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

Antegrade Femoral Puncture Using a Suture-Mediated Closure Device in Infrainguinal Endovascular Interventions

BACKGROUND

ProGlide is a suture-mediated vascular closure device (VCD) indicated for retrograde access closure at the common femoral artery (CFA). However, its off-label use for antegrade and/or superficial femoral artery (SFA) access has become common in many practices. This study evaluated the efficacy and safety of ProGlide for femoral artery access closure in patients undergoing antegrade infrainguinal endovascular procedures.

METHODS

In this single-center retrospective study, we analyzed data from patients with peripheral arterial disease (PAD) who underwent peripheral angioplasty between January 2017 and December 2023. The inclusion criteria were infrainguinal PAD disease, Rutherford classification 3 to 6, the use of an endovascular approach, and access performed through the ipsilateral antegrade femoral artery. The primary endpoint of the study was to evaluate the efficacy and technical success of the Perclose ProGlide closure device during antegrade percutaneous endovascular procedures. Secondary endpoints included intraoperative and postoperative inguinal and vascular complications.

RESULTS

A total of 301 participants were included in the study. All patients were classified according to the clinical categories of chronic limb ischemia: 111 patients (37%) had severe claudication (class 3) with walking distances of less than 20 meters, 42 patients (14%) had at least one limb with ischemic rest pain (class 4), and 148 patients (49%) had at least one limb with ischemic tissue loss (class 5 or 6). A 6 Fr introducer was used in the majority of cases (88%), with a mean hospital stay of 1.5 ± 0.5 days. Technical success was achieved in 298 patients (99%), and there were no early deaths. A total of 33 hematomas were identified, with 5 patients having major complications. One of these was treated with conservative management, while 4 patients required further interventions.

CONCLUSIONS

This retrospective study demonstrated the feasibility and safety of using the ProGlide single VCD for antegrade femoral puncture during infrainguinal endovascular interventions. The safety of its deployment can be further optimized by routinely utilizing ultrasound (US) guidance.

FEMOSEAL CLOSE: multi-centre observational study with FemoSeal™ vascular closure device following peripheral percutaneous endovascular procedures

BACKGROUND

The purpose of the FEMOSEAL CLOSE study was to assess the safety and effectiveness of FemoSeal™ vascular closure device in achieving haemostasis following transfemoral peripheral procedures in routine clinical practice.

MATERIALS AND METHODS

This prospective, European, multi-centre, single-arm, post-market clinical follow-up study enrolled patients undergoing diagnostic or interventional peripheral endovascular procedures with FemoSeal™ vascular closure device in inpatient or outpatient settings. The primary endpoint was a composite of safety and effectiveness, with effectiveness defined as cessation of arterial bleeding without adjunctive treatment, and safety as freedom from major vascular complications in the first 6 h. Secondary endpoints included: minor access-site complications and major complications 6 h to 30 days post-procedure, and time to haemostasis, ambulation and discharge. Quality of life was assessed at baseline, discharge and 30-day follow-up. Device usability was also surveyed.

RESULTS

Between December 2021 and July 2022, 230 patients were enrolled in three European centres. The primary composite endpoint was achieved in 95.1% (215/226) [95% confidence interval: 91.46-97.55] of patients. The effectiveness component was achieved in 96.9% (219/226) [95% confidence interval: 93.70-98.70], and the safety component in 95.2% (220/230) [95% confidence interval: 92.15-97.90] of patients. FemoSeal™ vascular closure device deployment failure occurred in 1.6% (4/230) of cases, with subsequent manual compression achieving haemostasis. The median time to haemostasis was 0.42 min.

CONCLUSIONS

The study device provides effective haemostasis and low rates of access-site complications up to 30 days post-procedure for patients undergoing peripheral endovascular interventions. It demonstrates good performance with rapid haemostasis.

TRIAL REGISTRATION

The study is registered at clinicaltrials.gov. (ClinicalTrials identifier: NCT05027698).

Vascular access: Femoral, radial and large-bore alternative access

Vascular access for coronary, peripheral, and structural interventions has changed significantly over the past two decades. The evolving demand for both large-bore access for valvular interventions and mechanical support devices, and for safer access for coronary interventions, in patients with comorbidities have driven progress in these areas. This review will provide an overview of the techniques of arterial access in the femoral, forearm (radial and ulnar), and alternative (transcarotid, transaxillary, and transcaval) locations based on the latest evidence and experience.

