Manual versus mechanical compression for femoral artery hemostasis after cardiac catheterization

Comparison of the boomerang wire vascular access management system versus manual compression alone during percutaneous diagnostic and interventional cardiovascular procedures: The boomerang™ wire vascular access management trial II

OBJECTIVES

To evaluate the use of the Boomerang™ Wire as an adjunct to manual compression (MC) in patients requiring diagnostic (Dx) or interventional (Ix) percutaneous procedures.

BACKGROUND

MC remains the standard of care for closure of femoral artery access sites. Adjunctive use of a device to facilitate closure, reduce time to hemostasis (TTH) and ambulation (TTA) without increasing complication rates could reduce costs and hospital resource demands.

METHODS

The Boomerang™ Trial was a prospective, multicenter, randomized, controlled trial comparing use of the Boomerang™ wire, (Cardiva Medical, Sunnyvale, CA) in conjunction with MC versus MC alone to achieve hemostasis in Dx and Ix patients undergoing percutaneous procedures requiring femoral artery access. Endpoints included TTH, TTA, major, and minor access-site related complications. Subjects were randomized 3:1, Boomerang versus MC.

RESULTS

No minor or major device-related adverse events were reported. Nondevice related complication rates were 3 (0.9%) in the Boomerang arm (n = 327) and 1 (0.8%) in MC arm (n = 123). Mean TTH for Boomerang vs. MC was 11.2 ± 4.3 vs. 23.2 ± 11 min for Dx (P < 0.0001) and 13.9 ± 5.4 vs. 38.4 ± 57.3 min for Ix patients (P < 0.0001). Mean TTA for Boomerang vs. MC was 3.3 ± 3.0 vs. 4.5 ± 2.0 hr (P < 0.0001)for Dx and 5.4 ± 3.3 vs. 6.8 ± 3.2 hr (P < 0.0001) for Ix patients.

CONCLUSIONS

Boomerang™ use, in conjunction with MC, was associated with low rates of complications and demonstrated that Boomerang™ as an adjunct to MC can significantly decrease TTH and TTA after both Dx and Ix procedures. © 2015 Wiley Periodicals, Inc.

4-French-compatible endovascular material is safe and effective in the treatment of femoropopliteal occlusive disease: results of the 4-EVER trial

PURPOSE

To report the 1-year results of a prospective multicenter trial to evaluate the safety and efficacy of treating symptomatic femoropopliteal occlusive disease using 4-F-compatible materials and no closure device.

METHODS

The non-randomized 4-EVER trial (4-F endovascular treatment approach to infrainguinal disease) was conducted at 5 European hospitals (ClinicalTrials.gov identifier NCT01413139). The protocol mandated the use of only 4-F sheaths, self-expanding nitinol stents (Astron Pulsar or Pulsar-18 stent), and balloons from a single manufacturer. Between June 2010 and June 2011, 120 symptomatic patients (82 men; mean age 71±9.7 years, range 47-90), primarily claudicants, treated for 120 femoropopliteal lesions (>90% TASC A/B) were enrolled. The mean lesion length was 71.0±45.9 mm. Follow-up evaluations were scheduled on day 1 and at 1, 6, 12, and 24 months. A duplex ultrasound was performed on all follow-up visits to determine vessel patency (primary outcome measure at 1 year), and biplanar radiography was performed at 12 and 24 months to assess stent fracture.

RESULTS

Stents were successfully implanted in all patients: an Astron Pulsar stent in 70 (58.3%) lesions and a Pulsar-18 stent in 46 (38.3%); 4 (3.3%) patients had both stents implanted for flow-limiting dissection after predilation. No closure devices were used; the mean manual compression time was 8.1 minutes (2-15). Four (3.3%) patients developed significant hematoma at the puncture site, but none required surgical repair. The overall 12-month primary patency rate was 81.4%: 85.2% for the Astron Pulsar and 73.4% for the Pulsar-18 (p=0.236). Freedom from target lesion revascularization at 12 months for the entire cohort was 89.3%.

CONCLUSION

Compared to published historical data for superficial femoral artery type A/B lesion stenting using 6-F devices, the 4-F devices applied in this trial showed similar patency at 12 months, fewer access site complications, and shorter manual compression times, supporting the supposition that 4-F endovascular treatment is safe and effective.

Safety and Efficacy of StarClose SE Vascular Closure System in High-Risk Liver Interventional Oncology Patients

Purpose

To assess the safety and efficacy of the StarClose SE Vascular Closure System (Abbott Vascular, Abbott Park IL, USA) in high-risk thrombocytopenic and coagulopathic interventional oncology (IO) patients.

Methods

In this single institution retrospective study, 63 high-risk thrombocytopenic or coagulopathic IO patients (M:F=51:12, mean age 58 years, range 31–88 years) who underwent 83 common femoral arteriotomy closures using the StarClose device were identified among all IO patients (n=131) undergoing StarClose closure (n=177) between 2008–2011. High-risk thrombocytopenia and coagulopathy were defined as platelet count ≤100 103/mL and international normalized ratio (INR) ≥1.5. Procedures included chemoembolization (n=67), radioembolization (n=8), and hepatic arterial mapping with technetium-99m macroaggrated albumin administration (n=8) for treatment of hepatocellular carcinoma (n=79) or liver metastases (n=4). Measured outcomes included technical success of arterial closure and closure-related adverse events, graded according to the Society of Interventional Radiology classification.

