Prospective comparison of angio-seal versus manual compression for hemostasis after neurointerventional procedures under systemic heparinization

Real-World Experience With the Angio-Seal Closure Device: Insights From Manufacturer and User Facility Device Experience Database

PURPOSE

Angio-Seal (Terumo Medical Corporations, Somerset, New Jersey) device is indicated for femoral arteriotomy closure. Real-world published data on complications are limited. We present 1 year of safety events involving Angio-Seal from the US Food and Drug Administration's post-market surveillance database of Manufacturer and User Facility Device Experience (MAUDE). Steps for managing frequent device-related problems are discussed.

MATERIALS AND METHODS

Angio-Seal MAUDE data from November 2019 to December 2020 was classified according to (1) mode of device failure, (2) complication, (3) treatment, and (4) Cardiovascular and Interventional Radiological Society of Europe (CIRSE) adverse event classification system.

RESULTS

There were 715 safety events, involving Angio-Seal VIP (93.1%), Evolution (5.7%), STS Plus (1.1%), and sizes 6F (62.5%) and 8F (37.5%). Failure mode involved unrecognized use of a damaged device (43.4%), failed deployment (20.1%), failed arterial advancement (6.3%), detachment of device component (4.9%), failed retraction (3.6%), operator error (1.1%), and indeterminate (20.6%). Of total, 44.8% of events were associated with patient harm. Complications involved minor blood loss (34.1%), hematoma (5.6%), significant blood loss (1.4%), and pseudoaneurysm (1.4%). Of total, 43.3% of cases required manual compression (MC), whereas 8.8% required more advanced intervention. Interventions included surgical repair (49.2%), thrombin injection (9.5%), balloon tamponade (6.3%), covered stent (4.8%), and unspecified (30.2%). Majority of safety events were CIRSE grade 1 (92.0%), followed by grades 2 (3.1%), 3 (4.6%), and 6 (deaths, 0.3%). Minority of devices were returned for manufacturer analysis (27.8%).

CONCLUSIONS

The majority of safety events were associated with minor blood loss or local hematoma and could be addressed with MC alone. Most events were attributed to damaged device; however, very few devices were returned to manufacturer for analysis. This should be encouraged to allow for root cause analysis in order to improve safety profile of devices. System-level strategies for addressing barriers to under-reporting of safety events may also be considered.

CLINICAL IMPACT

Our study highlights important safety events encountered in real-world practice with Angio-Seal closure device. The MAUDE database captures real-world device malfunctions not typically appreciated in conventional clinical trials. Our study provides valuable insight for clinician-users on anticipating and managing the most common device malfunctions. Additionally, our data provide feedback for manufactures to optimize product design and direct manufacturer user training to improve safety. Finally, we hope that the study promotes system-level strategies that foster reporting of safety events and undertaking of root cause analysis.

Supra-Aortic Arterial Injuries Following Central Venous Catheterization Managed with Percutaneous Closure Devices: A Comprehensive Literature Review of Current Evidence

BACKGROUND

Inadvertent supra-aortic arterial injuries during central venous catheterization can lead to devastating outcomes. These have been traditionally been managed with open repair or covered stent placement; only recently have percutaneous closure been incorporated into the management of these iatrogenic arterial injuries.

METHODS

We performed a MEDLINE literature search in the English language, using the PubMed web-based search engine across years 2000 to 2020. This report reviews 34 published case reports and series reporting 71 iatrogenic supra-aortic arterial injuries managed with percutaneous vascular closure devices.

RESULTS

In our review, the use of a closure device was successful in 87% of cases, even in some cases involving sheath sizes greater than 8F. The devices used in these situations caused minimal complications and offered a quick means to control bleeding. Thus, percutaneous closure devices are a helpful tool that offers an alternative to more invasive open surgical repair.

CONCLUSIONS

Vascular closure devices offer a minimally invasive and effective approach to the treatment of inadvertent supra-aortic arterial injury following CVC.

Safety and effectiveness of vascular closure devices in interventional radiological procedures

BACKGROUND

Although it is well known that vascular closure devices (VCD) are commonly used in therapeutic interventional radiological procedures, standard use in diagnostic procedures is not as well studied.

PURPOSE

The aim of this study was to determine the real-world safety and effectiveness of the VCD in both diagnostic and therapeutic interventional radiological procedures.

MATERIALS AND METHODS

A retrospective, single center study included all patients where VCDs were used for either a diagnostic or therapeutic interventional procedure. Various demographic and clinical risk factors were recorded and examined for any significant association with successful deployment and complications.

