Efficacy and Safety of Antegrade Common Femoral Artery Access Closure Using the Angio-Seal Device: Experience With 1889 Interventions for Critical Limb Ischemia in Diabetic Patients

Recanalization of superficial femoral artery chronic total occlusion through retrograde popliteal approach recanalization of superficial femoral artery chronic total occlusion

Purpose

This retrospective study aims to evaluate the safety, practicality, and efficacy of the independent retrograde popliteal approach for recanalization superficial femoral artery (SFA) occlusions when the bilateral common femoral artery approach is unavailable, such as after endovascular aneurysm repair or common iliac artery stenting.

Methods

This treatment was considered for patients with contralateral iliac artery occlusion, severe iliac tortuosity, or those who had previously undergone endovascular aneurysm repair or common iliac stenting. Patients with SFA lesions extending into the P1-P2 segment of the popliteal artery or with calcification in the P3 segment were excluded. Angioplasty and stenting were conducted via the popliteal artery approach, with hemostasis at the puncture site achieved using an EXOSEAL vascular closure device. Patients were routinely followed up at 3, 6, and 12 months, and annually thereafter.

Results

Forty-eight consecutive patients with SFA occlusion who underwent endovascular treatment via the retrograde popliteal artery approach were included in this study. Retrograde puncture of the popliteal artery was successful in all cases. Six-French sheaths were utilized in all procedures. The EXOSEAL vascular closure device was successfully applied in all 48 cases. No instances of pseudoaneurysms, arteriovenous fistulas, major bleeding, or embolic complications were observed. The technical success rate for SFA recanalization was 100 %. All patients experienced clinical improvement. The ankle-brachial index significantly increased from an initial 0.33 ± 0.11 at admission to 0.81 ± 0.19 at discharge (P < 0.001). The mean follow-up period was 25.1 ± 11.7 months. Kaplan-Meier analysis revealed primary patency rates of 82.5 % at 12 months and 71.8 % at 24 months. No patients required major amputation during the follow-up period.

Conclusion

The endovascular treatment of SFA occlusions via the independent retrograde popliteal approach is a viable alternative, demonstrating a low incidence of puncture-related complications and a high success rate of recanalization.

The Utility of Ultrasound Guidance to Improve the Safety of Closure of Antegrade Common Femoral Artery Access after Lower Limb Revascularization

This study aimed to investigate the feasibility of ultrasound (US)-guidance in reducing adverse event (AE) rates when using Angioseal device during antegrade lower limb angioplasty via common femoral artery access. From December 2016 to November 2022, 1,322 patients were identified, including 1,131 (85.6%) patients who underwent US-guided closure and 191 (14.4%) who underwent non-US-guided closure. Moderate AEs were encountered in 10 (5.2%) patients in the non-US-guided closure group compared to 38 (3.4%) patients in the US-guided closure group (P = .208). Severe AEs were encountered in 4 (2.1%) patients in the non-US-guided closure group compared to 3 (0.3%) patients in the US-guided closure group (P = .010). Overall AEs occurred in 14 (7.3%) patients in the non-US-guided closure group compared to 41 (3.6%) patients in the US-guided closure group (P = .029). Binary logistic regression showed that only non-US guidance was an independent risk factor for the occurrence of severe AEs (P = .008).

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.

Safety and efficacy of the Mynx Control vascular closure device in peripheral arterial procedures: A prospective study

OBJECTIVES

This article aims to present a prospective study investigating the safety and efficacy of the Mynx Control extravascular closure device (Cordis Corporation, FL, USA), for femoral arterial closure in patients undergoing peripheral arterial procedures.

METHODS

Between January 2020 and February 2021, 100 Mynx Control devices were deployed in 91 consecutive patients (mean age: 67.5 ± 16.9 years) who underwent peripheral arterial procedures. We used ultrasound and/or fluoroscopy during Mynx Control deployment and ultrasound post-procedure to detect complications. Femoral artery punctures included 62 (62%) antegrade and 38 (38%) retrograde punctures. The mean activated clotting time at time of device deployment was 221s. The primary endpoints were technical success, device failure, and complication rates up to 30 days.

RESULTS

A 5F vascular sheath was used in 43 cases (43%) (36 (36%) 6F and 21 (21%) 7F). The majority of our cases had antegrade access (62%). Overall technical success rate was 97% in both antegrade and retrograde cases. In total, there were 4 minor complications: 3 (3%) cases of pseudoaneurysm and 1 (1%) case of haematoma. No major complications were recorded post-procedure or 30 days post index procedure.

