in two of the meta‐analyses [39,41]. There are a number of limitations to assessing the relative rates of complications with manual compression and vascular closure devices. First, some trials have required femoral angiography, and higher risk patients may be eliminated from the trials, because of small caliber femoral vessels, atherosclerosis of the puncture site, or calcification. In addition, many of the trials have rigorous protocol specifications for the manner in which the closure devices are used, but generally give no guidance regarding manual compression methods, which can be highly variable. In some institutions, there are sheath removal teams who become quite expert at sheath removal, manual compression, and puncture site management used to exist, obtaining excellent results [42]. It is difficult to make comparisons between these programs and lower volume programs, or programs where new trainees are relegated to the task of sheath removal and manual compression.
The largest registry study of femoral hemostasis comes from the ACC‐NCDR [36]. From this registry, the outcomes of 166 680 patients who underwent diagnostic and interventional cardiac catheterizations in 2001 were evaluated, with suture devices used in 25 495 cases, collagen‐plug devices used in 28 160 cases, while the rest underwent manual compression. In the overall multivariate analysis, use of collagen plug devices was associated with reduced bleeding in diagnostic catheterization (odds ratio 0.68) and both types of closure devices were associated with reduced risk of pseudoaneurysm formation in diagnostic and interventional procedures (odds ratio 0.46–0.52). It is possible that among individual operators who develop special expertise with a particular closure device, there is potential to achieve improved success rates with lower complication rate [43]. A propensity analysis from the British Cardiovascular Intervention Society and the National Institute for Cardiovascular Outcomes Research showed a minor reduction in 30‐day mortality in patients treated with vascular closure devices, slightly more evident in women and in patients presenting with acute coronary syndrome or recent lysis [44]. A recent Cochrane review comparing collagen‐based, metallic‐clip, and suture‐based vascular closure devices with extrinsic compression confirmed reduced time to hemostasis using a closure device, no difference in infection rate between the different modalities and reduced incidence of groin hematomas and pseudoaneurysms with collagen‐based devices, no differences were found for other complications between the different types of hemostasis [45].
What then are the advantages of vascular closure devices? Unquestionably, the complete avoidance of compression with immediate hemostasis and early ambulation improves patient satisfaction [46]. This alone can justify the use of these devices in many cases. However, with no clear difference in complication rates, possibly the strongest benefit may be an early (same‐day) discharge of patients after percutaneous coronary intervention that could result from early ambulation [4,47]. Over the past years, major vascular complications have decreased among patients undergoing percutaneous coronary intervention in the Northern New England Cardiovascular Disease Study Group. In their database, with 36 631 patients undergoing percutaneous coronary intervention, arterial complications decreased from 3.37% in 2002 to 1.98% in 2006 [39]. Whether this reflects more careful attention to needle puncture and sheath insertion, improved management of anticoagulation, better manual compression, or optimized use of closure devices cannot be ascertained without a randomized trial. Such a trial would require such a large population that is unlikely ever to be performed.
Vascular closure devices shorten the time to hemostasis and ambulation, compared with manual compression, but the aggregate of reports is mixed regarding the potential for closure devices to increase or decrease the risk of vascular complications. In a recent study of patients undergoing diagnostic coronary angiogram with a 6 Fr system, the vascular closure devices were not inferior to manual pressure. There were no increased risks of vascular complications; however, it is important to note that in this study the patients did not undergo any coronary interventions so the results should be considered in the context of diagnostic angiography. This study compared FemoSeal (Terumo) with ExoSeal (Cordis). ExoSeal is not frequently used in the USA, and FemoSeal is only currently available in Europe [48].
Vascular closure devices for small arteriotomies have no clear benefit over external compression and their widespread use is mainly driven by the reduction of time to ambulation and discharge. Conversely, for large bore arteriotomies the use of percutaneous closure devices is perceived as mandatory. Observational data demonstrated that percutaneous approach to TAVR using suture‐mediated vascular closure devices with preclosure is associated with similar vascular outcomes to surgical cut‐down for arterial access, but with shorter length of stay and less wound complications [49,50]. Recently the new MANTA system, specifically designed for large bore arterial access closure, showed preliminary outcomes comparable to Proglide [51].
Routine use of vascular closure devices might reduce bleeding and vascular complications, facilitate patient ambulation and decrease hospital length of stay even though the inherent complications of vascular closure device use such as infection, embolization, and device failure leading to ischemia or access‐site bleeding will probably never be completely abolished.
Preclosure for large arterial sheaths
Large bore arterial sheaths (12–14 Fr) can be required for certain interventions such as retrograde balloon aortic valvuloplasty or, more recently, retrograde transcatheter aortic valve replacement (14–24 Fr). Such large bore arterial sheaths are historically associated with need for prolonged compression to achieve hemostasis, prolonged bed rest prior to mobilization (up to 12–24 hours in certain cases), and high risk of recurrent bleeding and need for transfusion. Transfusion rates after manual compression following balloon aortic valvuloplasty have been in the range of 25%. Preclosure is a technique using the Perclose or ProStar device to “preload” the suture around the puncture site prior to access with the large bore sheath to allow for subsequent suture closure at removal of the large arterial sheath. After puncture, a standard 6–8 Fr sheath is inserted and subsequently exchanged over the wire to introduce a Perclose or ProStar device. Deployment of the needle is performed with the standard manner to preload the suture around the arteriotomy. The suture is not tightened. A wire is reintroduced into the device over which an exchange is made with the subsequent large bore arterial sheath. At completion of the procedure requiring the large bore sheath, the sheath is removed and closure performed by tightening of the preloaded sutures. With this technique, a 6 Fr Perclose system had been successful in closing 12 Fr arteriotomies and a 10 Fr ProStar system had been successful in closing 14 Fr arteriotomies. In a non‐randomized comparison, this technique had been successful in significantly reducing length of hospital stay and almost eliminating the need for blood transfusions after retrograde arterial balloon aortic valvuloplasty [52,53]. Several novel devices for large vessel closure are under development. There are mainly three approaches of new technology to manage percutaneous closure following large bore vascular access: suture‐based, suture and plug/sealant, and ipsilateral/contralateral graft placement. There are a number of products under investigation that are entering the commercial market such as Manta (Essential Medical).
Arterial access management for transcatheter aortic valvular replacement procedures requiring large bore sheaths
In our catheterization laboratory, we use a standard approach for patients requiring transcatheter aortic valvular replacement (TAVR), adoptable also for other procedures requiring large bore sheath use (TEVAR, EVAR, Impella, Tandem Heart of ECMO placement, etc). This approach starts before the patient comes to the catheterization laboratory by meticulous attention to the aorto‐iliac and femoral artery anatomy on pre‐TAVR CT angiography. Understanding the location of calcifications of these vessels, tortuosity, diameter, and the presence of prior bypass grafts and/or stents is invaluable. The location of femoral bifurcations relative to the femoral head can be assessed as well as the distance between the skin surface and the vessel wall.
We start the procedure with the ancillary access, most often involving the contralateral femoral artery, however radial artery or ipsilateral superficial femoral artery can also be used. In the case of contralateral common femoral artery, we use a micropuncture needle with
