Histologic and duplex comparison of the perclose and angio-seal percutaneous closure devices

Percutaneous Ultrasound-Guided Carotid Access and Puncture Closure with Angio-Seal in Horses

Simple Summary

Endovascular surgery is a type of image-guided minimally invasive surgery that aims to solve different types of pathologies from inside the blood vessel. This technique requires access to a peripheral vessel (vein or artery) and the navigation through the vascular system to reach the operating site, using different catheters. In horses, the main indication for endovascular therapy involves access to the common carotid artery for different purposes. Traditionally, this was performed by open dissection of the neck to reach and incise the common carotid artery, followed by vascular suture of the vessel and skin closure when the procedure was over. However, this can also be performed by percutaneous puncture of the artery, using ultrasound to guide the needle to its adequate position in the artery, as has been reported in experimental horses. Along with that, in human medicine, commercial closure systems are used to seal these arterial punctures and avoid some complications (mainly haematomas and haemorrhages). We describe our experience in a series of 11 clinical cases in which this minimally invasive way of access was used, and the puncture site was sealed with one of these devices (AngioSeal arterial closure system), reporting its first use in horses. In all cases, the artery was effectively accessed, and the planned procedure could be performed. Our haematoma/bleeding rate (16.66%) was lower than in other studies using the same type of access, even considering two failures due to incorrect use of the device. However, further studies comparing AngioSeal use to simple manual compression would be necessary to be able to recommend their routine use in horses.

Abstract

Background: There are different indications for endovascular surgery in horses, mainly the treatment of guttural pouch mycosis. Traditionally, these procedures are carried out by open arteriotomy of the common carotid artery (CCA), although less invasive percutaneous ultrasound-guided carotid access (PUGCA) has been described in experimental horses. In human medicine, commercial closure systems are used to seal these arterial puncture sites and reduce complications. The aims of this study are to retrospectively describe our experience with PUGCA in clinical cases and to report, for the first time, the use of the commercial vascular closure device Angio-Seal after PUGCA in horses. Methods: Retrospective study of clinical case records. Collected parameters, including the feasibility of the PUGCA and variables related to the safety and efficacy of the use of the Angio-Seal. Results: Twelve PUGCA procedures in 11 horses were included. In all cases, the artery was effectively accessed, and the planned procedure could be performed. In two cases, haematoma/bleeding due to incorrect use of the Angio-Seal was recorded. This complication rate (16.66%) was lower than that obtained in other studies using PUGCA in horses, but where the puncture was sealed by manual compression only. Main limitations: A control group of clinical cases with PUGCA but without using Angio-Seal is not available. Conclusions: Clinical data confirm previous experimental results, which showed that PUGCA is safe and effective in horses. The Angio-Seal system, regardless of possible complications due to incorrect use, can be used safely and effectively in horses. Further studies comparing arterial access site management using manual compression or Angio-Seal would be necessary to state if its routine use in horses is advisable.

Development, preclinical evaluation and validation of a novel quick vascular closure device for transluminal, cardiac and radiological arterial catheterization

Following percutaneous coronary intervention, vascular closure devices (VCDs) are increasingly used to reduce time to ambulation, enhance patient comfort, and reduce potential complications compared with traditional manual compression. Newer techniques include complicated, more or less automated suture devices, local application of pads or the use of metal clips and staples. These techniques often have the disadvantage of being time consuming, expensive or not efficient enough. The VCD failure rate in association with vascular complications of 2.0-9.5%, depending on the type of VCD, is still not acceptable. Therefore, the aim of this study is to develop a self-expanding quick vascular closure device (QVCD) made from a bioabsorbable elastic polymer that can be easily applied through the placed introducer sheath. Bioabsorbable block-co-polymers were synthesized and the chemical and mechanical degradation were determined by in vitro tests. The best fitting polymer was selected for further investigation and for microinjection moulding. After comprehensive haemocompatibility analyses in vitro, QVCDs were implanted in arterial vessels following arteriotomy for different time points in sheep to investigate the healing process. The in vivo tests proved that the new QVCD can be safely placed in the arteriotomy hole through the existing sheath instantly sealing the vessel. The degradation time of 14 days found in vitro was sufficient for vessel healing. After 4 weeks, the remaining QVCD material was covered by neointima. Overall, our experiments showed the safety and feasibility of applying this novel QVCD through an existing arterial sheath and hence encourage future work with larger calibers.

Thermic sealing in femoral catheterization: First experience with the Secure Device

BACKGROUND

Devices currently used to achieve hemostasis of the femoral artery following percutaneous cardiac catheterization are associated with vascular complications and remnants of artificial materials are retained at the puncture site. The Secure arterial closure Device induces hemostasis by utilizing thermal energy, which causes collagen shrinking and swelling. In comparison to established devices, it has the advantage of leaving no foreign material in the body following closing. This study was designed to evaluate the efficacy and safety of the Secure Device to close the puncture site following percutaneous cardiac catheterization.