Comparing Transbrachial and Transradial as Alternatives to Transfemoral Access for Large-Bore Neuro Stenting: Insights From a Propensity-Matched Study

RATIONALE AND OBJECTIVES

This study aimed to evaluate the safety and effectiveness of transbrachial access (TBA) and transradial access (TRA) compared to transfemoral access (TFA) for large-bore neuro stenting (≥7 F).

METHODS

From January 2019 to January 2024, 4752 patients received large-bore neuro stenting in our center. The primary outcomes were procedural metrics. Safety outcomes were significant access site complications, including substantial hematoma, pseudoaneurysm, artery occlusion, and complications requiring treatment (medicine, intervention, or surgery). After propensity score matching with a ratio of 1:1:2 (TBA: TRA: TFA), adjusting for age, gender, aortic arch type, and neuro stenting as covariates, outcomes were compared between groups.

RESULTS

46 TBA, 46 TRA and 92 TFA patients were enrolled. The mean age was 67.8 ± 11.2 years, comprising 127 (69.0%) carotid artery stenting and 57 (31.0%) vertebral artery stenting. The rates of technical success (TBA: 100%, TRA: 95.7%, TFA: 100%) and significant access site complications (TBA: 4.3%, TRA: 6.5%, TFA: 1.1%) were comparable between the groups (P > 0.05). Compared to TFA, the TRA cohort exhibited significant delays in angiosuite arrival to puncture time (14 vs. 8 min, P = 0.039), puncture to angiography completion time (19 vs. 11 min, P = 0.027), and procedural duration (42 vs. 29 min, P = 0.031). There were no substantial differences in procedural time metrics between TBA (10, 14, and 31 min, respectively) and TFA.

CONCLUSION

TBA and TRA as the primary access for large-bore neuro stenting are safe and effective. Procedural delays in TRA may favor TBA as the first-line alternative access to TFA.

Comparative effectiveness and safety of Angio-Seal and StarClose vascular closure devices: a systematic review and meta-analysis

Objective

This systematic review and meta-analysis aims to evaluate the effectiveness and safety of Angio-Seal and StarClose vascular closure devices (VCDs) in achieving hemostasis after interventional surgery.

Methods

Randomized controlled trials (RCTs) and observational studies comparing Angio-Seal and StarClose were identified through systematic searches. Data on vascular closure success rate, complication rates, hematoma formation, pseudoaneurysm, arterial occlusion, and surgical intervention were extracted and pooled using a random effects model.

Results

Nine studies met the inclusion criteria, total 5,466 patients. The meta-analysis revealed a slight, statistically significant difference in the success rate of vascular closure in favor of Angio-Seal (risk ratio (RR) 1.05, 95% confidence interval (CI) [1.00-1.09], p = 0.03). No significant difference was found in the overall complication rate, hematoma formation, pseudoaneurysm, arterial occlusion, or surgical intervention.

Conclusions

Angio-Seal demonstrated a slightly higher success rate in vessel closure compared to StarClose. Both devices had a comparable safety profile with no significant differences in major complications.

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.

Procedure-Related Complication Rates With the Use of Vascular Closure Devices; Does Size Only Matter? A Large Single Centre Retrospective Study

INTRODUCTION

Our retrospective study aimed at assessing safety of vascular closure devices (VCDs) used in a large single-centre Interventional Radiology (IR) department. Complication and deployment failure rates using collagen-based (Angio-seal) and suture-based (ProGlide) devices for common femoral artery haemostasis were compared.

MATERIALS AND METHODS

Data from VCDs deployed over a 6-year period were retrospectively analysed for patient age, procedure indication, puncture mode (antegrade/retrograde), sheath size, deployment failure and complications (haematoma, pseudoaneurysm formation, limb occlusion). Numerical and statistical analysis was undertaken.

RESULTS

Overall, 1321 common femoral artery punctures in 1217 patients were closed using VCDs. Failure rate using ProGlide was significantly higher when compared with Angio-seal (P=<0.001) in sheath sizes ≤8 Fr. Heparin was not administered in embolisation procedures compared with angioplasty with or without stenting. Therefore, haematoma tended to occur more frequently following angioplasty without stenting (P = 0.003) and angioplasty with stenting (P = 0.001), when compared with embolisation. Deployment failure occurred more frequently when heparin was used during the procedure (P = 0.005).

