Large-bore Vascular Closure: New Devices and Techniques

A comparative study between surgical cut down and percutaneous closure devices in management of large bore arterial access

BACKGROUND

Compared to conventional open surgery, minimally invasive catheter-based procedures have less post procedural complications. Transcatheter aortic valve implantation (TAVI) and endovascular aneurysm repair (EVAR) require large bore arterial access. Optimal site management of large bore arterial access is pivotal to reduce the hospital-acquired complications associated with large bore arterial access. We wanted to compare surgical cutdown versus percutaneous closure devices in site management of large bore arterial access.

METHODS

Participants planned for TAVI or EVAR with large bore arterial access more than 10 French were included, while participants with history of bypass surgery, malignancies, thrombophilia, or sepsis were excluded. A consecutive sample of 100 participants (mean age 74.66 ± 2.65 years, 61% males) was selected, underwent TAVI or EVAR with surgical cutdown (group 1) versus TAVI or EVAR with Proglide™ percutaneous closure device (group 2).

RESULTS

The incidence rate of hematoma was significantly lower in group 2 versus group 1 (p = 0.014), the mean procedure time (minutes) and the median hospital stay (days) were significantly higher in group 1 versus group 2 (t(98) =  - 2.631, p = 0.01, and U = 2.403, p = 0.018, respectively), and the c-reactive protein pre-procedure and the c-reactive protein post-procedure were significantly lower in group 2 versus group 1 (U = -2.969, p = 0.003, and U = -2.674, p = 0.007, respectively).

CONCLUSIONS

Our study showed a lower incidence rate of large bore arterial access complications as hematoma, a shorter procedure time, and a shorter hospital stay with percutaneous closure devices compared to surgical cutdown.

The "Woggle" Technique for Venous Access Site Management: An Old Technique for a New Need

BACKGROUND

Several closure devices are routinely used for percutaneous arterial access, while a relatively low number is available for the management of large bore venous accesses. The Woggle technique is a modification of the purse-string suture which was introduced several years ago in patients undergoing hemodialysis.

METHODS

A population of 45 patients who underwent transvenous femoral structural heart interventions was retrospectively evaluated. The Woggle technique consists of a purge string suture with a collar to maintain the tension as stable over time and a suture lock to tighten the suture.

RESULTS

Sheaths magnitude ranged from 8 French (F) to 14 F. A rapid post-procedural hemostasis was achieved in the whole population, and in 95% of cases, definite hemostasis was obtained after the first single release; the mean time of release was 302 ± 83 min. Although no relevant bleedings were reported, a significant reduction in hemoglobin levels was found in the whole population. This decrement was statistically significant only in the group with sheaths higher than 12 F. A single mild local hematoma was recorded in the group in which smaller sheaths were used. Seventy-two percent of patients were pre-treated with a dual antiplatelet therapy.

CONCLUSIONS

The Woggle technique has shown to be a simple, effective, and safe approach for the management of large bore venous in percutaneous structural heart interventions.

CIRSE Standards of Practice on Arterial Access for Interventions

This CIRSE Standards of Practice document is aimed at healthcare professionals (including interventional radiologists) performing endovascular procedures to provide best practices for performing arterial access for interventions. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. This paper encompasses up-to-date clinical and technical aspects in performing safe and appropriate arterial access for interventions.

Suture-mediated closure devices for percutaneous endovascular abdominal aneurysm repair

Purpose

Endovascular procedures such as endovascular aneurysm repair or transcatheter aortic valve implantation have become very common because of reduced patient traumatisation and the ability to use shorter or local anaesthesia. In these procedures large-bore sheath devices are used. Access with percutaneous closure is an alternative method to surgical cutdown in groins. The aim of the study was to assess the correlation between sheath size and unsuccessful haemostasis. In addition, the effectiveness of haemostasis after a percutaneous procedure and the number and type of complications were evaluated.

Material and methods

There were 202 patients included in the study. Patients with abdominal aortic aneurysm were qualified to percutaneous aortic stentgraft implantation with Perclose Proglide preclosure technique.