RESULTS

A total of 2072 patients were included. VCDs were successfully deployed in 95.2% of the patients with 4.8% of perioperative complications, which included minor oozing from the puncture site, small hematoma less than or equal to 5 cm, large hematoma greater than 5 cm, pain, and loss of vascular access. Therapeutic (vascular interventional radiology (VIR) and neuro-interventional radiology (NIR)) procedures (OR 3.03, 95% CI 1.51-6.09, p = 0.002), use of Angioseal (OR 5.26, 95% CI 3.13-8.33), p < 0.001), and no use of antiplatelet medications (OR 0.47, 95% CI 0.22-0.97, p = 0.041) were independently associated with successful deployment of VCDs when controlled for other risk factors. Smoking (OR 3.50, 95% CI 2.00-6.05, p = <0.001), use of antiplatelet (OR 2.01, 95% CI 1.04-3.87, p = 0.037) and use of heparin (OR 1.78, 95% CI 1.10-2.86, p = 0.018) were independently associated with higher complication rates.

CONCLUSION

VCD's were successfully deployed in 95.2% of the patients with 4.8% of perioperative minor complications.

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 of a nursing outcome for a percutaneous procedure

OBJECTIVES

To develop a nursing outcome, consistent with the standardized format of outcomes within the nursing Outcomes Classification (NOC). This outcome will include an outcome label, an outcome definition, and clinical indicators. The proposed use for this outcome is to evaluate the access site of a percutaneous procedure.

METHODS

Concept analysis with a scoping review. Initially, content experts were recruited to validate the indicators of the proposed outcome in order to complete a consensus validation. After consensus validation, a review of the proposed outcome and its indicators was completed by two of the editors of the NOC team to confirm that the outcome label, definition, and indicators were consistent with the NOC taxonomy. During this review, edits were made on the label name and definition.

FINDINGS

After a series of reviews, the initial outcome of Vascular Status: Percutaneous Procedure Access was changed to Tissue Injury Severity: Percutaneous Procedure. In addition, the original definition of the condition of an access site for percutaneous procedure by venous or arterial puncture and health of surrounding tissues was edited to: Severity of complications from a needle-puncture access through the skin and into deeper tissues. The outcome has 11 indicators to be used to formulate a target rating for use in the clinical setting. The indicators were not edited over the course of the reviews.

CONCLUSION

The proposed outcome will assist nurses in evaluating the access site of percutaneous procedures and in identifying possible complications.

IMPLICATIONS FOR THE NURSING PRACTICE

This research contributes to the refinement of the NOC taxonomy by having a new outcome that meets clinical practice needs.

Safety and efficacy of Angio-Seal device for transfemoral neuroendovascular procedures: A systematic review and meta-analysis

INTRODUCTION

Angio-Seal is a commonly used device for femoral hemostasis in neuroendovascular procedures. This meta-analysis investigates of the safety and efficacy of Angio-Seal in patients undergoing endovascular neurointerventional procedures.

METHODS

A systematic review and meta-analysis on all studies evaluating the Angio-Seal device in neurointerventional procedures from inception through 2020 were performed. We studied rates of groin hematoma, retroperitoneal hematoma, pseudoaneurysm, ipsilateral DVT, and ischemic complications. Meta-analysis was performed using the random-effects model.

RESULTS

13 studies were included in our analysis. 2250 patients with 104 complications were found {4.5% (95% CI, 2.7%-6.3%)}. Of these complications, groin hematoma was the most common with a rate of 2.4% (95% CI, 1.1%-3.6%). Retroperitoneal hematoma {0.3% (95% CI, 0%-0.5%)}, pseudo-aneurysm {0.5% (95% CI, 0.2%-0.8%), and ipsilateral DVT {0.3% (95% CI, 0.1%-0.7%) were also not in negligible rate. The rate of other complications were as follows: vessel occlusion/stenosis; 0.2% (95% CI, 0%-0.4%), vascular surgery; 0.2% (95% CI, 0%-0.5%), and infection; 0.2% (95% CI, 0%-0.5%). One patient died as result of hemorrhagic complications {0.1% (95% CI, 0%-0.3%)}. Use of anticoagulant/antiplatelet therapy was found to be positively correlated with high risk of any groin complication and groin hematoma (p ≤ .05). Female gender was associated with high risk of ipsilateral DVT (p ≤ .05). Interestingly, large sheath size was associated with low risk of groin hematoma (p ≤ .05).

CONCLUSION

The safety and efficacy rate of Angio-Seal was approximately 95%. The most common complication was groin hematoma. Serious complications including retroperitoneal hematoma and femoral artery occlusion were rare.

Comparison of the effect of manual compression and closure pad on postangiography complications: A randomized controlled trial

BACKGROUND

Different methods are available for the closure of the femoral artery after catheterization. The present study aimed at comparing the effect of manual compression (MC) and closure pad (CP) on vascular complications (hematoma and bleeding) of coronary angiography.

