The novel echo-guided ProGlide technique during percutaneous transfemoral transcatheter aortic valve implantation

Feasibility and efficacy of real-time ultrasound-guided venous closure with suture-mediated vascular closure device

BACKGROUND

Venous vascular access complications are usually nonfatal but are the most common complications after transvenous catheter intervention. Vascular closure devices (VCDs) have recently become available for venous closure.

OBJECTIVE

This study aimed to evaluate the feasibility and efficacy of real-time ultrasound-guided venous closure with suture-mediated VCDs in patients who underwent catheter ablation.

METHODS

This single-center observational study enrolled 226 consecutive patients who underwent elective catheter ablation with femoral venipuncture. For hemostasis, vessel closure by VCD was performed with real-time ultrasound guidance after 2022 (n = 123) and without ultrasound guidance in 2021 (n = 103). The occurrence of venous access site-related complications (major, minor, or other) was compared.

RESULTS

The rate of device failure was significantly lower in patients with ultrasound guidance than in those without (1.6% vs 6.3%; P = .048). The occurrence of all venous access site-related complications was significantly lower in patients with ultrasound guidance than in those without (4.9% vs 18.4%; P = .001). Time to ambulation was shorter in patients with ultrasound guidance than in those without (2.0 ± 0.1 hours vs 2.2 ± 0.6 hours; P < .001).

CONCLUSION

Real-time ultrasound guidance can reduce device failure, access site-related complications, and time to ambulation in performing venous closure with a VCD.

Ultrasound-guided deployment of ProGlide™ device in transfemoral transcatheter aortic valve implantation and risk reduction of vascular complications: A propensity-matched cohort study

BACKGROUND

ProGlide is a percutaneous suture-mediated closure device used in arterial and venous closure following percutaneous intervention. Risk of vascular complications from use, particularly related to failure in hemostasis, or acute vessel closure, remains significant and often related to improper suture deployment. We describe a technique of ultrasound-guided ProGlide deployment in transfemoral transcatheter aortic valve implantation (TF-TAVI).

AIMS

The aim of this study is to assess vascular outcomes for ultrasound-guided deployment of ProGlide vascular closure devices in patients undergoing TF-TAVI.

METHODS

We collected relevant clinical data of patients undergoing TAVI in a large volume centre.

PRIMARY OUTCOME

main access Valve Academic Research Consortium 3 (VARC-3) major vascular complication.

SECONDARY OUTCOME

any major/minor VARC-3 vascular complication, its type (bleed or ischemia), and treatment required (medical, percutaneous, or surgical). We performed inverse weighting propensity score analysis to compare the population undergoing ultrasound-guided versus conventional ProGlide deployment for main TAVI access. Ultrasound technique for ProGlide insertion was performed as described below.

RESULTS

Five hundred and seventeen patients undergoing TF-TAVI were included.

PRIMARY OUTCOME

In 126 (ultrasound-guided) and 391 (conventional ProGlide insertion), 0% versus 1.8% (p < 0.001) had a major VARC-3 vascular complication, respectively.

SECONDARY OUTCOME

0.8% (one minor VARC-3 bleed) vs 4.1% (13 bleeds and three occlusions) had any VARC-3 vascular complication (major and minor) (p < 0.001). Surgical treatment of vascular complication was required in 0.8% versus 1.3% (p = NS).

CONCLUSIONS

Ultrasound-guided deployment of ProGlide for vascular closure reduced the risk of major vascular complications in a large population undergoing TAVI.

"Safe Femoral" Artery Approach in Endovascular Procedures: A Systematic Review of Its Safety and Feasibility

Femoral access site-related bleeding represent a prognostically impactful issue in interventional cardiology. The impact of a combined use of ultrasound guidance for femoral access and vascular closure device deployment for arteriotomy closure in femoral artery procedures on bleeding complications is still largely unknown. A systematic review was conducted on Pubmed (Medline), Cochrane library and Biomed Central databases between March and April 2023. A total of 9 studies have been selected, of namely 4 registries, 4 prospective studies and one randomized clinical trial. A systematic use of US guidance to access femoral artery resulted feasible and not time consuming, reduced venipuncture and increased first attempt success. Combination of US guidance and deployment of VCD's had the capacity to further decrease vascular and bleeding combination, especially in those patients at a higher risk of post-procedural bleeding. Ultrasound can be easily used during closure device deployment to reduce device failure and major vascular complications.