CONCLUSION

The Mynx Control vascular closure device is safe and effective in achieving haemostasis in patients undergoing antegrade and retrograde peripheral angioplasty procedures.

The modified interventional method of antegrade common femoral artery access closure using the Angio-Seal device: modified Angio-Seal haemostasis technique: Modified Angio-Seal haemostasis technique

AIMS

Antegrade femoral puncture is frequently performed in endovascular therapy, with haemostasis achieved through manual compression. The aim of this paper is to report the novel method of achieving haemostasis using the Angio-Seal device for antegrade punctures of the femoral artery.

METHODS AND RESULTS

Between September 2017 and March 2018, a total of 50 consecutive patients who underwent endovascular therapies (EVT) through the common femoral artery with an antegrade puncture using a 6 Fr introducer sheath were retrospectively analysed. After EVT, all patients received a 6 Fr Angio-Seal STS Plus Vascular Closure Device. All procedures were performed using the following new technique. First, we inserted the Angio-Seal guidewire from the inserted EVT sheath into the artery. Second, we removed the EVT sheath and inserted the Angio-Seal sheath and then removed the dilator and Angio-Seal guidewire. Under angiography using an 18 G needle sheath, we pulled back the Angio-Seal sheath as near to the insertion site of the vessel as possible. Finally, a collagen sponge and plug were inserted as per the standard technique. In all patients, the Angio-Seal was successfully deployed, and haemostasis was achieved within several minutes. No major complications occurred.

CONCLUSIONS

We demonstrated the feasibility and efficacy of achieving haemostasis using the Angio-Seal device in an antegrade femoral puncture using the novel method.

TRIACCESS Study: Randomized Comparison Between Radial, Femoral, and Pedal Access for Percutaneous Femoro-popliteal Artery Angioplasty

BACKGROUND

The aim of this randomized study was to compare the success and complication rates of different access sites for the treatment of superficial artery stenosis.

METHODS AND RESULTS

A total of 180 consecutive patients were randomized in a prospective study to treat symptomatic superficial femoral artery stenosis via radial (RA), femoral (FA), or pedal artery (PA) access. Technical success was achieved in 96.7%, 100%, and 100% of the patients in the RA, FA, and PA groups, respectively (p=0.33). Secondary access sites were used in 30%, 3.3%, and 30% of the patients in the RA, FA, and PA access groups, respectively (p=0.0002). Recanalization for chronic total occlusion was performed in 34/36 (94.4%), 30/30 (100%), and 46/46 (100%) patients in the RA, FA, and PA groups, respectively (p=0.17). The X-ray dose was significantly lower in the PA group than that in the RA and FA access groups (63.1 vs 162 vs 153 Dyn, p=0.0004). The cumulative rates of access site complications in the RA, FA, and PA groups were 3.3% (0% major and 3.3% minor), 16.7% (3.3% major and 13.3% minor), and 3.3% (3.3% major and 0% minor) (p=0.0085), respectively. The cumulative incidence of MACEs at 6 months in the RA, FA, and PA groups was 5%, 6.7%, and 1.7%, respectively. The cumulative incidence of MALEs at 6 months in the RA, FA, and PA groups was 20%, 16.7%, and 9.2%, respectively (p=0.54).

CONCLUSION

Femoral artery intervention can be safely and effectively performed using radial, femoral, and pedal access, but radial and pedal access is associated with a lower access site complication rate and hospitalization. Pedal access is associated with a lower X-ray dose than that with radial and femoral access.

Complication rates associated with antegrade use of vascular closure devices: a systematic review and pooled analysis

BACKGROUND

Vascular closure devices (VCDs) have become a mainstay in endovascular interventions in recent years. On-label use only allows for retrograde interventions originating at the common femoral artery (CFA). However, off-label use in antegrade and/or superficial femoral artery (SFA) access has become more common in the treatment of peripheral arterial disease. Despite this, there is a paucity of comparative literature assessing individual VCD safety profiles and relative complication risks of CFA vs SFA applications.

METHODS

MEDLINE and EMBASE systematic searches were performed from inception to October 2019 to identify studies assessing VCD use in antegrade CFA and SFA interventions. Abstract selection and data extraction were performed by two independent reviewers. Primary outcomes included bleeding-related complications, vessel occlusion or stenosis, embolization, pseudoaneurysm formation, or arteriovenous fistula formation.