METHODS

The Secure Device was evaluated in a prospective non-randomized single-center trial with patients undergoing 6 F invasive cardiac procedures. A total of 67 patients were enrolled and the device was utilized in 63 patients. Fifty diagnostic and 13 interventional cases were evaluated. Femoral artery puncture closure was performed immediately after completion of the procedure. Time to hemostasis (TTH), time to ambulation (TTA) and data regarding short-term and 30-day clinical follow-up were recorded.

RESULTS

Mean TTH was 4:30 ± 2:15 min in the overall observational group. A subpopulation of patients receiving anticoagulants had a TTH of 4:53 ± 1:43 min. There were two access site complications (hematoma > 5 cm). No major adverse events were identified during hospitalization or at the 30 day follow-up.

CONCLUSIONS

The new Secure Device demonstrates that it is feasible in diagnostic and interventional cardiac catheterization. With respect to safety, the Secure Device was non-inferior to other closure devices as tested in the ISAR closure trial.

Use of a vascular closure device during percutaneous arterial access in a dog with impaired hemostasis

OBJECTIVE

To report the use of a vascular closure device (VCD) to provide rapid arterial hemostasis following percutaneous femoral arterial catheterization and diagnostic angiography in a thrombocytopenic and coagulopathic dog.

CASE SUMMARY

A 6-year-old female spayed Kai Ken Tora dog presented after vehicular trauma. The dog was diagnosed with traumatic pneumothorax, degloving wounds of the right antebrachium, subcutaneous hemorrhage within the axillary tissues of the left thoracic limb, and anemia and thrombocytopenia secondary to acute hemorrhage. Treatment included therapeutic thoracocentesis and open wound management of the right thoracic limb as well as packed RBC and fresh frozen plasma transfusions. Diagnostic angiography of the left brachial artery was performed via percutaneous femoral arterial access to investigate the source of a persistent axillary hematoma. The arterial access site was closed using an extraluminal VCD and hemostasis was immediate with normal femoral arterial blood flow documented by Doppler ultrasound.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes use of a VCD for arterial closure following percutaneous access in a dog with impaired hemostasis; to the authors' knowledge, this is the first clinical report of a VCD used in a veterinary species.

Long Term Outcome after Application of the Angio-Seal Vascular Closure Device in Minipigs

Minipigs are frequently used in (neuro-)interventional research. Longitudinal experiments may require repeated vessel access via the femoral artery. Anticoagulation and incompliance of the animals necessitates the use of a vascular closure device (VCD). The effects of the Angio-Seal VCD in minipigs were longitudinally assessed. Minipig (42±8.4 kg body weight) femoral arteries were sealed using the 8F (n = 6) or 6F (n = 7) Angio-Seal VCD. The pre-interventional femoral artery diameter was 5.1±0.4 mm (4.3–5.8 mm). Sealed puncture sites were analysed angiographically as well as by computed tomography angiography (CTA) for a mean period of 14.1±8.0 weeks (1–22 weeks). All animals were constantly treated with acetylsalicylic acid (ASS) (450 mg/d (n = 7) or 100 mg/d (n = 1)) and clopidogrel (75 mg/d (n = 8)). Non-instrumented (n = 2) and arteries sealed using the VCD (n = 2) were examined histologically. No postoperative hemorrhagic complications were observed. Three arteries were occluded after VCD placement (1 animal diagnosed after 4 weeks (8F), 2 animals after 1 week (6F)) and remained so until the end of the experiments after 22, 12 and 4 weeks, respectively. In one artery a 50% stenosis 8 weeks after application of a 6F Angio-Seal was detected. In 69.2% (n = 9) the VCD was applied without complications. Histopathological analysis of the sealed arterial segments showed subtotal obliteration of the vessel lumen, formation of collagenous tissue and partial damage of the internal elastic lamina. The Angio-Seal VCD prevents relevant hemorrhagic complications in minipigs treated with dual platelet inhibition, but is associated with increased vessel occlusion rates.