Percutaneous Cannulation of Femoral Vessels in Minimally Invasive Cardiac Surgery

OBJECTIVE

Despite the recent trend of access miniaturization in minimally invasive cardiac surgery (MICS) surgical "cut down (CD)" for femoral cannulation remains the standard at many centers. Percutaneous vascular closure (PVC) devices have recently been introduced for minimizing invasiveness during interventional diagnostic and therapy. This report summarizes the initial experience with this new approach in the setting of MICS, with a special focus on safety and advantages.

METHODS

Percutaneous cannulation with a standard protocol including preoperative computer tomography imaging and intraoperative point-of-care ultrasound guidance was performed in 93 consecutive patients from September 2018 until February 2020, while conventional "CD" procedure performed in 218 patients in the previous period. We analyzed patients' characteristics and compared access site complications of PVC group versus conventional "CD" group.

RESULTS

As far as operative/postoperative outcome, the duration of intensive care unit stay as well as hospital stay was statistically shorter in PVC compared with CD (CD vs. PVC: 2.74 ± 3.83 vs. 2.16 ± 2.01 days, p < 0.01, 16.7 ± 8.75 vs. 13.0 ± 4.96 days, p < 0.001, respectively). Further, we found no femoral infection or lymphocele in the PVC group, whereas 4 cases of wound complications were observed in the CD group.

CONCLUSION

According to our results, percutaneous closure system for femoral vessels in MICS seems to be beneficial with the assist of preoperative computed tomography and intraoperative Doppler guidance.

Efficacy and Safety of Percutaneous Access Via Large-Bore Sheaths (22-26F Diameter) in Endovascular Therapy

PURPOSE

To evaluate the closure success rate's outcomes with suture-mediated vascular closure device Perclose ProGlide in patients undergoing aortic or iliac artery endovascular repair using large delivery systems (>21F).

MATERIALS AND METHODS

We screened all the patient records in aortic databases at 2 centers who had undergone vascular interventions via ProGlide for percutaneous femoral access >21F between 2016 and 2020. Patients were divided into 2 groups according to the delivery system size: large (L) (22F-23F) and extra-large (XL) (24F-26F). Demographics, anatomical details, and outcome of percutaneous access were evaluated.

RESULTS

Included were 239 patients: 121 in the L group and 118 the XL group. Intraprocedural conversion to open surgery because of bleeding was necessary in 2% L and 6% XL patients (p=0.253). Severe femoral artery calcification was the sole risk factor for converting to open surgery (odds ratio=23.44, 95% confidence interval=1.49-368.17, p=0.025). In all, 2% of L and 3% of XL (p=0.631) did require late percutaneous intervention due to stenosis (all treated with balloon angioplasty). Overall, 3% developed pseudoaneurysm treated conservatively in all except one patient requiring surgical repair. Hematoma and groin infection were observed in 9% and 1%, respectively; none required surgical therapy.

CONCLUSION

A femoral arterial defect after accessing the artery via a large bore sheath (22F-26F) can be closed successfully with ProGlide in more than 90% of patients. Severe femoral artery calcification is a risk factor for conversion to open surgery caused by bleeding.

CLINICAL IMPACT

This study adds evidence on efficacy of accessing the artery via a large bore sheath (22-26F) secured by ProGlide. In more than 200 patients conversion to open surgery was necessary in only 4%. Severe femoral artery calcification was the sole risk factor for converting to open surgery. Our findings encourage physicians to choose the percutaneous access even in patients requiring the use of large bore sheath.

Clinical outcomes of MANTA vs suture-based vascular closure devices after transcatheter aortic valve replacement: An updated meta-analysis

OBJECTIVE

A recently published randomized control trial showed different results with suture-based vascular closure device (VCD) than plug-based VCD in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR). The learning curve for MANTA device is steep, while the learning curve for suture based VCD is shallow as the devices are quite different. In this meta-analysis, we have compared suture-based (ProGlide and Prostar XL) vs plug-based VCDs (MANTA).