RESULTS

Twenty-four unique studies with 4124 vascular closure events via six unique VCDs were included (Angioseal, Exoseal, Femoseal, Glubran 2, Mynx, Starclose; 3698 CFA, 426 SFA). Pooled occurrence of all complications across closure devices used in the CFA and SFA ranged from 0.9% (Mynx) to 7.4% (Starclose) and 0% (Perclose) to 10.1% (Starclose), respectively, depending on VCD type. Clinically meaningful differences were identified between devices with a trend toward significance (P = .08 CFA, P = .07 SFA). Individual devices demonstrated a range of bleeding complication rates from 0.4% (Mynx) to 7.2% (Femoseal) for the CFA site and from 0% (Perclose) to 6.4% (Starclose) for the SFA site (P = .01 and P = .03, respectively). Significant heterogeneity between studies precludes definitive characterization of the device as cause for variations in bleeding complication rates. Pooled complication rates did not differ between the CFA and SFA arms (4.6% vs 5.8%, P = .56). Bleeding complication rates also did not differ between the CFA and SFA arms (3.6% vs 3.6%, P = .98).

CONCLUSIONS

Clinically meaningful differences in overall pooled complications were identified between VCDs with a trend toward significance. Significant differences between VCDs exist with respect to bleeding risk. However, this must be interpreted with caution as these differences could be secondary to interstudy heterogeneity. Finally, no difference was identified between antegrade SFA and CFA VCD use with respect to overall complication and bleeding risks.

Safety and Efficacy of Arterial Closure Devices Following Antegrade Femoral Access: A Case–Control Study

Purpose:

Vascular closure device (VCD) use following antegrade femoral access may present unique challenges relative to retrograde access. We retrospectively compared safety and efficacy of these devices between antegrade and retrograde patient cohorts undergoing percutaneous intervention.

Materials and Methods:

Over a 5-year period, a consecutive series of 107 limbs in 84 patients underwent VCD arteriotomy closure following percutaneous revascularization using an antegrade approach (VCD-A). Device deployment success rates, time to ambulation, and complication rates were compared to a contemporaneous control group of 401 limbs in 305 patients who underwent closure following retrograde access (VCD-R) during revascularization or embolization procedures.

Results:

Closure was attempted in VCD-A using 53 StarClose, 35 Perclose, and 19 Angio-Seal devices. Hemostasis (without supplemental manual compression) was achieved in 86/107 (80.4%) limbs. Closure was attempted in VCD-R using 215 StarClose, 119 Perclose, and 67 Angio-Seal devices with hemostasis in 357/401 (89.0%) limbs. Device deployment failure occurred in 7/107 (6.5%) of VCD-A and 20/401 (5.0%) of VCD-R ( P = .52), independent of specific device type. Femoral pseudoaneurysm developed in 1/107 and 1/401 of VCD-A and VCD-R ( P = .31), and minor hematoma developed in 3/107 and 8/401 of the VCD-A and VCD-R ( P = .61). Mean time to ambulation was 204.1 minutes in VCD-A and 204.8 minutes in VCD-R ( P = .97).

Conclusion:

Antegrade femoral closure was associated with high rates of technical success and low complications, similar to retrograde closure. Time to ambulation was the same in both groups despite higher heparin doses in the antegrade patients.

Antegrade common femoral artery closure device use is associated with decreased complications

OBJECTIVE

Antegrade femoral artery access is often used for ipsilateral infrainguinal peripheral vascular intervention. However, the use of closure devices (CD) for antegrade access (AA) is still considered outside the instructions for use for most devices. We hypothesized that CD use for antegrade femoral access would not be associated with an increased odds of access site complications.

METHODS

The Vascular Quality Initiative was queried from 2010 to 2019 for infrainguinal peripheral vascular interventions performed via femoral AA. Patients who had a cutdown or multiple access sites were excluded. Cases were then stratified into whether a CD was used or not. Hierarchical multivariable logistic regressions controlling for hospital-level variation were used to examine the independent association between CD use and access site complications. A sensitivity analysis using coarsened exact matching was performed using factors different between treatment groups to reduce imbalance between the groups.