Chitosan hemostatic dressing for control of hemorrhage from femoral arterial puncture site in dogs

Removal of an introducer-sheath from a femoral artery after completing transarterial embolization of a patent ductus arteriosus can cause life-threatening hemorrhage in dogs. In the present study, the effectiveness of chitosan acetate dressing in 10 experimental dogs was tested. Under general anesthesia, an introducer-sheath was placed into the femoral artery with percutaneous puncture using Seldinger's technique. The outer diameter of the introducer-sheaths varied from 3.0 to 4.0 mm with an introducer/artery ratio of 80 to 123%. The artery's diameter was measured using ultrasonography. Following removal of the introducer-sheath, a chitosan acetate dressing was applied to the wound and held in place with manual compression for 10 min. Successful hemostasis was reached on 12 arteries. However, on two arteries, hemorrhage was uncontrollable and led to a hypovolemic shock during 10 min of manual compression. Possible causes of the negative outcome in two dogs were their old age and an introducer-sheath with a too large diameter. The chitosan acetate dressing was easy to use and the artery remained patent. Dogs could walk directly after recovery from anesthesia and their femoral arteries were saved. In conclusion, the outer diameter of the introducer-sheath should not exceed 3 mm or the inner diameter of the artery.

Clinical and Subclinical Femoral Vascular Complications after Deployment of two Different Vascular Closure Devices or Manual Compression in the Setting of Coronary Intervention

BACKGROUND

In the past two decades vascular closure devices (VCD) have been increasingly utilized as an alternative to manual compression after percutaneous femoral artery access. However, there is a lack of data confirming a significant reduction of vascular complication in a routine interventional setting. Systematic assessment of puncture sites with ultrasound was hardly performed.

METHODS

620 consecutive patients undergoing elective or urgent percutaneous coronary intervention were randomly allocated to either Angioseal (AS; n = 210), or Starclose (SC; n = 196) or manual compression (MC; n = 214). As an adjunct to clinical evaluation vascular ultrasonography was used to assess the safety of each hemostatic method in terms of major and minor vascular complications. The efficacy of VCDs was assessed by achievement of puncture site hemostasis.

RESULTS

No major complications needing transfusion or vascular surgery were observed. Furthermore, the overall incidence of clinical and subclinical minor complications was similar among the three groups. There was no differences in the occurrence of pseudoaneurysmata (AS = 10; SC = 6; MC = 10), arteriovenous fistula (AS = 1; SC = 4; MC = 2) and large hematoma (AS = 11; SC = 10; MC = 14). The choice of access site treatment had no impact in the duration of hospital stay (AS = 6.7; SC = 7.4; MS = 6.4 days).

CONCLUSIONS

In the setting of routine coronary intervention AS and SC provide a similar efficacy and safety as manual compression. Subclinical vascular injuries are rare and not related to VCD use.

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.

Long-term clinical outcomes after deployment of femoral vascular closure devices in coronary angiography and percutaneous coronary intervention: an observational single-centre registry follow-up

OBJECTIVES

There are few data evaluating the long-term effect of femoral vascular closure devices (FCDs) on patients' clinical outcome. We aim to evaluate the incidence of peripheral vascular disease (PVD) in patients who received FCD following its deployment in coronary angiography and percutaneous coronary intervention (PCI) procedures.

DESIGN AND SETTING

Observational study of a single-centre registry.

PARTICIPANTS

From June 2000 to September 2004, 265 patients who received FCD after coronary angiography and PCIs were enrolled on the study.

OUTCOME MEASURES

Clinical follow-up (using Rutherford's categories of claudication), ankle brachial index (ABI) and duplex ultrasound of femoral arteries (using the non-accessed side as control) were performed to evaluate the presence of PVD.

RESULTS

The mean follow-up interval was 3320±628 days. 1 patient (0.4%) suffered from grade 2 claudication and another (0.4%) suffered from grade 1 claudication. The mean ABIs of the accessed side and non-accessed side were 1.06±0.13 and 1.08±0.11, respectively (p=0.17). For duplex ultrasound, the mean common femoral artery peak systolic velocities of the accessed side and non-accessed side were 87.4±22.3 and 87.7±22.1 cm/s, respectively (p=0.73); the mean superficial femoral artery peak systolic velocities of the accessed side and non-accessed side were 81.4±20.1 and 81.31±17.8 cm/s, respectively (p=0.19).

CONCLUSIONS

The use of FCD after a coronary angiogram and PCI is safe and does not increase the long-term risk of PVD.

Long term clinical outcomes after deployment of femoral vascular closure devices in coronary angiography and percutaneous coronary intervention

BACKGROUND

We evaluated the long term clinical outcomes of femoral vascular closure devices following its deployment in coronary angiography and percutaneous coronary intervention (PCI) procedures.

METHODS

From June 2000 to September 2004, 265 patients who received femoral vascular closure devices after coronary angiography and PCIs were enrolled into the study. Patients' medical records were reviewed and vascular complications within 1 year of follow-up period were recorded. Rutherford's categories of claudication were used to quantify different degrees of claudication and leg ischaemia. Duplex ultrasonography of both femoral arteries (using the nonaccessed site as control) was performed at 1 year after deployment of vascular closure devices. Vessel diameter and flow velocities for both common femoral arteries were obtained.

