Vascular closure devices

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Editor-In-Chief: Michael S. Fenster, MD [1]

Vascular Closure Devices

At the very heart of any successful endovascular procedure is successful arterial entry and exit. The first successful cardiac catheterization, according to Andre Cournand, was performed on an equine patient in 1844 utilizing a retrograde approach through both the jugular vein and carotid artery. Human retrograde left heart catheterization was first reported by Zimmerman and Limon-Lason in 1950. Shortly thereafter in 1953, Seldinger developed the percutaneous technique and this technique was quickly adapted to left heart cardiac catheterizations. With the growth of Interventional Cardiology in the years following Grüntzig’s introduction of coronary angioplasty in 1977, the percutaneous approach became, and today remains, by far the most common method of performing catheterization, angiography and endovascular intervention.

Within the realm of percutaneous approaches, the majority of the procedures are performed from the femoral approach, with a minority being done from a radial approach. Brachial and axillary are also used in a minority of procedures. Reasons for the continued preference of the femoral route for access includes the vessel size, operator training and equipment, radiation exposure (operator), and the advent of vascular closure devices. Studies have suggested that between 8-10% of all patients selected for a transradial approach will convert to a transfemoral route.

Current Limitations of Vascular Closure Devices

• Require long learning curve
• Small vessel size (<4.0–5.0mm); a contraindication to use
• Non-common femoral artery ‘sticks’; a contraindication to use
• Peripheral vascular disease; a contraindication to use (very common problem)
• Significant endoluminal device components (prone to thrombosis)
• High costs
• Require bed rest post closure
• Impaired or delayed common femoral artery re-entry (re-access concerns)
• Non-inert, very reactive, permanent and absorbable device components (therefore may be prone to infection and common femoral artery scarring)
• Catastrophic complications (1–2%, but may be under-reported)
• Poorly compatible with anticoagulated patients (increased bleeding)

Complications

Infection

• After an incubation period of 2 to 29 days (average of 8 days) a vascular closure device infection can occur.
• Symptoms include local pain and fever. The pain may improve and then worsen.
• Blood cultures are positive
• Most common pathogen is staphylococcus aureus infecting a mycotic aneurysm
• Medical and surgical treatment are both required

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)

Vascular Closure Devices (DO NOT EDIT)

Class I

"1. Patients considered for vascular closure devices should undergo a femoral angiogram to ensure their anatomic suitability for deployment. (Level of Evidence: C)"

Class III (No Benefit)

"1. The routine use of vascular closure devices is not recommended for the purpose of decreasing vascular complications, including bleeding. (Level of Evidence: B)"

Class IIa

"1. The use of vascular closure devices is reasonable for the purposes of achieving faster hemostasis and earlier ambulation compared with the use of manual compression.(Level of Evidence: B)"