RESULTS

Overall, 11,562 cases were identified and 5693 (49.2%) used a CD. Patients treated with a CD were less likely to be white (74.1% vs 75.2%), have coronary artery disease (29.7% vs 33.4%), use aspirin (68.7% vs 72.4%), and have heparin reversal with protamine (15.5% vs 25.6%; all P < .05). CD patients were more likely to be obese (31.6% vs 27.0%), have an elective operation (82.6% vs 80.1%), ultrasound-guided access (75.5% vs 60.6%), and a larger access sheath (6.0 ± 1.0 F vs 5.5 ± 1.0 F; P < .05 for all). CD cases were less likely to develop any access site hematoma (2.55% vs 3.53%; P < .01) or a hematoma requiring reintervention (0.63% vs 1.26%; P < .01) and had no difference in access site stenosis or occlusion (0.30% vs 0.22%; P = .47) compared with no CD. On multivariable analysis, CD cases had significantly decreased odds of developing any access site hematoma (odds ratio, 0.75; 95% confidence interval, 0.59-0.95) and a hematoma requiring intervention (odds ratio, 0.56; 95% confidence interval, 0.38-0.81). A sensitivity analysis after coarsened exact matching confirmed these findings.

CONCLUSIONS

In this nationally representative sample, CD use for AA was associated with a lower odds of hematoma in selected patients. Extending the instructions for use indications for CDs to include femoral AA may decrease the incidence of access site complications, patient exposure to reintervention, and costs to the health care system.

The FREEDOM Study: A Pilot Study Examining the Feasibility and Safety of Early Walking following Femoral Manual Compression after Endovascular Interventions Using 5F Sheath-Compatible Devices

BACKGROUND

Increasing prevalence of peripheral arterial disease (PAD) burning and pressure to reduce costs and promote patient empowerment make outpatient endovascular procedures an attractive alternative to conventional hospitalization. For outpatient peripheral endovascular procedures, femoral manual compression could replace the use of arterial closure devices for small-bore punctures. Presently, safety and feasibility evidence for femoral manual compression is still lacking. FREEDOM is a pilot study designed to demonstrate the feasibility and safety of early walking after femoral manual puncture point compression following a therapeutic endovascular procedure for PAD.

METHODS

From May to August 2015, all patients requiring endovascular treatment for PAD were prospectively screened. Those patients that received therapeutic endovascular procedures involving retrograde femoral punctures with a 5F sheath were included. Manual compression and pressure dressing of the femoral puncture points was applied. The primary end point was defined as the walking ability 5 hr after index procedure (H5), which was assessed by a walk test.

RESULTS

In total, 129 consecutive patients were screened, and 30 patients met the study criteria. The mean age was 66 ± 11 years. The mean duration of the procedure and of the manual compression was 63 ± 24 min and 12.8 ± 4 min, respectively. At 5 hr following the procedure, 97% of the patients were able to walk 100 m. Two patients failed to walk due to cardiac arrhythmia and to a false aneurysm at the femoral puncture site. No further complications were observed at 1 month, and quality of life assessed by EQ-5D test was significantly increased compare to baseline (72.3 vs. 60.4; P = 0.001).

CONCLUSIONS

This pilot study demonstrated the benefits of manual compression to close arterial punctures over procedures using 5F shealth-compatible endovascular devices. A sufficiently powered randomized controlled trial is needed to further characterize the potential benefits of manual compression following use of low-profile devices.

Haemostasis with the FISH Vascular Closure Device after 6 French Transfemoral Accesses in Interventional Radiology: Clinical Results

INTRODUCTION

Endovascular procedures have increased for different indications over the recent years. To achieve a safe haemostasis after arterial puncture and for more comfort for the patients different vascular closure devices have been developed.

AIM

To evaluate the effectiveness and safety of a percutaneous closure system based on a matrix patch for achieving haemostasis.

MATERIALS AND METHODS

In this study from 2014 to 2015 a percutaneous vascular closure system Femoral Introducer Sheath and Haemostasis (FISH) was used in 54 patients (mean age 69.0±10.7 years), in an antegrade and retrograde technique within the context of an angiographic intervention. The system was used in conjunction with transfemoral approaches with a sheath size of 6F. Postinterventionally (on the following day and after 6 weeks), follow-up was conducted clinically and using colour coded ultrasound.

RESULTS

Immediate haemostasis was achieved in 50/54 patients (92.6 %). In 4 cases, an immediate haemostasis was not achieved. In these cases, manual compression was successful. There was one major complication, a retroperitoneal bleeding requiring transfusion. Minor complications were not observed.

CONCLUSION

Safe and effective haemostasis is possible with the percutaneous FISH closure system at puncture sizes of 6 F. An immediate re-puncture after using FISH is possible.

Comparison of a collagen plug arterial closure device with manual compression after endovascular interventions for peripheral artery disease

OBJECTIVE

Arterial closure devices (ACDs) seem to be safe and effective to obtain hemostasis for cardiac interventions and diagnostic vascular procedures. However, only limited evidence is presented on therapeutic interventions in patients with peripheral atherosclerotic disease. We compared ischemic and hemorrhagic complications of an ACD vs manual compression (MC) after puncture of the femoral artery for endovascular lower extremity procedures.