CONCLUSION

Although complications relating to sheath size are well established in the literature, there remains a paucity of data assessing the impact of procedure specific factors when comparing VCDs. Our study challenges that size is the sole determinant of VCD success and invites a more holistic view of VCD deployment strategies. This study advocates continued research into the nuances of other potential confounding variables to optimise patient outcomes.

Advancements in Vascular Closure Devices for Effective Hemostasis in Femoral Artery Interventions

With medical technology development, endovascular intervention has been widely used in clinical practice, and the establishment of surgical access through the femoral artery, where most vascular interventions are performed, is a common method. Postoperative hemostasis at the femoral artery puncture site is a key part of interventional procedures and is particularly important to ensure the safety and effectiveness of hemostasis. Some patients undergoing interventional therapy also use anticoagulant and antiplatelet drugs preoperatively and undergo systemic heparin session intraoperatively, which leads to abnormal coagulation, thus increasing the difficulty of hemostasis at the puncture point postoperatively. Certain patients with specific conditions, such as combined vascular calcification, obesity, diabetes mellitus, and renal impairment, present more challenging cases for postoperative puncture point hemostasis. Femoral artery puncture site hemostasis methods include manual compression, arterial compression devices, and vascular closure devices, which are a kind of equipment that helps interventional doctors stop bleeding quickly at the femoral artery puncture site. From the 1990s to the present, vascular occluders with many different concepts and mechanisms have emerged. Based on different hemostatic principles and materials, the mechanisms and principles of action are varied and include sealant occlusion, collagen patch embolization, polyester suture closure, absorbable polyethanol embolic agents, nickel-titanium alloy clips, polydiethanol sealant embolization, and suture bioabsorbable patches. Many studies have compared the hemostatic effect of vascular closure devices with those of manual compression. In this article, we review the hemostatic effects of the 2 modalities and the advances in the use of vascular closure devices in vascular intervention.

Feasibility, safety, and efficacy of a novel external compression vascular closure device: The LockeT® study

INTRODUCTION

Hemostasis following large-bore femoral vein access remains a challenge. Manual compression has been the standard of care but requires bedside staff, prolonged bed rest, and longer length of stay. The LockeT is an external compression device that attempts to address these issues while achieving venous hemostasis.

OBJECTIVES

We evaluate postprocedural hemostasis and vascular closure outcomes after using LockeT following cardiac electrophysiologic procedures.

METHODS

We performed a single-center, observational study of patients who underwent vascular closure for electrophysiology procedures using LockeT. Postprocedural outcomes were subsequently analyzed.

RESULTS

We studied 102 patients (N) for whom LockeT was used to close 182 separate vascular access sites (n). Common procedures were atrial fibrillation ablation (56.9%, N = 58) and left atrial appendage occlusion (28.4%, N = 29). Most often, 8-Fr [48.3% (n = 126)], 11-Fr [27.2% (n = 71)], and 8.5-Fr [16.9% (n = 44)] sheaths were used, with an average procedure time of 82.1 ± 29.4 min. Hemostasis was achieved in 97.8% (n = 187) of all LockeT cases. Time to ambulation and discharge were 3.93 ± 1.10 h and 8.1 ± 4.4 h, respectively. No major complications were noted. Postprocedurally, 52% (N = 53) of patients were discharged on the same day. There were no differences in hemostasis (p = .859) or ambulation times (p = .202) between procedure types.

CONCLUSION

The LockeT can effectively close venous access sites with no major complications.

A Novel Suture-Based Vascular Closure Device to Achieve Hemostasis after Venous or Arterial Access While Leaving Nothing behind: A Review of the Technological Assessment and Early Clinical Outcomes

Vascular hemostasis after venous and arterial access in cardiovascular procedures remains a challenge. As sheath size gets larger for structural heart and vascular procedures, no dedicated closure devices exist that can overcome all the challenges of achieving vascular hemostasis, in particular on the venous side. Efficiently and reliably ensuring hemostasis at the access point is crucial for enhancing the safety of a procedure. Historically, hemostasis relied on manually compressing venous access sites. However, the shift towards larger sheaths and the more frequent use of continuous anticoagulation has strained this approach. Achieving hemostasis solely through compression in these scenarios demands heightened vigilance and prolonged application, resulting in increased patient discomfort and extended immobility. Consequently, manual compression may consume more time for healthcare providers and contribute to bed occupancy in hospitals. This review article summarizes the development of the SiteSeal® Vascular Closure Device, a novel leave-nothing-behind approach to achieve hemostasis. The introduction of this technology has provided clinicians with a safer and more effective way to achieve immediate hemostasis, facilitate early ambulation, and enable earlier discharges with fewer access site complications compared with traditional manual compression.