Results

In all cases, 5 French common femoral arterial access was used. Platelet count was ≤100 103/mL in 80/83 (96.4%) cases and INR was ≥1.5 in 35/83 (42.2%) cases. Mean pre-procedure platelet count was 71 (range 26–347) 103/mL and mean INR was 1.4 (range 1.0–2.1). The StarClose device effectively sealed the arteriotomy in 83/83 (100%) cases, 60/83 (72.3%) cases were first-time closures, and 20/83 (24.1%) cases were repeat closures. Small groin hematomas, graded as class A minor complications, developed in 3/83 (3.6%) cases. No other complications were encountered.

Conclusions

The StarClose SE Vascular Closure System confers high technical success and safety in common femoral arteriotomy closure in high-risk IO patients.

A propensity analysis of the risk of vascular complications after cardiac catheterization procedures with the use of vascular closure devices

BACKGROUND

Complications of vascular access are one of the most common adverse events after coronary angiography and percutaneous coronary intervention (PCI) and are reported to occur in 1% to 9% of cases. There are conflicting reports of the association of vascular complications with the use of vascular closure devices (VCDs). The purpose of this study was to assess femoral arterial access-related vascular outcomes after invasive cardiology procedures with the routine use of VCDs.

METHODS

A total of 12,937 consecutive patients were studied for inhospital outcomes through a prospective registry from January 2002 to December 2005. Of these, 6913 (53%) patients underwent PCI and 9996 (77%) patients received VCDs. Univariate and multivariate logistic regression analyses were used to determine the predictors of vascular complications. A propensity analysis of VCD use was performed to account for potential bias in the likelihood of using such devices.

RESULTS

Vascular complications occurred in 0.7% of diagnostic angiography and 2.7% of PCI patients. The risk of vascular complications was significantly lower with closure device use compared with manual compression in both diagnostic angiography (0.5% vs 1.1%, P = .01*) and PCI (2.4% vs 4.9%, P < .001*) groups. Multivariate logistic regression analysis, after accounting for the propensity to use such devices, revealed that VCD use was associated with a 58% (95% CI 19%-88%) reduction in the risk of vascular complications in diagnostic procedures catheterization and a 42% (95% CI 17%-59%) reduction in PCI patients.

CONCLUSIONS

In contemporary practice, VCDs offer reduced risk of vascular complications as compared with manual compression in appropriately selected patients undergoing diagnostic and therapeutic cardiac catheterizations.

Peripheral arterial sheath removal program: a performance improvement initiative

The increasing number of endovascular procedures by both cardiologists and vascular surgeons strain available resources, such as recovery space, creating delays in the throughput of patients. The use of alternative settings, personnel, and approaches to postprocedural care has been proposed to maximize the number of procedures that can be done with existing procedure rooms. However, a key question remains about whether this can be done safely and achieve good patient outcomes. A performance improvement project was conducted to evaluate the safety and effectiveness of shifting postprocedural care and removal of intraarterial sheaths by the staff in the cardiac catheterization laboratory to specially trained acute care nurses on an inpatient vascular surgical unit. The purpose of this project was to develop a performance improvement project that included administrative, educational, and clinical components and to evaluate effects on key patient outcomes, prospectively, over 15 months.

Efficacy of femoral vascular closure devices in patients treated with anticoagulant, abciximab or thrombolytics during percutaneous endovascular procedures

OBJECTIVE

This study assessed the outcomes of using vascular closure devices following percutaneous transfemoral endovascular procedures in the patients who were treated with heparin, abciximab or thrombolytics (urokinase or t-PA) during the procedures.

MATERIALS AND METHODS

From March 28, 2003 to August 31, 2004, we conducted a prospective and randomized study in which 1,676 cases of 1,180 patients were treated with one of the two different closure devices (the collagen plug device was Angio-Seal; the suture-mediated closure device was The Closer S) at the femoral access site after instituting percutaneous endovascular procedures. Among the 1,676 cases, 108 cases (the drug group) were treated with heparin only (n = 94), thrombolytics only (n = 10), heparin and thrombolytics (n = 3), or abciximab and thrombolytics (n = 1) during the procedures; 1,568 cases (the no-drug group) were treated without any medication. We compared the efficacy and complications between the two groups. Of the drug group, 42 cases underwent arterial closures with the collagen plug devices and 66 cases underwent arterial closures with the suture-mediated closure devices. We also compared the efficacy and complications between these two groups.