METHODS

We performed a meta-analysis of all published studies (using PubMed/Medline and Cochrane databases) reporting the clinical outcome of plug-based vs suture-based VCDs in transfemoral TAVR patients.

RESULTS

We included nine studies with a total of 2865 patients (plug-based n = 1631, suture-based n = 1234). There was no significant difference in primary outcome of all bleeding when using plug-based as opposed to suture-based VCDs (RR 1.14 [0.62-2.06] I2 = 72%). There was no significant difference in the incidence of secondary outcomes between two groups including major life threatening bleeding (RR 1.16 [0.38-3.58] I2 = 65%), major vascular complications (RR 0.84 [0.35-2.00] I2 = 55%), minor vascular complications (RR 1.05 [0.56-1.95] I2 = 42%), pseudo aneurysm (RR 1.84 [0.11-29.98] I2 = 44%), stenosis-dissection (RR 0.98 [0.66-1.47] I2 = 0%), VCD failure (RR 1.71 [0.96-3.04] I2 = 0%), and blood transfusion (RR 1.01 [0.38-2.71], I2 = 61%).

CONCLUSION

Large bore arteriotomy closure with plug-based VCD was not superior to suture-based VCDs in this transfemoral TAVR population. There was very frequent use of secondary VCDs in suture-based VCD group which is not practical when using MANTA. Additional high-powered studies are required to determine the safety and efficacy of MANTA device.

Acute limb ischemia after minimally invasive cardiac surgery using the ProGlide: A case series

BACKGROUND

We report two cases of acute femoral artery occlusion following the use of ProGlide in minimally invasive cardiac surgery and insertion of large-bore catheters through the common femoral artery. This will add to the existing body of literature by highlighting the possible complications associated with the use of ProGlide and reiterate that the use of the sono-guided ProGlide skill will reduce the incidence of these complications.

CASE SUMMARY

A 78-year-old man underwent minimally invasive cardiac surgery for severe aortic valve stenosis. After the operation, the puncture site of the common femoral artery was closed using ProGlide. The next morning, after regaining consciousness, he complained of pain, motor weakness (grade 2), and coldness in the right lower extremity. A 65-year-old man underwent minimally invasive cardiac surgery for a large secundum atrial septal defect (5 cm × 5 cm). After the operation, the puncture site of the common femoral artery was closed using ProGlide. After extubation, the patient complained of paresthesia of the right thigh. Both the patients underwent emergency surgery for acute occlusion of the common femoral artery.

CONCLUSION

If the sono-guided ProGlide skill is used, complications can be prevented, and ProGlide can be safely used.

Simplified TAVR Procedure: How Far Is It Possible to Go?

Increasing operators’ experience and improvement of the technique have resulted in a drastic reduction in complications following transcatheter aortic valve replacement (TAVR) in patients with lower surgical risk. In parallel, the procedure was considerably simplified, with a routine default approach including local anesthesia in the catheterization laboratory, percutaneous femoral approach, radial artery as the secondary access, prosthesis implantation without predilatation, left ventricle wire pacing and early discharge. Thus, the “simplified” TAVR adopted in most centers nowadays is a real revolution of the technique. However, simplified TAVR must be accompanied upstream by a rigorous selection of patients who can benefit from a minimalist procedure in order to guarantee its safety. The minimalist strategy must not become dogmatic and careful pre-, per- and post-procedural evaluation of patients with well-defined protocols guarantee optimal care following TAVR. This review aims to evaluate the benefits and limits of the simplified TAVR procedure in a current and future vision.

Incidence and Predictors of Access Site Vascular Complications Following Ultrasound-Guided MANTA Closure Deployment

Purpose:

There is no report on the reproducibility of the ultrasound-navigated MANTA deployment (US-MANTA) technique and little is known about predictors for US-MANTA-related vascular complication (VC). This study aimed to assess the incidence and predictors of access-site VC using the US-MANTA technique and report insights of MANTA-related VC from consecutive cases following large-bore arteriotomy.