RESULTS

There was no occurrence of late vascular complications like arteriovenous fistula, pseudoaneurysm, surgical repair of access site complications, late groin bleeding and infection. By Rutherford categories of claudication, 99.2% of patients had grade 0 claudication while the remaining 0.8% was in grade 1. By arterial Duplex ultrasonography, the peak systolic velocity of the accessed femoral artery (predominantly right side) was nonsignificantly higher, 94.9 + or - 26.0 cm/s when compared to 91.5 + or - 24.8 cm/s in the control site (P = 0.12). As for vessel diameter, no significant difference was found in the mean end-diastolic vessel diameter 8.8 + or - 1.3 mm (puncture site) versus 8.7 + or - 4.4 mm (control site) (P = 0.72).

CONCLUSION

We found that the use of femoral closure devices was safe and it was not associated with any adverse long term vascular complications.

Vascular closure device failure: frequency and implications: a propensity-matched analysis

BACKGROUND

Vascular closure devices (VCDs) are effective in reducing the time to ambulation for patients undergoing cardiac catheterization procedures and in reducing the risk of vascular complications in selected patient cohorts. However, the frequency and consequence of failure of VCDs is not well defined.

METHODS AND RESULTS

From a prospective registry of consecutive patients undergoing cardiac catheterization at our center, 9823 patients who received either a collagen plug-based (Angio-Seal) or a suture-based (Perclose) VCD were selected for the study. VCD failure was defined as unsuccessful deployment or failure to achieve hemostasis. Major vascular complication was defined as any retroperitoneal hemorrhage, limb ischemia, or any surgical repair. Minor vascular complication was defined as any groin bleeding, hematoma (> or = 5 cm), pseudoaneurysm, or arteriovenous fistula. Any vascular complication was defined as either a major or minor vascular complication. Among the 9823 patients in the study, VCD failed in 268 patients (2.7%; 2.3% diagnostic versus 3.0% percutaneous coronary intervention; P=0.029). Patients with VCD failure had significantly increased risk of any (6.7% versus 1.4%; P<0.0001), major (1.9% versus 0.6%; P=0.006), or minor (6.0% versus 1.1%; P<0.0001) vascular complication compared with the group with successful deployment of VCD. The increased risk of vascular complication was unchanged in a propensity score-matched cohort.

CONCLUSIONS

In contemporary practice, VCD failure is rare, but when it does fail, it is associated with a significant increase in the risk of vascular complications. Patients with VCD failure should be closely monitored.

Thrombus formation after percutaneous catheterization and manual compression of the femoral artery in heparinized sheep

The purpose of this study was to evaluate the angiographic and histopathologic changes in the superficial femoral artery (SFA) in heparinized sheep shortly after catheterization with an 8-Fr sheath and manual compression hemostasis either with standard manual compression (SMC) or with the use of a procoagulant chitosan-based HemCon Bandage. The evaluation was done in 38 SFAs of 19 heparinized (100 mg/kg) sheep. After a 5-min catheterization with an 8-Fr sheath, a 5-min compression was applied. Follow-up angiograms to evaluate hemostasis were done immediately after release of compression and then at 2.5-min intervals until no extravasation was present. Compression was reapplied between angiograms. Final angiograms were performed approximately 30 min after hemostasis and after 3 min of passive flexion and extension of sheep hind limbs. Sheep were then euthanized and SFA specimens with surrounding tissues excised for histopathologic evaluation. Both types of compression caused similar changes in the catheterized SFAs. Follow-up angiograms showed mild arterial narrowing in 14 SFAs and intraluminal clots in 9 SFAs. Histology revealed periarterial hematoma in all 38 specimens. Intraluminal thrombi consisting predominantly of platelets and fibrin were present in 32 SFAs. Their size varied from superficial elevations (8 arteries) to medium-sized, 1- to 2-mm, polypoid protrusions (15 arteries) to large polypoid clots, 3-4 mm long (9 arteries). In six SFAs, the arterial access sites were not included in the obtained specimens. In conclusion, hemostasis with manual compression is achieved in the acute phase by formation of a predominantly platelet-fibrin thrombus occluding the arterial wall access site and often extending significantly into the arterial lumen. The healing process of arterial access sites should be explored several days after catheterization.

Femoral vascular closure device: the surgical view

This case report describes the surgical findings of a percutaneous closure device, which was used after diagnostic coronary angiography. The features of the device are described. Surgeons should be familiar with the existence of these devices to avoid complications during vascular access procedures at the level of the common femoral artery.