Results

There were 384 access sites performed with 12F to 22F sheaths during aortic stentgraft implantation with Perclose Proglide (Abbott Vascular, Santa Clara, CA, USA) preclosure technique. High effectiveness of haemostasis (98%), low percentage of short- and mid-term complications (2.6%), and infinitesimal number of surgical conversions (n = 5) were stated in the study. There was no correlation between diameter of used introducer sheath and lack of haemostasis observed (Fisher-Freeman-Halton test; p = 0.122). No relationship between diameter of introducer sheath and number of closure devices was observed (c² = 2.436; df = 5; p = 0.786).

Conclusions

Large-bore device percutaneous procedures with closure devices are effective and safe. High effectiveness of haemostasis (98%) was observed in the study group, with a low percentage of complications (2.6%). There was no correlation between size of the vascular access and the lack of haemostasis found in the study.

Handling high-risk patients in the catheterization laboratory

Protected percutaneous coronary intervention is considered a life-saving procedure for high-risk patients. Therefore it is important that the interventional cardiology team is prepared, the procedure is planned, and potential complications, as well as bail out strategies are considered. Throughout the procedure, it is critical to monitor the patient to identify any early signs of deterioration or changes in patient well-being to avoid any potential complications.

Comparison of Suture-Based and Collagen-Based Vascular Closure Devices for Large Bore Arteriotomies-A Meta-Analysis of Bleeding and Vascular Outcomes

BACKGROUND

Large bore access procedures rely on vascular closure devices to minimize access site complications. Suture-based vascular closure devices (S-VCD) such as ProGlide and ProStar XL have been readily used, but recently, newer generation collagen-based vascular closure devices (C-VCD) such as MANTA have been introduced. Data on comparisons of these devices are limited.

METHODS

PubMed, Scopus and Cochrane were searched for articles on vascular closure devices using keywords, ("Vascular closure devices" OR "MANTA" OR "ProStar XL" OR "ProGlide") AND ("outcomes") that resulted in a total of 875 studies. Studies were included if bleeding or vascular complications as defined by Valve Academic Research Consortium-2 were compared between the two types of VCDs. The event level data were pooled across trials to calculate the Odds Ratio (OR) with 95% CI, and analysis was done with Review Manager 5.4 using random effects model.

RESULTS

Pooled analyses from these nine studies resulted in a total of 3410 patients, out of which 2855 were available for analysis. A total of 1229 received C-VCD and 1626 received S- VCD. Among the patients who received C-VCD, the bleeding complications (major and minor) were similar to patients who received S-VCD ((OR: 0.70 (0.35-1.39), p = 0.31, I² = 55%), OR: 0.92 (0.53-1.61), p = 0.77, I² = 65%)). The vascular complications (major and minor) in patients who received C-VCD were also similar to patients who received S-VCD ((OR: 1.01 (0.48-2.12), p = 0.98, I² = 52%), (OR: 0.90 (0.62-1.30), p = 0.56, I² = 35%)).

CONCLUSIONS

Bleeding and vascular complications after large bore arteriotomy closure with collagen-based vascular closure devices are similar to suture-based vascular closure devices.

Changes in demographics, treatment and outcomes in a consecutive cohort who underwent transcatheter aortic valve implantation between 2005 and 2020

Introduction

Transcatheter aortic valve implantation (TAVI) has matured to the treatment of choice for most patients with aortic stenosis (AS). We sought to identify trends in patient and procedural characteristics, and clinical outcomes in all patients who underwent TAVI between 2005 and 2020.

Methods

A single-centre analysis was performed on 1500 consecutive patients who underwent TAVI, divided into three tertiles (T) of 500 patients treated between November 2005 and December 2014 (T1), January 2015 and May 2018 (T2) and June 2018 and April 2020 (T3).

Results

Over time, mean age and gender did not change (T1 to T3: 80, 80 and 79 years and 53%, 55% and 52% men, respectively), while the Society of Thoracic Surgeons risk score declined (T1: 4.5% to T3: 2.7%, p < 0.001). Use of general anaesthesia also declined over time (100%, 24% and 1% from T1 to T3) and transfemoral TAVI remained the default approach (87%, 94% and 92%). Median procedure time and contrast volume decreased significantly (186, 114 and 56 min and 120, 100 and 80 ml, respectively). Thirty-day mortality (7%, 4% and 2%), stroke (7%, 3% and 3%), need for a pacemaker (19%, 22% and 8%) and delirium (17%, 12% and 8%) improved significantly, while major bleeding/vascular complications did not change (both approximately 9%, 6% and 6%). One-year survival was 80%, 88% and 92%, respectively.