Materials and Methods:

Consecutive patients who underwent transfemoral transcatheter aortic valve replacement with the US-MANTA technique from November 2018 to February 2020 were evaluated. MANTA-related VC was defined as access-site complications leading to major or minor VCs based on Valve Academic Research Consortium-2 criteria.

Results:

Among 378 patients, 23 cases (6.1%) of MANTA-related VC (major VC: n=7 [1.9%], minor VC: n=16 [4.2%]) were identified. No significant difference was observed in the incidence of MANTA-related VC over the observational period (first quartile: 5.3%, second: 5.4%, third: 7.4%, and fourth: 6.3%, p>.50). In 7 patients with MANTA-related major VC, 4 (57.1%) of complications resulted from incomplete apposition of the toggle due to anterior wall calcification of the common femoral artery (CFA). Anterior calcification of the CFA determined by computed tomography was identified as an independent predictor of MANTA-related VCs.

Conclusions:

The US-MANTA technique sustainably provides a low rate of access-site VCs following large-bore arteriotomy. Incomplete apposition of the toggle due to anterior calcification of the CFA may lead to ongoing vascular and bleeding complications.

Percutaneous cannulation for cardiopulmonary bypass in robotic mitral valve surgery with zero groin complications

INTRODUCTION

Robotic valve surgery utilizes the femoral vessels to set up cardiopulmonary bypass (CPB) which translates to groin wound and lower extremity vascular complications. A less invasive technique is a totally percutaneous bypass using vascular closure devices (VCDs) with concerns for lower limb ischemia and arterial stenosis. Since April 2018, we have adopted the standard use of total percutaneous CPB in our robotic mitral cases. We report our institutional results with this technique.

METHODS

All consecutive patients who underwent robotic mitral valve surgery between April 2018 and December 2020 in our institution were included in our study. Hospital database data on demographics, operative variables, and surgical outcomes were recorded and analyzed.

RESULTS

Robotic mitral valve surgeries were performed on 32 consecutive patients (mean age 57.2 ± 14.8) between April 2018 and December 2020. None of our patients developed an infection at any site. Seroma, hematoma, or pseudoaneurysm were not observed at puncture sites. Surgical repair of the femoral vessels or an additional VCD was not necessary for any of our patients. Patients were followed up for a mean duration of 23.5 months. Our patients did not present with a late wound infection, a seroma, or a pseudoaneurysm, nor had complaints of limb ischemia or claudication.

CONCLUSION

Total percutaneous bypass is the least invasive method of establishing extracorporeal circulation for cardiac surgery and can be performed with excellent results. The benefits of robotic surgery can be expanded with better results in groin cannulation by the adoption of total percutaneous CPB.

Comparison of Success Rate and Complications of Totally Percutaneous Decannulation in Patients With Veno-Arterial Extracorporeal Membrane Oxygenation and Endovascular Aneurysm Repair

Background: Total percutaneous closure for the site of femoral arterial puncture using Perclose ProGlide (PP) has become prevalent post-percutaneous endovascular aortic repair (EVAR) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

Objective: To evaluate the safety and efficacy of total percutaneous closure of the femoral artery access site post-EVAR compared with VA-ECMO.

Methods: This was a retrospective observational study conducted over 4 years, including 88 patients who underwent EVAR (64 patients) and VA-ECMO (24 patients). Perclose ProGlide devices were used in the femoral artery puncture sites closed percutaneously. In this study, technical success was defined as successful arterial closure of the common femoral artery (CFA) without additional surgical or endovascular procedures to prevent vessel leaking. Access site complications, including overt bleeding requiring transfusion or surgical intervention, minor bleeding, tinea cruris, pseudoaneurysm, and lymphocele, were recorded 24 h and 30 days after arterial closure.

Results: Each group's technical success rates were 95.8% (VA-ECMO) and 92.2% EVAR, respectively. There were no differences in the periprocedural complications of major bleeding, pseudoaneurysm, minor bleeding, acute limb ischemia, and groin infection. Furthermore, we did not observe any complications such as arterial thrombosis, dissection, stenosis, arteriovenous fistula, hematoma, groin infection, or lymphocele at the access site by following-up an ultrasound examination. There was no significant difference in the technical success rate of percutaneous closure by the PP device in the EVAR and VA-ECMO oxygenation groups. Also, no periprocedural or 30-day complications were observed at the access site of the EVAR and VA-ECMO patients.