RESULTS

The immediate hemostasis rates were 92.9% (1,456/1,568) in the no-drug group and 91.7% (99/108) in the drug group. Early complications occurred in four cases of the drug group. These included two episodes of rebleeding with using the Closer S, which required manual compression for at least 10 minutes, and two episodes of minor oozing with using one Angio-Seal and one Closer S, which required two hours of additional bed rest. There was no late complication. So, the total success rates were 90.8% (1,423/1,568) in the no-drug group and 88.0% (95/108) in the drug group. These results were not significantly different between the two groups (p = 0.34). In the drug group, the difference of the successful hemostasis rate between the collagen plug devices and the suture-mediated devices was also not statistically significant (92.9% vs. 84.8%, respectively; p = 0.21).

CONCLUSION

Arterial closure of the femoral access site with using vascular closure devices is both safe and effective, even in the patients who received heparin, abciximab or thrombolytics.

Arterial Puncture Site Management After Percutaneous Transluminal Procedures Using a Hemostatic Wound Dressing (Clo-Sur P.A.D.) Versus Conventional Manual Compression:A Randomized Controlled Trial

PURPOSE

To investigate the efficacy and safety of a novel hemostatic wound dressing designed for rapid hemostasis at arterial puncture sites.

METHODS

Over a 15-month period, 209 consecutive patients were randomized to conventional manual compression (n=105) or the use of the Clo-Sur P.A.D. hemostatic device (n=104) after removal of the sheath. Puncture-related and device-related complications, time to hemostasis, time to ambulation, and patient and physician discomfort were recorded.

RESULTS

In 209 patients, 21 (10.0%) puncture-related complications were observed, including 11 (5.3%) pseudoaneurysms, 9 (4.3%) hematomas, and 1 (0.5%) major bleeding complication. There was no significant difference (p=0.36) in complications between the hemostatic device (9/104, 8.7%) and the conventional group (12/105, 11.4%). In the hemostatic device group compared to the conventional group, respectively, the average time to hemostasis (13.6 versus 20.3 minutes; p<0.001), time to ambulation (6.5 versus 17.4 hours, p<0.001), patient discomfort (VAS 2.1 versus 4.7, p<0.001), and physician discomfort (VAS 3.8 versus 5.2, p<0.001) were significantly lower. Twenty (19%) sheath removals in the hemostatic device group were classified as a technical failure of the device.

CONCLUSION

The use of this hemostatic wound dressing for arterial access site management after percutaneous vascular procedures significantly reduced the time to hemostasis, enabled early mobilization, and reduced patient discomfort without increasing the risk for complications compared to conventional manual compression. A high rate of technical failures, however, warrants further improvement before routine use can be recommended.

Effectiveness of Mechanical Compression Devices in Attaining Hemostasis After Femoral Sheath Removal

• Background Cardiac interventions are widely accepted as a practical treatment option for coronary artery disease. However, few changes have occurred in the techniques used for percutaneous arterial cannulation and for attaining hemostasis after cardiac interventions. To date, researchers have focused on techniques to achieve optimal hemostasis at the time of removal of the arterial catheter and to minimize the impact and complications of arterial puncture.

• Objective To summarize the best available evidence on the effectiveness of mechanical compression devices used to obtain hemostasis following femoral sheath removal after cardiac interventional procedures.

• Method An attempt was made to detect both published and unpublished reports of research evaluations of mechanical compression techniques used to attain hemostasis after femoral sheath removal. Methodological quality was assessed by using predesigned criteria. Data were extracted from information on randomized controlled trials and were statistically combined in meta-analysis where possible. Evidence was also synthesized by using narrative summaries.

• Results Twelve studies met the inclusion criteria; however, only 3 were included in the meta-analysis. The results of meta-analysis indicated that the mechanical compression technique was the most effective for preventing formation of hematomas. The prevalence of bleeding did not differ significantly for different methods of compression.

• Conclusion A gap exists in the literature on quality randomized controlled trials of various devices used to attain hemostasis after femoral sheath removal.

[Safety and efficacy of an early deambulation protocol after PTCA with an angio-seal device]

INTRODUCTION

In order to assess the efficacy and safety of an early deambulation (1-2 h) protocol after coronary angioplasty using the Angio-seal collagen plug, we analyzed a consecutive series of patients treated with this device versus a reference group treated with mechanical compression.

PATIENTS AND METHODS

Two hundred and seven coronary angioplasty patients were included from February to August 2000. Ninety-eight were treated with mechanical compression and one hundred and nine with the Angio-seal collagen plug. All patients were followed at discharge and fifteen days after surgery.

RESULTS

Eighty percent of the patients receiving the Angio-seal device achieved immediate hemostasis (< 1 min). In patients with mechanical compression hemostasis was achieved within 30 min in 68.3%, whereas 25.5% of patients required more than 40 min. First deambulation in the Angio-seal group was achieved within 2 h in 94.5% of the patients. The incidence of major complications was low in both groups (1 case in the Angio-seal group and 2 in the C-clamp group) without statistically significant differences. The Angio-seal group showed a lower incidence of overall vascular complications as compared to the C-clamp group (4.6% vs. 14.3%; p = 0.02).

CONCLUSION

Following our protocol, an early deambulation strategy after coronary angioplasty with the use of the Angio-seal collagen plug was feasible, safe and efficacious.