METHODS

The records of all subsequent endovascular interventions for peripheral artery disease performed in a large teaching hospital, from January 2012 to April 2014, were retrospectively reviewed. The primary outcome was an ischemic complication requiring reintervention. Secondary outcomes were hematoma (needing conservative or invasive intervention) and infection (needing intervention or antibiotics). Multivariate analysis was performed to identify predictors for any complication.

RESULTS

The Angio-Seal (St. Jude Medical, Minnetonka, Minn) closure device was used in 244 of 463 endovascular interventions (54%). Five patients (2%) who received an ACD needed emergency surgery for ischemic complications vs none in the MC group (P = .06). Hematomas occurred in 22 patients (9%) after ACD vs in six (3%) after MC (adjusted odds ratio [OR], 3.4; 95% confidence interval [CI], 1.4-8.9; P = .015). There were no infections in either group. ACD (OR, 3.8; 95% CI, 1.5-9.7) and current smoking (OR, 2.6; 95% CI, 1.01-6.7) were independent predictors for any complication.

CONCLUSIONS

This study demonstrates that ACD use in patients with peripheral artery disease can lead to serious adverse events resulting in increased morbidity. Therefore, the potential benefits of an ACD over MC should be carefully weighed.

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.

Exoseal for puncture site closure after antegrade procedures in peripheral arterial disease patients

PURPOSE

Exoseal is a vascular clo-sure device consisting of a plug applier and a bio-absorbent polyglycolic acid plug available in sizes 5 F, 6 F, and 7 F. In this study, we aimed to evaluate the effectiveness and safety of the Exoseal vascular closure device (Cordis Corporation, Bridgewater, New Jersey, USA) for puncture site closure after antegrade endovascular procedures in peripheral arterial occlusive disease (PAOD) patients.

MATERIALS AND METHODS

In this retrospective study, a total of 168 consecutive patients who underwent an interventional procedure due to PAOD, were included. In each case, an antegrade peripheral endovascular procedure was performed via the common femoral artery using the Seldinger technique, and Exoseal 5 F, 6 F, or 7 F was used for access site closure. The primary endpoint was a technically successful application of Exoseal. All complications at the access site within 24 hours were registered as a secondary endpoint.

RESULTS

In a group of 168 patients (64.9% men, average age 71.9±11.9 years), the technical application of Exoseal was successful in 166 patients (98.8%). Within the first 24 hours after the procedure, 12 complications (7.2%) were recorded including, three pseudoaneurysms (1.8%) and nine hematomas (5.4%). None of the complications required surgical intervention.

CONCLUSION

Exoseal is a safe and effective device with high technical success and acceptable complication rates for access site closure after antegrade peripheral endovascular procedures.

A novel technique to retrieve a maldeployed vascular closure device

PURPOSE

To report a novel technique for endovascular retrieval of a maldeployed vascular closure device, obviating the need for a femoral cutdown.

TECHNIQUE

To remove a 6-F Angio-Seal device that embolized to the superficial femoral artery, the contralateral common femoral artery was accessed, and an 8-F, 65-cm-long sheath was inserted just proximal to the embolus. A second semistiff 0.035-inch buddy wire was advanced past the lesion along the sheath. A 0.014-inch wire was advanced past the embolus, and a SpiderFX embolic protection device was deployed 1 cm past the embolized Angio-Seal device. The sheath was advanced so as to push the embolus into the filter. The sheath and the filter containing the Angio-Seal device were then removed.

CONCLUSION

Endovascular retrieval of an embolized Angio-Seal device can be done using an embolic filter device, restoring arterial flow to the limb.

Access and hemostasis: femoral and popliteal approaches and closure devices-why, what, when, and how?

This article reviews the arterial access sites used in the treatment of peripheral arterial disease, including common femoral, superficial femoral, and popliteal arterial puncture. The optimal approach and techniques for arterial puncture will be described and technical tips and tricks will be discussed. An overview of the currently available vascular closure devices will also be presented. Indications, contraindications, and complications will be discussed. Results of the use of vascular closure devices compared with manual compression will be presented.

Efficacy and time-to-hemostasis of antegrade femoral access closure using the ExoSeal vascular closure device: a retrospective single-center study

OBJECTIVE

To retrospectively evaluate the efficacy and time-to-hemostasis of antegrade femoral access closure using the ExoSeal vascular closure device (VCD).