Successfully managed access-site complication was not associated with worse outcome after percutaneous transfemoral transcatheter aortic valve implantation: Up-to-date insights from the OCEAN-TAVI registry

BACKGROUND

Access-site complications during transfemoral transcatheter aortic valve implantation (TF-TAVI) cause serious issues in the future, if unresolved, but the best strategies to manage these complications remains unclear. This study aimed to comprehensively assess access-site complications during percutaneous TF-TAVI in terms of their management.

METHODS

Using the prospective, multicentre, observational registry OCEAN (Optimized Transcatheter Valvular Intervention), 1497 patients who underwent percutaneous TF-TAVI between October 2013 and May 2017 were identified. The incidence, predictors, temporal changes, and prognosis of access-site complications along with its treatment strategy and re-intervention rate were evaluated.

RESULTS

Access-site complications occurred in 105 patients (7.0%) and was predicted with lower body-mass-index (OR, 0.94; 95% CI; 0.89-0.99; p = 0.03) and higher sheath-to-femoral-artery-ratio (OR, 1.12; 95% CI, 1.03-1.24; p < 0.002). The incidence of access-site complications declined over time, irrespective of the increasing number of percutaneous TF-TAVI cases. Access-site complications were treated by conservative therapy (n = 19, 18%), interventional procedures (n = 42, 40%), rescue surgical repair (SR) (n = 10, 10%), and primary SR (n = 34, 32%). The severity of complications differed but the re-intervention rate was similar among 4 groups (p = 0.46). Re-intervention was not needed, except for a case of common femoral artery stenosis/occlusion induced by ProGlide. The need for all SRs decreased annually. Access-site complications were not associated with 30 days- and 1 year-survival rate.

CONCLUSIONS

The incidence of access-site complications was not low but has declined annually. Access-site complications are not related to worse outcomes after successful management. Interventional procedure is acceptable as the first-line strategy to treat access-site complications.

Percutaneous artErial closure devices and ultrasound-guided Trans-femoRal puncture ObservatioNal InvestigatiOn: Insights from the PETRONIO registry

OBJECTIVE

To evaluate the safety of a single and combined use of ultrasound-guided femoral puncture (U) and percutaneous arterial closure devices (P) in femoral artery procedures (FAP) compared to fluoroscopic guidance (F) and manual compression (M) in a large radial-focused interventional centre.

BACKGROUND

U and P, taken individually, have improved safety in femoral arterial access procedures compared to traditional techniques.

METHODS

All FAP performed between July 2017 and December 2018 in our centre were divided into three phases: (a) control period with F and M mainly performed; (b) phase out period where U and P were introduced; (c) intervention period where a 6-month expertise on the novel techniques was acquired. The overall population was further stratified into subgroups: F/M, U/M, F/P, U/P. The primary study endpoint was in-hospital access site bleeding events (BE) according to the BARC criteria. The secondary endpoint was vascular site complications (VASC).

RESULTS

Four hundred eighteen procedures (14%) out of 3025 were performed via FA access during the study period. The overall access-site in-hospital BE were 97 (23%). Decreasing rates of BE (phase 1: n = 46, 29%; phase 2: n = 38, 22% e phase 3: n = 13, 15%; p = 0.027) and VASC were observed during the three periods. BE occurred significantly more often in F/M group (F/M: n = 48; 32%; U/M: n = 12, 16%; F/P: n = 18, 21%; U/P: n = 19, 17%; p = 0.008). F/M subgroup was an independent predictor of BE both in multivariable analysis and propensity score matching analysis.

CONCLUSIONS

The introduction of ultrasound-guided femoral puncture and percutaneous arterial closure devices has reduced access site bleedings with a progressive improvement after the first 6 months learning period.

Single versus double use of a suture-based closure device for transfemoral aortic valve implantation

BACKGROUND

The most common method of percutaneous closure in transfemoral transcatheter aortic valve implantation (TAVI) employs two obtusely oriented ProGlide devices. The aim of this study was to assess the feasibility and safety of using a single ProGlide system for primary access site closure in comparison with the double ProGlide approach in an all-comers TAVI population.