Conclusion

Over our 15 years’ experience, patient age remained unchanged but the patient risk profile became more favourable. Simplification of the TAVI procedure occurred in parallel with major improvement in outcomes and survival. Bleeding/vascular complications and the need for pacemaker implantation remain the Achilles’ heel of TAVI.

Supplementary Information

The online version of this article (10.1007/s12471-022-01662-2) contains supplementary material, which is available to authorized users.

Interventional Treatment of Access Site Complications During Transfemoral TAVI: A Single Center Experience

Introduction: Transcatheter aortic valve implantation (TAVI) has rapidly developed over the last decade and is nowadays the treatment of choice in the elderly patients irrespective of surgical risk. The outcome of these patients is mainly determined not only by the interventional procedure itself, but also by its complications. Material and Methods: We analyzed the outcome and procedural events of transfemoral TAVI procedures performed per year at our institution. The mean age of these patients is 79.2 years and 49% are female. All the patients underwent duplex ultrasonography of the iliac arteries and inguinal vessels before the procedure and CT of the aorta and iliac arteries. Results: Transfemoral access route is associated with a number of challenges and complications, especially in the patients suffering from peripheral artery disease (PAD). The rate of vascular complications at our center was 2.76% (19/689). Typical vascular complications (VC) include bleeding and pseudoaneurysms at the puncture site, acute or subacute occlusion of the access vessel, and dissection or perforation of the iliac vessels. In addition, there is the need for primary PTA of the access pathway in the presence of additional PAD of the common femoral artery (CFA) and iliac vessels. Balloon angioplasty, implantation of covered and uncovered stents, lithoplasty, and ultrasound-guided thrombin injection are available to treat the described issues. Conclusion: Interventional therapy of access vessels can preoperatively enable the transfemoral approach and successfully treat post-operative VC in most of the cases. Training the heart team to address these issues is a key focus, and an interventional vascular specialist should be part of this team.

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.

Vascular Complications in TAVR: Incidence, Clinical Impact, and Management

Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.

Propensity-matched comparison of large-bore access closure in transcatheter aortic valve replacement using MANTA versus Perclose: A real-world experience

OBJECTIVE

Compare two large-bore vascular closure devices (VCDs), collagen-plug-based MANTA and suture-based dual Perclose ProGlide (PP), in patients undergoing contemporary transfemoral transcatheter aortic valve replacement (TAVR).

BACKGROUND

The SAFE MANTA IDE clinical trial demonstrated that the collagen-plug-based MANTA VCDs were safe and effective in closing large-bore arteriotomies. However, data comparing this collagen-plug-based VCD to the suture-based VCD in contemporary practice are sparse.

METHODS

This was a retrospective observational study in which we screened transfemoral (TF) TAVR patients at our institution from 2017 to 2020. Included were those whose large-bore TF access was closed using either MANTA or PP with and without Angio-Seal. Our primary outcome was VCD success. Additional in-hospital outcomes included major and minor vascular complications, post-TAVR length of stay, and mortality.

RESULTS

We screened 696 patients who underwent TAVR. Using propensity scores, we matched 124 patients who received MANTA with 124 patients who received PP. Patients had a mean age of 77.2 years, 69.0% were men, and their mean Society of Thoracic Surgeons score was 3.4%. VCD success was equivalent between VCDs (95.2% vs. 95.2%; p = 1.000). Patients had similar rates of mortality (0% vs. 0.8%; p = .316), and no patients had major vascular complications.

CONCLUSIONS

In contemporary TAVR, the collagen-plug-based MANTA VCD appears to be as safe and effective as the suture-based dual PP VCD, with no differences in VCD success, vascular complications, or mortality. Therefore, selection of VCD for TAVR should be left to operator discretion, taking into account anatomical considerations.

Mechanical Circulatory Support Devices: Management and Prevention of Vascular Complications

The use of mechanical circulatory support devices has seen a dramatic rise over the last few years owing to their increased use not only in acute circulatory collapse but also their prophylactic use in high-risk procedures. These devices continue to have their overall benefits marginalized due to the relatively high rates of complications. Vascular complications are the most common and are associated with increased risk of mortality in these patients. Preventive measures at each stage of procedure, frequent monitoring and assessment to recognize early signs of deterioration are the best ways to mitigate the effects of vascular complications.

