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Despite the low injury of endovascular interventions, there are a number of complications that significantly worsen the prognosis of patients. The most unfavorable complications in patients with ST-segment elevation myocardial infarction during primary percutaneous coronary intervention are stent thrombosis, coronary artery perforation, tamponade, complications at the arterial access site, distal embolism, development of the "no-reflow", stroke. The article is devoted to the study of the frequency of these complications in primary percutaneous coronary intervention in combination with manual thromboaspiration.

Introduction Embolisation of type II internal iliac artery endoleaks is challenging given limited options for obtaining transarterial access and for achieving access site haemostasis. Report An 86 year old woman who had undergone endovascular repair for an aorto-iliac aneurysm was found to have serial enlargement of the left common iliac artery portion of the aneurysm observed over a period of two years. At the time of the initial repair, the left internal iliac artery was embolised using coils, and then was covered by extending the iliac limb endoprosthesis into the external iliac artery. However, computed tomography angiography showed recanalisation of the previously coiled left internal iliac artery, thus allowing contrast to flow into the left common iliac aneurysm sac. Given that the internal iliac artery origin was covered and there was no visible collateral pathway, direct puncture of the superior gluteal artery was selected to access the left internal iliac artery in a retrograde fashion. This presented a challenge in terms of achieving haemostasis given the deep position of the arterial access site, which was unlikely to be amenable to manual compression. Off label StarClose was chosen for closure of the superior gluteal arterial access, with successful haemostasis and preserved patency of the vessel. Discussion Off label StarClose was used successfully to obtain haemostasis after obtaining percutaneous transgluteal access to the superior gluteal artery in order to embolise a type II endoleak arising from the internal iliac artery. Keywords: StarClose; Iliac artery type II endoleak; Arterial closure device; Haemostasis; Superiorgluteal artery

Preservation of the arterial access site after removal of large caliber mechanical circulatory devices (MCD) can be challenging. In this paper, we describe two novel techniques and review the current literature focusing on the maintenance of arterial access after Impella removal.

Background: Various types of vascular closure devices (VCDs) are frequently utilized in patients undergoing percutaneous coronary intervention (PCI) in order to prevent arterial access site bleeding, which represents one of the most relevant complications associated with adverse clinical outcomes. This study aims to compare directly two mechanistically different types of femoral closure (FC) devices in patients undergoing PCI. Methods: This single-center, prospective, observational study includes consecutively patients either treated by the extravascular StarClose SE® (Abbott, Illinois, U.S.A.) or the intravascular AngioSeal™ FC (St. Jude Medical, Inc., St. Paul, MN, U.S.A.) after PCI. The primary endpoint was bleeding complications, the secondary endpoint was major adverse cardiac events (MACE) at 30 days of follow-up. Results: 200 patients in each group (StarClose SE® and AngioSeal™) were enrolled following PCI. The rates of overall and non-access site bleedings were significantly higher in the AngioSeal™ group (56%; 6%) compared to the StarClose SE® group (43.5%; 0.5%) (p = 0.012; 0.003). Additionally, complicated access site bleedings were also significantly higher in the AngioSeal™ group (p = 0.011). No significant differences of MACE were observed in both groups. However, there was a higher rate of unsuccessful implantation of the StarClose SE® (n=12, excluded from the study). Conclusions: In case of successful implantation, FC by the AngioSeal™ is associated with the higher rate of both access and non-access site bleedings, but similar rates of MACE at 30 days compared to the StarClose SE® device.

Objectives Using the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, temporal trends, predictors, and outcomes of radial access (RA) versus femoral access (FA) for unprotected left main stem percutaneous coronary intervention (LMS-PCI) were studied. Background Data on arterial access site for LMS-PCI are poorly defined. Methods Data were analyzed from 19,482 LMS-PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes. Results The frequency of FA use fell from 77.7% in 2007 to 31.7% in 2014 (p Conclusions In contemporary practice, the radial artery is the predominant access site for unprotected LMS-PCI, and its use is associated with shorter length of stay, less vascular complications, and less major bleeding than femoral access.

Coronary artery disease is one of the leading causes of mortality in the world. The presence of concomitant peripheral artery disease increases the risks of cardiovascular events along with limiting the arterial access for coronary intervention. Invasive management of such cases includes either alternate site access or combined peripheral and coronary revascularization. We hereby report a patient of the infrarenal abdominal aorta and bilateral subclavian arterial occlusion, who presented with acute coronary syndrome. To perform the percutaneous coronary intervention, we first performed the endovascular stenting of occluded aortoiliac disease, followed by stenting of the right coronary artery. We had discussed the limitation of arterial access to perform PCI in such a situation.