METHODS

Between March 2016 and December 2018, a total of 1105 patients underwent transfemoral TAVI for severe aortic stenosis at our center. Application of two ProGlide systems was standard until April 2017 (n = 432), whereas thereafter a single ProGlide system was used (n = 663). A 1:1 propensity score matching was performed to adjust for baseline differences between the two groups, resulting in 327 matched cases. Primary outcomes of interest were main access site-related vascular complications.

RESULTS

The mean number of ProGlide devices used per patient was 1.03 (SD 0.2) in the single-ProGlide group versus 2.01 (SD 0.14) in the double-ProGlide group. An additional vascular closure device was required to obtain full hemostasis in 23.2% versus 9.5% of patients (p < 0.001) in the two groups, respectively. Technical success of ProGlide usage was similar (94.3% versus 92.1%, p = 0.163). In the matched cohorts, the rates of main access site-related major vascular complications were similar (4.0% vs. 6.4%, p = 0.217).

CONCLUSION

The single-ProGlide technique is feasible, with rates of technical success similar to those of the double-ProGlide technique. Use of this method did not lead to more frequent access site-related complications but was more cost effective than the double-ProGlide approach.

Serial angioscopy during treatments for ProGlide-related femoral occlusion following transcatheter aortic valve implantation

Vascular complications associated with vascular closure device use is uncommon; however, it sometimes occurs in transfemoral transcatheter aortic valve implantation (TF-TAVI). We present a case of ProGlide (Abbott Vascular, Santa Clara, CA, USA)-related right femoral occlusion following TF-TAVI. An 83-year-old woman, who underwent TF-TAVI using double ProGlide pre-closure technique, presented with right claudication three days after TAVI. Computed tomography showed femoral occlusion of the puncture site. Recanalization without pressure gradient between the proximal and distal sites of the lesion was achieved by balloon angioplasty (BA) with a 4.0 mm balloon; however, early re-occlusion of the lesion occurred the next day after BA. Repeated BA was performed for the re-occlusion site 30 days after TAVI because of persistent claudication. Serial angioscopic images of the lesion revealed that the intima, which was injured at the first BA, had healed at the second BA, indicating that BA with larger balloons could be safely performed. We performed BA with a 6.0-mm balloon without stent implantation. The patency of the lesion was maintained during the 6-month follow-up period. The serial angioscopic findings, which revealed the healing process of the intima injury, were useful in determining a suitable endovascular therapy strategy for ProGlide-related occlusion. <Learning objective: ProGlide-related femoral occlusion can occur in arteries without stenosis, calcification, and vessel branching, suggesting that ProGlide should be carefully used with echo-guidance to avoid the occlusion of a puncture site. If endovascular therapy is performed for the lesion to avoid surgical repair, sufficient expansion is required to maintain patency. Angioscopy may be useful for determining a suitable endovascular therapy strategy for the lesion by evaluating the properties of the intima.>.

Perclose Proglide™ for vascular closure

In the past 20 years, numerous percutaneous vascular closure devices have been tested and compared with manual compression and to surgical cut-down. The suture-mediated closure device Perclose ProGlide™ system (Abbott Vascular, CA, USA) emerged as a safe and effective alternative for many procedures requiring either small or large bore vascular accesses. In this review, we will discuss the characteristics of this vascular closure device and the main studies that proved its potential to reduce vascular complications, time to deambulation, time to discharge and patient discomfort.

Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair

OBJECTIVE

The objective of this study was to evaluate the performance of percutaneous femoral access with large-bore sheaths (>21F outer diameter) mainly employed for thoracic and thoracoabdominal aortic endovascular treatment and to stratify the outcomes on the basis of the introducer size.

METHODS

Between December 2015 and December 2018, all consecutive patients who received endovascular repair through a percutaneous approach with a suture-mediated vascular closure device (VCD) and the preclose technique were included in a retrospective single-center study called Totally Percutaneous Approach to Endovascular Treatment of Aortic Aneurysms (PEVAR-PRO). The morphologic characteristics of the access vessels and patients' demographics were recorded, and 30-day closure success was defined as the primary end point. Analysis of the closure success comparing large-bore sheaths vs small-bore sheaths (≤21F outer diameter) was performed after 1:1 propensity score matching of preoperative confounding variables.