Use of Impella RP for Acute Right Ventricular Failure Post-Pericardiectomy

Surgical pericardiectomy is the accepted treatment for patients with constrictive pericarditis. Right ventricular failure in patients that undergo pericardiectomy is a frequent complication due to sudden volume overload. Impella RP is used to bypass the right ventricle and tackle the transient right ventricular failure. It is implanted percutaneously and provides enough support to achieve haemodynamical stability and recover end-organ function. We report the case of a patient that developed acute right ventricular failure in the early postoperative period of a pericardiectomy. He underwent the implantation of an Impella RP in the setting of acute right ventricular failure and was successfully explanted after 6 days of support.

Pledget Reinforcement and Tractional Compression as Adjunctive Techniques for Suture-Mediated Closure (SMC) in Percutaneous Endovascular Aneurysm Repair (pEVAR): A Retrospective Observational Cohort Study

BACKGROUND

Percutaneous endovascular aneurysm repair (pEVAR) is commonly utilized and requires the use of suture-mediated closure (SMC) devices to ensure adequate femoral artery hemostasis. Despite the use of such devices, puncture-related complications remain relatively common. We introduced two new adjuncts (pledget reinforcement and tractional compression) along with SMC to reduce such puncture-related complications. The aim of the study was to assess the efficacy and safety of the new adjunct techniques.

METHODS

This retrospective observational cohort study examines the impact of two adjunctive techniques on puncture-related complications compared with the previous year data before this new introduction of adjunct techniques.

RESULTS

Sixty-one percutaneous femoral punctures (in 31 patients) utilizing adjunct techniques for closure (the adjunct group) were retrospectively compared with 89 punctures (in 46 patients) closed with standard SMC technique (the standard group). The use of adjunctive techniques led to a significant reduction in overall puncture-related complications (3/61 (4.9%) vs. 20/89 (22.5%), P = 0.0106) and the need for emergent surgical repair after failed hemostasis (2/61 (3.3%) vs. 13/89 (14.6%), P = 0.037).

CONCLUSIONS

These novel adjunctive techniques (pledget reinforcement and tractional compression) of SMC for pEVAR reduce puncture-related complications and increase the confidence to offer percutaneous techniques for more patients.

Outcomes of heart transplantation in patients bridged with Impella 5.0: Comparison with native chest transplanted patients without preoperative mechanical circulatory support

The Impella (Abiomed, Danvers, MA, USA) has become an important adjunct treatment modality in bridging patients with end-stage heart failure to recovery or orthotopic heart transplantation (HTx). We compared the outcome of patients directly bridged to HTx with the Impella 5.0 versus patients without mechanical circulatory support (MCS). Patients with no previous sternotomy or MCS, who were transplanted between September 2014 and March 2019 were included in this retrospective analysis. Impella 5.0 was implanted using surgical access and transesophageal echocardiography guidance. Forty-two out of 155 transplanted patients fulfilled the insertion criteria. Eight (19%) were bridged with Impella 5.0 to HTx. Recipient and donor baseline characteristics were comparable in both groups. There were no significant differences in survival between the groups at 30-day (94% no MCS vs. 87.5% Impella group, P = .47) or 6 months (94% vs. 87.5%, P = .51). Patients on Impella 5.0 showed a significant recovery of hemodynamic parameters and end-organ function. Average duration of support to HTx was 16 ± 17 days. Impella 5.0, when used in suitable patients in a timely fashion can be a good strategy for bridging patients to HTx. The axillary approach allows for early extubation and mobilization. Outcomes of patients bridged to HTx with Impella 5.0 in acute cardiogenic shock are comparable to those of patients with no MCS.

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.

Transcatheter Aortic Valve Replacement versus Surgical Aortic Valve Replacement: A Review of Aortic Stenosis Management

Severe aortic stenosis (AS) affects 3.4% of the elderly over 60 years of age. It presents with exertional dyspnea, syncope, angina, and progression to irreversible congestive heart failure. Early intervention produces a better outcome in preventing the clinical deterioration of AS. The choice of intervention is transcatheter aortic valve implantation or surgical aortic valve replacement (SAVR). The decision should be made after evaluating an individual case based on its clinical features and the user’s experience with transcatheter aortic valve replacement (TAVR). We reviewed available data to illustrate the types of ASs, the background of interventions, current guidelines for TAVR, and its comparison with SAVR in terms of adverse effects.