DESIGN

Retrospective, single-center analysis.

MATERIALS AND METHODS

Between September 2010 and February 2013, 148 ExoSeal VCD closures (5-7F) of antegrade femoral accesses were performed in 119 patients (70 males, mean age 71.6 years, range 40-97 years). In all cases initial diagnostic angiography was performed via an 18G/3.8F retrograde femoral access, which was left in place during intervention (in-house standard) and was used to obtain control angiography after successful closure of the antegrade access to determine hemostasis. Technical device success was defined as ExoSeal closure without major VCD-related complications; procedural success as hemostasis within 5 minutes. Statistical analysis was performed using a logistic regression model and correlation analyses.

RESULTS

145/148 (98.0%) ExoSeal closures were technically successful (5F: n = 76; 6F: n = 65; 7F: n = 7). Angiographic control showed closure after 2 minutes in 130/145 cases. In a further 14 cases hemostasis was achieved after an additional 3 minutes MC, so that closure was successful within 5 minutes in 144/148 cases (97.3%). No major complication occurred. One minor complication was recorded in a 6F access case. Pre-interventional activated partial thromboplastin time (aPTT) was the only statistically significant predictor of necessary manual compression (MC) > 2 minutes (p = .01), but with an odds-ratio of only 1.038. The INR showed an odds-ratio of 2.455 for need for 5 minutes MC (NS). Significant correlations were found between the need for 5 minutes MC and medication with acetylsalicylic acid (p = .01), clopidogrel (p < .01), and abciximab (p < .001).

CONCLUSION

ExoSeal vascular closure of antegrade femoral punctures is safe and effective with a low complication rate. Two minutes of MC are sufficient to achieve hemostasis in the majority of cases. However, in patients on antiplatelet therapy, especially after abciximab, the authors advocate prolonging MC to 5 minutes.

Feasibility of vascular access closure in arteries other than the common femoral artery using the ExoSeal vascular closure device

PURPOSE

To describe the feasibility of vascular access closure in arteries other than the common femoral artery (CFA) using the ExoSeal vascular closure device (VCD).

MATERIALS AND METHODS

Between December 2011 and August 2013, 8 patients (4 males, 4 females, mean age 64 years [range 42-81]) underwent 13 extrafemoral access site closure using the ExoSeal VCD (brachial artery n = 7, venous femoropopliteal bypass n = 3, femoropopliteal segment n = 2, proximal superficial femoral artery n = 1). Patient history, procedural characteristics, and complications were recorded.

RESULTS

Technical success was achieved in 12 of 13 VCD procedures. In 1 case of brachial puncture, safe plug-deployment was not possible, so manual compression was applied. In this case, angiographic and clinical control showed residual bleeding 5 min after the procedure. After additional manual compression for 5 min, the haemorrhage stopped, but a hematoma <3 cm was detectable (procedural success rate 12 of 13 closures). Overall no major complications were observed. Heparin, 5,000 IU, was administered in all cases. Six ExoSeal closures were performed under additional acetylsalicylic acid (ASS) and clopidogrel, three under additional ASS, and the remaining four under heparin only. International normalized ratio and thrombocytes were within normal values in all patients.

CONCLUSION

Successful vascular access closure using the ExoSeal VCD in puncture sites other than the CFA is feasible with a low complication rate. These applications, however, remain an "off-label" use in selected patients.

Lower extremity amputations in persons with and without diabetes in Italy: 2001-2010

Objective

To analyze hospitalization for lower extremity amputations (LEAs) and amputee rates in persons with and without diabetes in Italy.

Research Design and Methods

All patients with LEAs in the period 2001–2010 were identified analyzing the National Hospital Discharge Record database. For each year, amputee and hospitalization rates for LEAs were calculated either for persons with diabetes or without. Time trend for major and minor amputations were analysed.

Results

From 2001 to 2010 a mean annual number of 11,639 individuals underwent a lower extremity amputation: 58.6% had diabetes accounting for 60.7% of total hospitalizations. In 2010, the crude amputee rate for LEAs was 20.4 per 100,000 inhabitants: 247.2 for 100.000 persons with diabetes, and 8.6 for those without diabetes. Having diabetes was associated to an increased risk of amputation (Poisson estimated RR 10.9, 95%CI 9.4–12.8). Over the whole period, a progressive reduction of amputee rates was observed for major amputations either among persons with diabetes (−30.7%) or without diabetes (−12.5%), while the rates of minor amputations increased progressively (+22.4%) among people without diabetes and were nearly stable in people with diabetes (−4.6%). A greater number of minor amputations were performed among persons with than without diabetes: in 2010, the minor-to-major ratio among persons with diabetes (2.5) was more than twice than in those without diabetes (1.0).

