Resticking of the artery in which an Angioseal device has been placed has been discouraged for up to 90 days after the initial device placement because of theoretical concerns of disruption or dislodgment of the hemostatic plug. However, no data are available to address this concern. We evaluated the incidence of vascular complications following restick of the artery in which an Angioseal device had been deployed </= 90 days previously in 181 patients. Restick occurred 1-7 days after device placement in 80 patients, 8-30 days in 34 patients, and 31-90 days in 66 patients. There were no major bleeding, vascular repair, vessel occlusion, or embolizations. Three large hematomas (1.7%) were noted. These data suggest that restick can be performed safely after initial Angioseal deployment.

Infectious and ischemic complications from percutaneous closure devices used after vascular access

The introduction of percutaneous closure devices (PCDs) to seal arteriotomy sites following percutaneous vascular access (PVA) can lead to greater complications than those with manual compression. The aim of this study was to compare complications and outcome between patients requiring surgery after receiving a PCD and those undergoing standard manual compression. This retrospective study evaluated 56 patients (mean age, 63 years) requiring surgical intervention from January 1, 1998 to April 30, 2002, following complications of PVA. Operative indications were pseudoaneurysm, hemorrhage, infectious complications, and limb ischemia. Patients were divided into two groups for comparison: group I (n = 15, PCD) and group II (n = 41, no PCD). In group 1 patients there were 18 limbs in which 20 Perclose devices were used and 1 limb in which a Duett device was used. From the outcomes in these two groups we concluded that patients undergoing surgical intervention following complications of PVA are at a significantly increased risk for infectious and ischemic complications and require more complex vascular repair when percutaneous closure devices are used.

Management of vascular complications following femoral artery catheterization with and without percutaneous arterial closure devices

Percutaneous arterial closure devices allow earlier mobilization and discharge of patients after arterial catheterization than with manual compression for puncture site hemostasis. We reviewed our recent experience managing the complications of femoral artery catheterization with and without these devices on the vascular surgery service at a tertiary hospital. Thirty-one patients presenting over an 18-month period with complications after femoral artery catheterization with manual compression (n = 21) or percutaneous arterial closure devices (n = 10) were retrospectively reviewed.

Obturator Bypass: A Classic Approach for the Treatment of Contemporary Groin Infection

As the number of cardiac and interventional radiologic procedures has risen, the frequency with which surgeons are called to treat groin complications has increased. Infectious groin problems that often involve foreign prosthetic material or remnants of percutaneous femoral closure devices are particularly challenging and require control of bleeding, removal of foreign material, wide debridement, and sometimes arterial resection. Management of the consequential limb ischemia in such cases is controversial. The purpose of this study is to review the utility of extra-anatomic common femoral bypass through the obturator foramen (obturator bypass) as a method of treating limb ischemia after arterial groin infection. From July 1992 through June 2001 a total of 12 patients (six male) presented with severe vascular infections of the groin and underwent obturator bypass. Infections occurred as a consequence of an isolated vascular graft infection (nine) or after a percutaneous interventional femoral access procedure (three). Patients presented with systemic sepsis and a draining sinus (six), infected pseudoaneurysm (two), or hemorrhage (four). Treatment included debridement of the groin wound, sartorius muscle flap coverage of the femoral vessels, antibiotics and synthetic (eight polytetrafluoroethylene and four Dacron) obturator bypass via a lower abdominal extraperitoneal incision from an aortobifemoral bypass graft limb to the superficial femoral artery (six), native iliac to femoral artery (three), iliac to popliteal artery (two), and aortobifemoral bypass limb to the popliteal artery (one). Graft patency and limb salvage were assessed by Kaplan-Meier life table analysis. There were two (17%) deaths (multisystem organ failure at postoperative days 9 and 6) and four major complications (25%) requiring reoperation in the first 30 days. Ten patients (83%) survived, healed their groin wounds, and are infection free. With a mean follow-up of 37 months graft patency and limb salvage at 60 months were 80 and 60 per cent, respectively. There were no late graft infections. We conclude that the obturator bypass is an effective and durable means of revascularization in the presence of the septic groin. This procedure belongs in the armamentarium of all surgeons managing these complications.

Angiographic follow-up after suture-mediated femoral artery closure

PURPOSE

Percutaneous closure devices are used in as many as 30% of all endovascular studies. Despite widespread use of these devices, only limited imaging has been performed after percutaneous closure. In this study, arteriograms of patients who had undergone suture-mediated closure with the Perclose device were reviewed.

MATERIALS AND METHODS

Between June 1998 and November 2001, 31 patients who had previously undergone closure with use of the Perclose device at our institution returned for additional angiographic procedures. Twenty-one patients underwent closure with use of the Perclose device after embolization, including hepatic artery chemoembolization (n = 18), treatment of hypervascular sacral metastases (n = 2), and bronchial artery embolization (n = 1). Nineteen of these patients had thrombocytopenia. Ten patients underwent closure with use of the Perclose device after diagnosis and treatment of peripheral vascular disease.

RESULTS

Of 31 patients, 28 had normal follow-up studies, including one patient who underwent four previous closures. These 28 patients all had normal femoral artery caliber at initial angiography and a platelet count of more than 18,000/mm(3). Two patients with preexisting atherosclerotic change had progression of disease at the puncture site and a third with severe thrombocytopenia developed a small asymptomatic posterolateral pseudoaneurysm.

CONCLUSION

In patients with normal femoral arteries, the long-term effects of closure with use of the Perclose device, even performed multiple times, appears to be minimal.