RESULTS

The closure success rate of the entire study cohort was 94% (622 femoral accesses in 360 patients; median age, 74 years; 84% male). Univariate analysis identified eight different factors associated with failure, but only two remained significant on multivariate analysis: diabetes (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .011) and common femoral artery stenosis >50% (OR, 4.5; 95% CI, 1.3-13.7; P = .019). After propensity score matching (1:1, 172 femoral accesses per group), closure success rate was not significantly different between large-bore and small-bore sheaths (90.7% vs 93.0%; P = .43). Multivariate analysis of the large-sheath group identified two factors associated with failure: small (<9 mm) femoral arteries (OR, 6.9; 95% CI, 1.5-31.6; P = .13) and access vessel calcifications involving more than one-third of the circumference (OR, 7.9; 95% CI, 2.1-29.4; P = .002). Neither previous femoral cutdown (44 accesses [23%]) nor percutaneous closure with VCDs (38 accesses [20%]) affected the closure success rate in the large-sheath group. Closure failure did not significantly increase the need for postoperative blood transfusions or hospital length of stay.

CONCLUSIONS

Off-label use of VCDs and the preclose technique for percutaneous approach with large-bore sheaths needed for complex aortic endovascular procedures is safe and feasible. Closure success rate is not significantly different from that obtained with on-label application of VCDs with smaller sheaths.

The ARAHKEY technique: A novel method for the management of access site bleeding during percutaneous transfemoral transcatheter aortic valve replacement

OBJECTIVE

This retrospective study assessed the safety and efficacy of the ARAHKEY (ARterial sealing with Additional Hemostatic device Kissing with Extravascular and suture-based device deeplY) technique during transcatheter aortic valve replacement (TAVR).

BACKGROUND

Access site complications are still a major issue to be solved during TAVR using a large caliber sheath.

METHODS

From February 2014 to June 2019, a total of 302 patients underwent TAVR in our hospital. Twenty-five patients (10.2% of patients who underwent percutaneous transfemoral TAVR [n = 246]) were treated using the ARAHKEY technique, which is the additional use of Exoseal for the common femoral artery puncture site when hemostasis was not achieved with ProGlide alone.

RESULTS

Complete hemostasis was achieved in all patients (100%). The mean procedural time for hemostasis was 9.8 ± 4.5 min. No complications, including recurrent bleeding, infection, and late acquired hematoma, were observed in this study cohort.

CONCLUSION

The ARAHKEY technique is a safe method and should be considered as a secondary option when hemostasis is not achieved with ProGlide during TAVR.

Feasibility and safety of total percutaneous closure of femoral arterial access sites after veno-arterial extracorporeal membrane oxygenation

To evaluate the safety and efficacy of total percutaneous closure of the femoral artery access site after veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with the Perclose ProGlide device.This retrospective observational study during an almost 2-year period included 21 patients who underwent VA-ECMO in whom the femoral artery puncture site was closed percutaneously with Perclose ProGlide devices. Technical success was defined as successful arterial closure of the common femoral artery, without the need for additional surgical or endovascular procedures. Access site complications were recorded at 24 hours and 30 days after arterial closure, such as major bleeding requiring transfusion or surgical intervention, minor bleeding, groin infection, pseudoaneurysm, and lymphocele.Technical success was achieved in 20 patients (95.2%). One patient required surgical repair for an access site pseudoaneurysm. Eighteen femoral arteries were closed with 2 devices each, while 3 patients required the use of a third device for femoral artery access site closure to achieve adequate hemostasis. No arterial thrombosis, arterial dissection, arterial stenosis, groin infection, or arteriovenous fistula occurred during the periprocedural period (within 24 hours of arterial closure) or during 30-day follow-up.Percutaneous closure with the Perclose ProGlide device is a feasible procedure for closing femoral arterial access sites after VA-ECMO, with a low incidence of access site complications.