Conclusions

The nationwide analyses confirm a progressive reduction of hospitalization and amputee rates for major LEAs, suggesting an earlier and more diffuse approach aimed at limb salvage.

Percutaneous Vascular Closure System Based on an Extravascular, Bioabsorbable Polyglycolic Plug (ExoSeal): Results from 1000 Patients

PURPOSE

The objective of this prospective study was to evaluate the effectiveness and safety of a percutaneous closure system based on a polyglycolic acid plug for achieving hemostasis.

MATERIAL AND METHODS

In this study from 2011 to 2014, a percutaneous vascular closure system (ExoSeal) was used in 1000 patients (mean age 70.6 ± 10.2 years), using antegrade and retrograde techniques within the context of an angiographic intervention. The system was used in conjunction with transfemoral approaches with a sheath size of 6F. Post the intervention (on the following day and after 6 weeks), follow-up was conducted clinically and using color-coded duplex ultrasound.

RESULTS

Immediate hemostasis was achieved in 939/1000 patients (93.9%). In the remaining 61 cases, a correct positioning of the polyglycolic acid plug was not possible because of malfunctioning of the device, massive vascular wall calcifications, postoperative scar tissue, or too steep a puncture angle. In these cases, manual compression was successful. There was one retroperitoneal bleeding requiring transfusion. Minor complications were observed (7.4% in total) with 10 pseudoaneurysm (1%), 63 inguinal hematomas (up to 3 cm; 6.3%), and 1 stenosis (0.1%).

CONCLUSION

Safe and effective hemostasis is possible with the percutaneous ExoSeal closure system at puncture sizes of 6F.

[Arterial closure devices. What device for which clinical situation?]

CLINICAL/METHODICAL ISSUE

Access site complications after endovascular catheterization sometimes require open surgery and negatively impair safety, patient comfort and reimbursement. Increasing numbers of procedures and patients with multiple anticoagulants as well as cost pressure explain the demand for an immediate and stable access site closure.

STANDARD RADIOLOGICAL METHODS

Manual compression followed by compression bandage and bed rest for 4-24 h is still the gold standard but is unable to prevent access site complications in all cases.

METHODICAL INNOVATIONS

Arterial vascular closure devices allow immediate and stable closure of the puncture channel either by suture or by implantation of occluding foreign bodies or gluing fluids.

PERFORMANCE

The safety has been proven in several clinical trials. The main advantage lies in closing large lumen access sites without surgery and in patients treated with multiple anticoagulants as well as in outpatient procedures.

ACHIEVEMENTS

They have become a valuable supplement to the interventional arsenal.

PRACTICAL RECOMMENDATIONS

The physician, however, has to decide between different systems and mechanisms with respect to patient constitution, selected access vessel and level of calcification and diameter. Furthermore, all systems require a defined training prior the first use.

Evaluation of the 6-F ExoSeal vascular closure device in antegrade femoral artery punctures

PURPOSE

To evaluate the safety, comfort, and efficacy of an extravascularly deployed bioabsorbable plug-based vascular closure device (VCD) for sealing 6-F antegrade access sites in patients requiring peripheral endovascular intervention.

METHODS

A single-center, single-arm, prospective study to evaluate the 6-F ExoSeal VCD in terms of technical success, adverse events, and patient comfort enrolled 59 unselected symptomatic patients (42 men; mean age 72.1 ± 9.3 years) suffering from peripheral artery disease in an 11-month period. Patients with high body mass index (BMI) or calcification at the access site were not excluded. Calcifications of the access vessel were scored as grades 1-4 from fluoroscopic images. The pain level during implantation was evaluated after the procedure using a visual rating scale.

RESULTS

Technical success rate was 98.3%; 1 primary device failure was converted to manual compression. In addition, 1 (1.7%) pseudoaneurysm, 2 (3.4%) minor hematomas, and 1 (1.7%) minor secondary bleeding were observed. There was no intravascular application of the device detected. Neither BMI, calcification of the access vessel (present in 74.6%, mean score 1.4 ± 1.1), age, nor blood clotting had any statistically significant influence on adverse events. In total, 55 (93.2%) patients felt no pain during the VCD implantation.

