the 0.018 inch crossover wire, the balloon is placed in the terminal segment of the external iliac artery or proximal segment of the common femoral artery inflated to 1–2 atm. This creates proximal control and hemostasis with a non‐traumatic occlusion of the vessel during sheath removal and knot delivery.
Large bore venous sheath management
Currently, the most common indications for using large sheaths in the common femoral vein are shunt closure, left atrial appendage occlusion, paravalvular leak closure, interventions for mitral and tricuspid valve disease (MitraClip, transcatheter valve implantation in mitral position; valve‐in‐valve, valve‐in‐ring; valve‐in‐MAC, and various mitral and tricuspid percutaneous valvuloplasty techniques). Some devices such as percutaneous left ventricular assist devices can also require large access to the venous system; however, more frequently, patients who require percutaneous left ventricular assist devices may have to leave the catheterization laboratory with the device in place, in which case there is a long delay before sheath removal and closure devices should not be used because of the high risk of infection.
The strategy for managing large sheaths in the venous system is easier than for arterial punctures because of the lower pressure of the venous system. Similarly to the arterial access, ultrasound‐guided venous puncture helps to reduce complications and increases safety of the procedure [58]. After the access is carefully obtained by a regular 18‐gauge needle, we place a 7 Fr dilator in the vein. Blunt dissection of subcutaneous tissue facilitates delivery of larger sheaths. The sheath is inserted in the standard manner. After completion of the procedure, we use a “figure of eight” suture for hemostasis. For this technique, we use a 0 silk suture and we start from the distal edge of the access site, below the insertion of the sheath through the skin. The orientation of the needle entry can be either from medial to lateral or vice versa. When the needle is withdrawn from the skin, we use the same needle on the more proximal segment of the sheath, superior to the sheath insertion, with same the same direction of passage (medial to lateral or vice versa). After cutting off the needle, we take one end of the suture line and wrap around the other end three times, and finally tie down over the skin, while the sheath is still through the skin. The first operator keeps active force on the suture over the sheath as the second operator removes the sheath from the skin. Finally, the reinforcing knots will be placed. The suture is removed after 4 hours of bed rest. It can also be helpful, especially for the subsequent management in the ward, outside the catheterization laboratory, to tighten the suture over a gauze, in order to minimize patient discomfort and make the suture well recognizable for removal. Very rarely do we see any ongoing oozing from the venous access site by using this simple and cost‐effective technique that is simple and cost‐effective [59], even though the data on the rate of venous thrombosis and stricture are lacking so far. Recently the Proglide suture‐mediated closure device was approved for use in the USA and Europe for large‐bore venous access closure (up to 24 Fr; 29 Fr outer diameter). The use of Proglide is safe and allows for earlier patient mobilization and shorter length of hospitalization [60] even though the VARC‐2 outcomes in terms of vascular complications and bleeding are not significantly different from the figure‐of‐eight stitch mentioned earlier [61]. A word of caution should be spent on the possible stricture effect anecdotally observed after double ProGlide pre‐closure for large bore venous access hemostasis that is not observed with an equally effective and simpler single ProGlide use.
Conclusions
Proper management of femoral access is vital in reducing the femoral vascular adverse events, which are the most common complications in cardiac catheterizations and interventions. Refinements in antithrombotic and antiplatelet regimens, and reductions in access size have reduced ambulation times and the risks of complications. Vascular closure devices have further significantly improved hemostasis and ambulation times, and current data suggest they are mostly safe. However, there is no unequivocal evidence to suggest they reduce vascular complications in either diagnostic or interventional subgroups. Experience and expertise with whichever technique for femoral access site management one chooses are the best ways to minimize complications.
Just as important as management of vascular closure, careful attention to obtaining vascular access is important. Careful assessment of bony landmarks by fluoroscopy prior to femoral access will maximize the chance of sheath insertion into the common femoral artery with reductions in complications. Similarly, routine femoral angiography after femoral access to confirm sheath position is useful not only for assessing suitability of applications of vascular closure device, but also for assessing the risks of bleeding with use of antithrombotics which can affect interventional decision making. Femoral vascular access and closure approaches have been greatly refined by the demands of TAVR, with CT assessment for procedure planning, the use of micropuncture and ultrasound, and crossover techniques.
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