Endovascular Perclose ProGlide complication puncture site, treated successful by cutting balloon dilatation: A case report and literature review

Perclose ProGlide were created as preferred for puncture site closure of femoral artery. Femoral artery occlusion is one of the serious device-related complications. This report presents a continuous endovascular technique combined with peripheral cutting balloon (PCB) treatment for a case of a 32s woman diagnosed with lower extremity ischaemia caused by right superficial femoral artery (SFA) occlusion following the use of the Perclose ProGlide system in minimally invasive cardiac surgery. During the primary operation, limb ischaemia symptoms were relieved with vessel perfusion and reconstruction after regular balloon dilatation. A secondary operation was conducted 6 weeks later, and the obstructive lesions were recanalised without residual stenosis after PCB dilatation. No vessel-related adverse events such as dissection, rupture or distal embolisation occurred during the perioperative period. The patient recovered uneventfully after the operation, with complete alleviation of symptoms. Follow-up computed tomography angiography 3 month post-operatively revealed an undeformed shape and excellent patency of the right SFA.

A single institution experience of the Manta closure device in endovascular aortic repair

BACKGROUND

Majority of EVAR procedures are performed with percutaneous arterial access, unless there is severe steno-occlusive disease in the common femoral arteries (CFA). We present our experience of using MANTA closure device with a retrospective evaluation of its safety and efficacy, in the elective setting, and in the emergent setting for ruptured aortic aneurysm.

DESIGN AND METHODS

Between Feb 2021 and May 2023 a total of 75 EVAR procedures were closed with a Manta device. Data was collected prospectively and analysed retrospectively. In 75 patients, 128 CFAs were closed with a Manta closure device including 4 emergent ruptured aneurysms.

RESULTS

67 male and 8 female patients with a median age of 77 years had percutaneous EVAR using Manta as a closure device. 128 CFAs were closed with Manta closure device. 3% (4/128) had deployment failures, with three requiring surgical cut down and closure. In one patient, a second Manta device deployment achieved satisfactory haemostasis. Three deployments were complicated by pseudoaneurysms of the CFA, all requiring no further interventions/treatment. No death related to severe haemorrhage from device failure. The pre- and post-procedure CFA puncture site AP diameter was recorded in a total of 106 cases with appropriate follow-up. 66% of these (70/106) had no reduction in CFA diameter post Manta closure. 34% (36/106) had some reduction of vessel AP size CFA post EVAR. No adverse features or further treatment was required due to reduction of vessel diameter in these cases (ongoing yearly surveillance).

CONCLUSIONS

Manta closure device is safe and easy to deploy with an overall success rate of 97%. There is a short learning curve. Ultrasound assessment and precise puncture at the healthy section of femoral artery are the key to achieve successful haemostasis with Manta closure device. Our findings suggest there is an association of non-clinically significant mild reduction in CFA vessel AP diameter post Manta closure device, which does not require further intervention.

Iatrogenic Vascular Injuries in Resource-Limited Setting: A 4-Year Experience Monocentric Retrospective Study

Background

Iatrogenic vascular injuries (IVIs) due to diagnostic and therapeutic interventions are known but rare or probably under-reported. We present our four-year findings on patients with IVIs after catheterization or surgery who underwent vascular surgical repairs in a resource-limited setting.

Methods

A retrospective case series study between Jun 2018 and Sep 2022 of 35 patients diagnosed with IVIs and treated surgically at our hospital was included. The data on IVIs including patient characteristics, causes and type of injury, treatment, and outcomes were collected and analyzed.

Results

The mean age was 37.12± 17.0 years, and most patients (65.7%) were male. Of the 35 IVIs, 21 were caused by percutaneous procedures, while 14 occurred intraoperatively and affected various arteries and veins. The main injured vessels were the femoral artery (20%) and direct blood vessel puncture made by non-qualified specialists (42.9%) during dialysis cannulation was the main cause. The intraoperative IVI affected the inferior vena cava in three patients, the aorta in two patients, the external iliac artery in four, the tibial and popliteal arteries in four, and the internal carotid artery in one. The following types of repairs were recorded: direct suture of the vessel with or without endarterectomy (71.4%), synthetic patch placement (25.7%), ligation (8.6%), bypass or interposition graft (14.3%), and thromboembolectomy (5.7%). Vascular repair was successful in 32 (91.4%) patients while three patients (8.6%) were expired. Complications occurred in 7 (20%) patients, of which superficial wound infections were the common complication (11.6%) and were treated with proper antibiotic therapy.