CONCLUSION

The tested VCD was safe, with an excellent technical success rate even in cases with severe access vessel calcification.

Basic data underlying clinical decision making in vascular surgery: arterial access for percutaneous procedures

Percutaneous arterial access has become a mainstay in the armamentarium of vascular specialists. Vascular surgeons for decades have managed iatrogenic complications sustained by other specialists and now are more frequently performing catheter-based procedures themselves. A thorough understanding of the basic data underlying complications related to these procedures is imperative and is thoroughly reviewed.

Suitability of Exoseal vascular closure device for antegrade femoral artery puncture site closure

PURPOSE

To assess the efficacy and safety of the Exoseal vascular closure device for antegrade puncture of the femoral artery.

METHODS

In a prospective study from February 2011 to January 2012, a total of 93 consecutive patients received a total of 100 interventional procedures via an antegrade puncture of the femoral artery. An Exoseal vascular closure device (6F) was used for closure in all cases. Puncture technique, duration of manual compression, and use of compression bandages were documented. All patients were monitored by vascular ultrasound and color-coded duplex sonography of their respective femoral artery puncture site within 12 to 36 h after angiography to check for vascular complications.

RESULTS

In 100 antegrade interventional procedures, the Exoseal vascular closure device was applied successfully for closure of the femoral artery puncture site in 96 cases (96 of 100, 96.0 %). The vascular closure device could not be deployed in one case as a result of kinking of the vascular sheath introducer and in three cases because the bioabsorbable plug was not properly delivered to the extravascular space adjacent to the arterial puncture site, but instead fully removed with the delivery system (4.0 %). Twelve to 36 h after the procedure, vascular ultrasound revealed no complications at the femoral artery puncture site in 93 cases (93.0 %). Minor vascular complications were found in seven cases (7.0 %), with four cases (4.0 %) of pseudoaneurysm and three cases (3.0 %) of significant late bleeding, none of which required surgery.

CONCLUSION

The Exoseal vascular closure device was safely used for antegrade puncture of the femoral artery, with a high rate of procedural success (96.0 %), a low rate of minor vascular complications (7.0 %), and no major adverse events.

Complications Related to Femoral Artery Access for Transcatheter Procedures

Percutaneous-based procedures continue to increase as endovascular techniques improve and provide a less morbid approach than the open vascular procedures. The most common complications associated with either cardiac interventions or peripheral interventions involve the access point of the procedure. The retrograde femoral access has and is currently the most frequently used arterial access. Vascular surgeons have been responsible for management of complications following femoral-based procedures and now are a significant contributor to catheter-based diagnostic and interventional procedures. This review provides in-depth review of the literature on specific complications encountered during percutaneous femoral artery puncture. This review includes access complications related to the method of obtaining access (ie, best pulse fluoroscopic guided), direction of access either retrograde or antegrade, risk factors and incidence of complications based on best literature sources, and management strategies for specific complications.

Delayed complication from a percutaneous vascular closure device following a neuro-interventional procedure

Percutaneous vascular closure devices are being increasingly used as alternatives to manual compression for the closure of femoral arteriotomy after endovascular procedures as they appear to reduce time to ambulate, improve patient's comfort, and are implicated with cost saving. However, vascular closure devices have been associated with an increased risk of complications including hematoma formation, local bleeding, arteriovenous fistula formation, pseudoaneurysm and arterial leg ischemia. To our knowledge, if the above complications occur it is usually within the first 30 days after the procedure. None have been reported in a delayed fashion ten months or longer after closure. We describe a 30-year-old man with a history of a giant basilar trunk aneurysm. He was placed on aspirin and clopidogrel prior to the procedure. He had bilateral femoral access with 6 French sheaths. Following the procedure, 6 French Angio-Seals (St. Jude Medical, St. Paul, MN, USA) were used for closure of bilateral femoral arteriotomies. Ten months after the procedure, the patient kicked a metal cart and developed a large right retroperitoneal iliopsoas hematoma. There was no evidence of pseudoaneurysm. The patient was managed conservatively and his serial hematocrit stayed stable. He did not require surgical intervention. Use of percutaneous vascular closure devices is associated with complications including risk of hematoma, pseudoaneurysm, intravenous fistula, rectal peritoneal hemorrhage, limb ischemia and possible surgical repair. Most complications occur peri-procedure or within 30 days post-procedure. This is the first reported case of a delayed complication at ten months after the initial procedure. Site-related complications associated with percutaneous vascular closure devices may occur in a delayed fashion, even ten months post-procedure, so should be considered in the management of patients.