Percutaneous coronary interventions (PCIs) are nonsurgical procedures to open blocked blood vessels to the heart, frequently using a catheter to place a stent. The catheter can be inserted into the blood vessels using an artery in the groin or an artery in the wrist. Because clinical trials have indicated that access via the wrist may result in fewer post procedure complications, shortening the length of stay, and ultimately cost less than groin access, adoption of access via the wrist has been encouraged. However, patients treated in usual care are likely to differ from those participating in clinical trials, and there is reason to believe that the effectiveness of wrist access may differ between males and females. Moreover, the choice of artery access strategy is likely to be influenced by patient or physician unmeasured factors. To study the effectiveness of the two artery access site strategies on hospitalization charges, we use data from a state-mandated clinical registry including 7,963 patients undergoing PCI. A hierarchical Bayesian likelihood-based instrumental variable analysis under a latent index modeling framework is introduced to jointly model outcomes and treatment status. Our approach accounts for unobserved heterogeneity via a latent factor structure, and permits nonparametric error distributions with Dirichlet process mixture models. Our results demonstrate that artery access in the wrist reduces hospitalization charges compared to access in the groin, with higher mean reduction for male patients., Comment: 11 tables, 5 figures

A single-access technique during mechanical circulatory support (MCS) and percutaneous coronary intervention (PCI) has been described for those patients where an additional arterial access site is not available or desired. This technique utilizes the Impella (Abiomed, Danvers, MA) 14 French (F) sheath as a single-access point, with a 7 F sheath through the 14 F sheath hemostatic valve next to the Impella catheter (Abiomed). However, this technique is limited to a 7 F sheath or smaller and can be difficult requiring multiple attempts and limit guide catheter manipulation. We describe a single-access technique utilizing the Impella (Abiomed) 14 F sheath and a standard 7 F guide catheter placed sheathless through the 14 F sheath hemostatic valve utilizing the Railway Sheathless Access System (Cortis, Santa Clara, CA).

Aim: The purpose of this paper was to evaluate the efficacy of ultrasound-guided percutaneous thrombin injection as a treatment method for arterial access site pseudoaneurysm. Materials and methods: A total of 148 patients with iatrogenic arterial access site pseudoaneurysms were treated in the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin. Of those, 142 pseudoaneurysms were located in the common femoral artery, 3 in the brachial artery and the remaining 3 in the radial artery. The study included 77 woman and 71 men (mean age 64.5 ± 14 years). Patients were qualified for percutaneous thrombin injection after Doppler examination during which pseudoaneurysm size and morphology were assessed as well as the presence of arteriovenous fistula was excluded. Results: In the reported study, 94.8% (128/135) of patients were successfully treated during the initial thrombin injection. Additional 400 IU dose of thrombin after 24 hours was effective in 5 out of 7 patients with recanalization during the follow-up. A total of 98.5% (133/135) of patients were successfully treated with a percutaneous ultrasound-guided thrombin injection. Conclusions: The 10-year experience presented in this study as well as literature reports prove that percutaneous ultrasound-guided thrombin injection is an effective and safe treatment method for iatrogenic arterial access site pseudoaneurysm.

Studies have shown reduction in major bleeding with trans-radial intervention (TRI) compared with trans-femoral intervention (TFI), and with use of bivalirudin compared with heparin+glycoprotein IIb/IIIa inhibitors (GPI). We compared major bleeding, mortality and the interaction between arterial access site and the anticoagulant used for PCI in Veterans.A retrospective cohort of 1192 consecutive patients who underwent PCI at a VA hospital between 2006 and 2012 was divided into TFI-heparin (n=192), TFI-bivalirudin (n=272), TRI-heparin (n=274) and TRI-bivalirudin (n=454) groups. Primary outcomes were in-hospital major bleeding, in-hospital and 1-year all-cause mortality. Secondary outcomes were in-hospital MI, in-hospital and 1-year MACE and net adverse cardiovascular events (NACE - composite of major bleeding+MACE).Femoral access was associated with a significantly increased risk of major bleeding compared with radial access (OR 11.87, p0.001). Correspondingly, radial access was protective against major bleeding compared with femoral access (OR 0.128, p0.01), but did not lower mortality or MACE by itself. Severe anemia was the only predictor of in-hospital all-cause mortality (OR=27.62, p0.008). Presence of anemia and age70 predicted 1-year mortality, whereas major bleeding and anemia predicted 1-year MACE. An interaction was noted between anticoagulant and access site, such that heparin showed significantly greater major bleeding in the femoral group compared with the radial group. Bivalirudin resulted in similar risk of bleeding, regardless of access site. There was a synergistic interaction between radial access and heparin (HR 0.38, p0.05), but not radial access and bivalirudin, on reduction in 1-year NACE.Radial access for PCI is associated with reduction in major bleeding, but does not have an effect on in-patient or 1-year MACE and mortality. Major bleeding is associated with poor short and intermediate term outcomes. In addition, anemia is strongly associated with increased in-patient and 1-year mortality. There is a differential effect of heparin but not bivalirudin on major bleeding, depending on the access site. There is no synergism between radial access and bivalirudin in lowering the composite outcome of MACE and major bleeding at 1year.