METHODS

In the current clinical trial, a total of 238 patients who were candidates for angiography were randomly assigned to the MC and CP groups. In the MC group, after removal of the arterial sheath, the arterial puncture site was manually compressed for 5-10 minutes and hemostasis was achieved. In the CP group, after removal of the arterial sheath, the arterial puncture site was first manually compressed for 5-10 minutes and initial coagulation was achieved. Then, to continue the coagulation process, a CP was attached to the artery puncture site. Postangiography complications including bleeding and hematoma were monitored in both groups immediately and up to 24 hours after hemostasis. Data were analyzed by SPSS-18 software.

RESULTS

After angiography, 7 (9.5%) and 5 (2.4%) patients had hematoma in the MC and CP groups, respectively; however, no significant difference was found between the groups. Rebleeding after hemostasis was observed in 2 (7.1%) patients in the MC group, but none of the subjects in the CP group had rebleeding. There was no significant difference in bleeding volume between the groups.

CONCLUSION

The results indicated the same efficacy of MC and CP methods in the prevention of postangiography vascular complications. Given the advantages of CP such as the possibility of changing the position in bed and increased physical comfort in the patient, this method is recommended for angiography and catheterization.

Prospective Evaluation of Factors Affecting the Safety and Efficacy of Perclose Proglide Vascular Closure Device in Neurovascular Interventions

Background

Most of the neurointerventional procedures use various anticoagulants, antiplatelets, and fibrinolytic drugs, and it can predispose arterial access site complications. Safe and efficient closure arteriotomy site has extreme importance in reducing the morbidity. Percutaneous vascular closure devices (VCDs) enable us to close the arteriotomy sites. In this prospective study, we evaluated the factors affecting the safety and efficacy of Perclose ProGlide VCD in neurovascular interventions.

Materials and Methods

In this prospective study, we have evaluated the safety and efficacy of 327 Perclose ProGlide devices deployed in 217 patients who underwent various neurointerventions in our institute from October 2014 to October 2016. Time to achieve hemostasis (TAH) was calculated for various groups and the statistical significance of mean values between groups was estimated.

Results

Out of the 327 Perclose ProGlide deployed, complication rate was 0.91% and the mean TAH was 77.14 s. Assessment of TAH mean value showed statistically significant prolongation of TAH in obesity and those with larger arterial sheaths. Age, sex, post-heparin ACT, peri-procedure medications, and type of diseases had no significant role in increasing TAH. The evaluation also showed the presence of a learning curve in using this device.

Conclusion

Perclose ProGlide VCD is safe and effective in closing the arteriotomy after neurointerventions. Obesity and larger arterial sheaths are independent factors prolonging the TAH. Learning curve associated with this device mildly increases the hemostatic time and device-related complications.

Vascular access complications in patients undergoing percutaneous procedures in hemodynamics: a scoping review

OBJECTIVE

To map the production of knowledge on vascular access complications in patients undergoing percutaneous procedures in hemodynamic laboratories.

METHODS

Scoping review study. The search strategy was developed in three stages, considering the period from July 2005 to July 2015 in the PubMed, CINAHL, Scopus, and LILACS databases. The collected data were analyzed and summarized in a narrative form.

RESULTS

One-hundred twenty-eight publications that made it possible to map the contexts of study of complications, occurrence according to access routes, as well as an understanding of diagnosis and clinical management, were included. Three theme categories were identified: complications; predictive factors; and diagnosis/treatment.

CONCLUSION

Vascular access site complications range according to the access route used. Knowledge of factors that permeate the occurrence of these events may contribute to early detection, planning, and monitoring of the care implemented.

Safety profile of an 8F femoral arteriotomy closure using the Angio-Seal device in thrombolysed acute stroke patients undergoing thrombectomy

Background The relationship between bridging thrombolysis and femoral access site complications after mechanical thrombectomy remains contested. Use of a closure device could minimise bleeding complications. This study aimed to elucidate the rate of access site complications in a cohort of patients treated using an 8F groin sheath with subsequent closure using the Angio-Seal to assess safety and the impact of bridging thrombolysis on access site complication rate. Methods All patients with large vessel occlusive stroke treated between 2014 and 2017 with thrombectomy with or without bridging thrombolysis were reviewed. A prospectively acquired departmental database was used to obtain baseline data, and the radiology information and haematology reporting systems were used to record imaging or transfusion relating to subsequent access site complications. Results Seventy-five patients treated with thrombectomy alone were compared to 70 patients treated with prior intravenous thrombolysis. All had an 8F femoral sheath placed for arterial access, and all underwent attempted haemostasis with an 8F Angio-Seal. Two patients (1.14%) suffered Angio-Seal device failure necessitating manual pressure. One patient (0.6%) suffered a small femoral pseudo-aneurysm. No retroperitoneal haemorrhage, haematoma requiring transfusion, ipsilateral deep-vein thrombosis or ipsilateral acute limb ischaemia was encountered. There was no significant difference in the rate of haemorrhagic, ischaemic or infective complications between those treated with bridging thrombolysis or thrombectomy alone. Conclusion Use of the Angio-Seal closure device for 8F femoral access is safe in acute stroke patients. Intravenous thrombolysis prior to endovascular thrombectomy does not significantly alter femoral access site complication rate if this approach is used.