Conclusion

Prompt identification of IVIs, as well as proper triage for future treatment, can enhance patient outcomes. Our data showed that non-qualified specialists seem to be responsible for the majority of IVIs. For that, we emphasize the importance of performing vascular procedures by a qualified specialist with adequate training.

Comparison of manual compression, Z-stitch, and suture-mediated vascular closure device techniques in dogs undergoing percutaneous transvenous intervention

INTRODUCTION/OBJECTIVES

Manual compression has been standard of care for maintaining hemostasis after percutaneous endovascular intervention, but can be time-consuming and associated with vascular complications. Alternative closure methods include the figure-of-eight suture (Z-stitch) and vascular closure device (VCD) techniques. We hypothesized that compared to manual compression, Z-stitch and VCD would significantly reduce time-to-hemostasis after transvenous access, and the proportion of dogs with vascular patency would not differ significantly among treatments.

ANIMALS

Forty-six client-owned dogs undergoing percutaneous transvenous interventional procedures.

MATERIALS AND METHODS

Dogs with vessel diameter <5 mm were randomized to undergo manual compression or Z-stitch, while those with vessel diameter ≥5 mm were randomized to undergo manual compression, Z-stitch, or VCD. Time-to-hemostasis, bleeding scores, presence of vascular patency one day and two to three months post-procedure, and complications were recorded. Data are presented as median (95% confidence interval).

RESULTS

In all 46 dogs, the right external jugular vein was used. Time-to-hemostasis was significantly shorter in the Z-stitch (2.1 [1.8-2.9] minutes) compared to VCD (8.6 [6.1-11.8] minutes; P<0.001) and manual compression (10.0 [10.0-20.0] minutes; P<0.001) groups. Time-to-hemostasis was significantly shorter in the VCD vs. manual compression (P=0.027) group. Bleeding scores were significantly greater at 5 and 10 min (P<0.001 and 0.013, respectively) in manual compression, compared to Z-stitch group. There was no difference in the proportion of dogs with vascular patency between groups (P=0.59).

CONCLUSIONS

Z-stitch and VCD are effective venous hemostasis methods after percutaneous transvenous intervention, with Z-stitch providing the most rapid time-to-hemostasis. Both Z-stitch and VCD techniques have low complication rates and effectively maintain vascular patency.

Efficacy and Safety of Axiostat® Hemostatic Dressing in Aiding Manual Compression Closure of the Femoral Arterial Access Site in Patients Undergoing Endovascular Treatments: A Preliminary Clinical Experience in Two Centers

BACKGROUND

Hemostasis of the femoral arterial access site by manual compression or a vascular closure device is critical to the safe completion of any endovascular procedure. Previous investigations evaluated the hemostatic efficacy at the radial access site of some chitosan-based hemostatic pads. This study aims to assess the efficacy and safety of a new chitosan-based hemostatic dressing, namely Axiostat®, in aiding manual compression closure of the femoral arterial access site in patients undergoing endovascular treatments. Furthermore, the outcomes were compared with evidence on manual compression alone and vascular closure devices.

METHODS

This investigation is a two-center retrospective analysis of 120 consecutive patients who had undergone, from July 2022 to February 2023, manual compression closure of the femoral arterial access site aided by the Axiostat® hemostatic dressing. Endovascular procedures performed with introducer sheaths ranging from 4 Fr to 8 Fr were evaluated.

RESULTS

Primary technical success was achieved in 110 (91.7%) patients, with adequate hemostasis obtained in all cases of prolonged manual compression requirements. The mean time-to-hemostasis and time-to-ambulation were 8.9 (±3.9) and 462 (±199) minutes, respectively. Clinical success was achieved in 113 (94.2%) patients, with bleeding-related complications noted in 7 (5.8%) patients.

CONCLUSIONS

Manual compression aided by the Axiostat® hemostatic dressing is effective and safe in achieving hemostasis of the femoral arterial access site in patients undergoing endovascular treatment with a 4-8 Fr introducer sheath.