Complications with the use of Angio-Seal vascular closure device and their management

Vascular closure devices (VCDs) are being increasingly used for achieving hemostasis after diagnostic and therapeutic endovascular procedures. Although uncommon, complications may be encountered which are associated with the use of these VCDs. We report four cases where the use of Angio-Seal (Terumo, Somerset, New Jersey, USA) was followed by complications. Three cases presented with acute limb ischemia, among them, two patients had arterial occlusion at the vascular access site and one patient had embolization of the footplate anchor of the closure device. One case presented with pseudoaneurysm at the common femoral artery access site along with occlusion at origin of the superficial femoral artery. We have described the mechanism in which these complications occur and the successful management of these cases preventing potential amputation and limb loss. The risk factors which increase the risk of complications with the use of Angio-Seal VCD were reviewed and the strategy to avoid these complications with particular emphasis on the utility of ultrasound when using Angio-Seal VCD is discussed. A strategy to manage these complications has been discussed while deciding on endovascular management or surgical management, especially in patients with challenging presentation and those with multiple comorbidities making them at very high risk for surgery.

Cumulative sum analysis of the learning curve for the preclosure technique using Proglide

OBJECTIVES

Our study aims to assess the technical quality and the learning curve of the preclosure technique for a vascular surgeon using Proglide using cumulative sum analysis (CUSUM analysis).

METHODS

This study was designed retrospectively and enrolled 81 consecutive patients with 88 access sites who underwent endovascular aortic repair or thoracic endovascular aortic repair with the preclosure technique using Proglide between July 2017 and February 2018. The patients were divided into 2 groups chronologically: (A) the first 40 cases and (B) the latter 41 cases. Logistic regression analysis was used to assess the impact of technical risk factors on the success of the preclosure technique, and the χ2 test and 1-way ANOVA were applied to analyse the distribution of individual characteristics and risk factors between the 2 groups. CUSUM analysis was adapted to analyse the learning curve and to monitor the technical quality, with a predetermined target failure rate of 5%, an alternative failure rate of 20% and calculated 80% 'alert', 95% 'alarm' and 80% 'reassurance' lines.

RESULTS

Primary technical success was obtained in 81 (92.05%) access sites. There were no significant correlations between primary technical success and risk factors, including, common femoral artery diameter (P = 0.88), common femoral artery depth from the skin (P =0.94), the level of common femoral artery calcification (P =0.86) and size of sheath (P =0.96). Moreover, the distribution of related risk factors was not significantly different between groups A and B. CUSUM analysis showed that the cumulative failure rate never crossed the 80% 'alert' and 95% 'alarm' lines. Additionally, the failure rate began to approach the 80% 'reassurance' line after ∼22 cases and crossed the 80% 'reassurance' line after 36 cases.

CONCLUSIONS

The technique of totally percutaneous access using Proglide is safe and effective for an experienced vascular surgeon, even if the operator has no previous experience with any preclosure techniques. CUSUM analysis showed that 36 cases are necessary to achieve the target failure rate of 5%.

FemoSeal® Device Use for Femoral Artery Closure by Different Techniques

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endovascular therapy for Angio-sealTM -related acute limb ischemia: Perioperative and long-term results

OBJECTIVES

To investigate the perioperative and long-term outcomes of endovascular therapy for Angio-seal^TM -related acute limb ischemia.

BACKGROUND

Currently, limited data are available on the optimal treatment strategy for Angio-seal^TM -related acute lower limb ischemia.

METHODS

The prospectively maintained patient database of our institution was retrospectively searched to identify all patients who developed acute lower limb ischemia after use of the Angio-Seal^TM and received endovascular treatment from January 2010 to February 2016. The clinical and follow-up data were evaluated.

RESULTS

Thirty-two patients with Angio-Seal^TM -related acute limb ischemia underwent endovascular therapy, resulting in an approximated incidence of 0.29% of all implanted devices. The overall procedural success rate was 96.9%. With regard to the patients who underwent successful endovascular treatment, the culprit lesion was located in the common femoral artery in 22 (71.0%) cases, the femoral artery bifurcation in 3 (9.7%) cases and the superficial femoral artery in 6 (19.4%) cases. Ten (31.3%) patients had thrombosis in other distal lower limb arteries ipsilateral to Angio-seal^TM use. Eighteen (58.1%) patients underwent balloon angioplasty alone, while nine (29.0%) patients underwent balloon angioplasty and thrombolysis, and four (12.9%) patients underwent stent implantation. One patient suffered from minor bleeding at the site of application of the Angio-seal^TM . During an average of 43.5 ± 22.9 months of follow-up, three patients with symptomatic restenosis underwent a second successful balloon angioplasty and remained asymptomatic until the last follow-up.

CONCLUSIONS

Balloon angioplasty with selective thrombolysis or stent placement was safe and effective, with a low incidence of complication and restenosis. © 2017 Wiley Periodicals, Inc.

Incidence, predictors, and treatment options of critical limb ischaemia after use of collagen plug-based vascular closure devices

AIMS

Limited data are available on the frequency and predictors of vascular closure device (VCD) failure with subsequent vascular complications. The aim of this study was to investigate the incidence, clinical characteristics, and treatment options in patients with critical limb ischaemia (CLI) after use of a collagen plug-based VCD.

METHODS AND RESULTS

A high-volume, single-centre prospectively maintained database was retrospectively interrogated, and cases of collagen plug-based VCD-related CLI were identified between June 2006 and December 2013. CLI was defined as acute onset of rest pain after VCD application requiring endovascular or surgical treatment. Among 13,595 coronary procedures, 43 patients (0.3%) were identified with an Angio-Seal-related CLI. In a multivariable logistic regression analysis, peripheral artery disease and renal insufficiency were identified as independent predictors for CLI after Angio-Seal application. Treatment was performed in 27 patients (63%) by surgery and in 16 patients (37%) with endovascular angioplasty.

CONCLUSIONS

CLI after use of a collagen plug-based VCD is rare. Peripheral artery disease was identified as an independent predictor of CLI. Interventional cardiologists should be aware of potentially high-risk patients and complications after use of a VCD to provide prompt and adequate therapy.

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.