Accelerated ambulation after vascular access closure device

BACKGROUND

Patients who are candidates to receive an Angioseal® (St. Jude Medical) device for arteriotomy closure are allowed to ambulate 20 min after the deployment of the device. More frequently, however, patients are kept on bed rest for several hours following Angioseal® deployment. The purpose of this study was to prospectively assess patients when ambulating 20 min after Angioseal® deployment instead of prolonged best rest of 2-3 h.

METHODS

Patients undergoing angiography from the common femoral artery approach were included in the study if they received a 6 Fr Angioseal® closure device.

RESULTS

Twenty-nine patients were successfully enrolled in the study; 27 (93.1%) patients ambulated at 20 min, 1 (3.45%) patient ambulated at 28 min, and 1 (3.45%) patient ambulated at 27 min due to transport times. There were zero complications with regard to hemorrhage or other groin complications. There is a substantial time difference in ambulation times between the conventional and early ambulation groups.

CONCLUSION

Our study demonstrates that it is probably safe to ambulate patients who undergo diagnostic cardiac catheterization as early as 20 min after deployment of the 6 Fr Angioseal® closure device. ClinicalTrials.gov identifier: NCT03142126.

Hemostatic Wound Dressing for Postinterventional Hemostasis in Large Femoral Artery Access Sites

Purpose: To present the results of a prospective single-center study that evaluated the safety and efficacy of a hemostatic dressing following femoral artery access. Methods: Within a 9-month period, 80 patients (mean age 68±14 years; 55 men) were treated with a hemostatic dressing patch (Hematrix Active Patch) containing aminocaproic acid, calcium chloride, and thrombin after endovascular procedures via a 6- to 8-F femoral artery access. After removing the sheath, the wound dressing was placed on the puncture site followed by constant manual compression adapted to the sheath size (specified pressure times: 8 minutes for 6-F, 9 minutes for 7-F, and 10 minutes for 8-F). Patients were treated with an additional pressure bandage for 24 hours. Hemostasis was checked clinically and with duplex ultrasound after patch removal and at 24 hours. Patient characteristics [platelets, systolic blood pressure, international normalized ratio (INR), and partial thromboplastin time (PTT)], sheath sizes, and approach direction were compared among patients with successful hemostasis (within specified pressure times) vs those with prolonged compression. Results: A total of 39 6-F, 19 7-F, and 22 8-F sheaths were employed. In 73 (91.2%) of 80 patients, hemostasis was reached within the prespecified pressure times (mean 8.8±0.8 minutes). In 7 patients (4 6-F, 1 7-F, 2 8-F) a longer compression time was necessary (mean 34±30 minutes). No serious major complication occurred. Twelve (15.0%) minor and 5 (6.3%) moderate subcutaneous hematomas were observed. Two (2.5%) false aneurysms were treated successfully. Ambulation and discharge was possible within 24 hours in 79 (98.7%) cases. Patients with initial hemostasis and those with prolonged compression did not differ substantially (p>0.05) according to sheath size, approach direction, INR (1.09±0.3 vs 1.11±0.3), platelets (234±47×103/µL vs 249±93×103/µL), systolic blood pressure (150±26 vs 152±17 mm Hg), or PTT (31±7.9 vs 34.8±10.0 seconds). Conclusion: The evaluated wound dressing seems to be safe and effective in reducing time to hemostasis in large arterial access sites. However, a randomized trial with a larger population and an active control group is necessary to confirm these preliminary data. Moreover, additional focus on shortening the time to ambulation is required in future studies.

Delayed Vascular Claudication Following Diagnostic Cerebral Angiography: A Rare Complication of the AngioSeal Arteriotomy Closure Device

With rapidly increasing numbers of neuroendovascular procedures performed annually in recent years, use of arterial closure devices after femoral artery access has been exceedingly common secondary to reduced time to hemostasis, decreased patient discomfort, earlier mobilization, and shortened hospital stay. Although uncommon, use of these devices can lead to a different spectrum of complications, as compared to manual compression. Ischemic symptoms following the use of these devices can have unexpected clinical sequelae and can occur in a delayed fashion. Awareness and recognition of such complications is important with the dramatically increased use of these devices in recent years. We report on a case of delayed vascular complication manifesting as vascular claudication following use of the AngioSeal closure device.