Objective To report the use of a vascular closure device (VCD) to provide rapid arterial hemostasis following percutaneous femoral arterial catheterization and diagnostic angiography in a thrombocytopenic and coagulopathic dog. Case Summary A 6-year-old female spayed Kai Ken Tora dog presented after vehicular trauma. The dog was diagnosed with traumatic pneumothorax, degloving wounds of the right antebrachium, subcutaneous hemorrhage within the axillary tissues of the left thoracic limb, and anemia and thrombocytopenia secondary to acute hemorrhage. Treatment included therapeutic thoracocentesis and open wound management of the right thoracic limb as well as packed RBC and fresh frozen plasma transfusions. Diagnostic angiography of the left brachial artery was performed via percutaneous femoral arterial access to investigate the source of a persistent axillary hematoma. The arterial access site was closed using an extraluminal VCD and hemostasis was immediate with normal femoral arterial blood flow documented by Doppler ultrasound. New or Unique Information Provided This report describes use of a VCD for arterial closure following percutaneous access in a dog with impaired hemostasis; to the authors’ knowledge, this is the first clinical report of a VCD used in a veterinary species.

Background Pre-procedural anemia is associated with increased bleeding and mortality post-percutaneous coronary intervention (PCI). The effect of trans-radial PCI (TR-PCI) in improving outcomes compared to trans-femoral PCI (TF-PCI) in anemic patients is not known. Objective The aim of this study was to evaluate the association between arterial access site (radial versus femoral) and outcomes in anemic Veterans undergoing PCI. Methods Patients with baseline anemia, undergoing PCI at Veterans Affairs (VA) facilities between 2009 and 2015, were divided into two groups based on primary radial or femoral access. The association between anemia and access site with in-hospital and one-year adverse outcomes was evaluated using multivariable analysis. Results 7330 veterans were included in the analysis, with 1712 (23%) treated via radial access. Baseline anemia was independently associated with in-hospital major bleeding (OR 3.8, 95% CI 2.5–5.6 for moderate anemia, OR 18.6, 95% CI 11.6–29.7 for severe anemia), and in-hospital mortality (OR 3.2, 95% CI 1.8–5.8 for moderate anemia, OR 7.9, 95% CI 3.7–16.8 for severe anemia). Anemia was also associated with increased one-year MACE and mortality. PCI performed via radial access was not associated with different outcomes compared with femoral access in the presence of anemia. Comparable results were noted when analysis was restricted to only patients with acute coronary syndrome (ACS). Conclusions Moderate and severe anemia were strongly associated with increased in-hospital and one-year mortality in a large healthcare system, though there was no interaction between arterial access site for PCI and clinical outcomes among patients with moderate or severe anemia.

Objectives This study aimed to assess the feasibility of percutaneous arterial access site closure after percutaneous transfemoral transcatheter aortic valve implantation (TF-TAVI) using single versus double Perclose ProGlide devices. Backgrounds Although suturing with the preclose technique has been widely adopted during TF-TAVI, the optimal vascular closure strategy is still under debate. Methods Data from 279 patients who underwent TF-TAVI, obtained from the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) Japanese multicenter registry. Technical, procedural, and clinical outcomes were compared between the single ProGlide group (n = 99) and double ProGlide group (n = 180). They were also analyzed by propensity adjusted matching model (single [n = 69] vs. double [n = 69]). All patients were treated through a 16-Fr to 20-Fr eSheath. Technical success of the closure device was defined as hemostasis not requiring alternative invasive treatment. Access site-related vascular complications, bleedings, and other procedural complications were defined according to the Valvular Academic Research Consortium-2 (VARC-2) criteria. Results The rates of technical success and access site-related vascular complications were similar in the 2 groups (94.9% vs. 91.6%, p = 0.44; 5.0% vs. 7.7%, p = 0.54, respectively). The prevalence of bleeding complications did not differ between the 2 groups (1.0% vs. 3.3%, p = 0.43). Thirty-day mortality rate also showed no difference between the 2 groups (2.0% vs. 1.1%, p = 0.95), although these events were not associated with access site failure. These results were not attenuated in the propensity matching model. Conclusions Vascular closure with a single ProGlide in TF-TAVI could achieve equivalent, acceptable rates of technical success and procedural complications compared with the double ProGlide technique. © 2016 Wiley Periodicals, Inc.

Objectives The aim of this meta-analysis was to study the relation between access site and bivalirudin use on outcomes in patients with acute coronary syndrome (ACS). Background Bivalirudin and radial access use are 2 strategies that are increasingly used to lower major bleeding in patients with ACS undergoing invasive approaches. The interaction between these 2 strategies and the benefit of using them in combination are unclear. Methods This analysis included randomized controlled trials that compared bivalirudin to heparin with or without glycoprotein IIb/IIIa inhibitors in patients with ACS and reported outcomes stratified by arterial access site. Meta-analyses of outcome data were performed on the basis of access site and anticoagulation regimen. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated from event rates using random-effects models. Results Eight trials with a total of 27,491 patients were included. Bivalirudin reduced major bleeding risk in patients with femoral access (OR: 0.51; 95% CI: 0.46 to 0.6; p Conclusions Bivalirudin reduces bleeding risk only with femoral access, and radial access reduces bleeding risk only with heparin anticoagulation. Therefore, there is no additional benefit to the combined use of bivalirudin and radial access strategies in patients with ACS.

Background— The transradial access (TRA) site has become the default access site for percutaneous coronary intervention in the United Kingdom, with randomized trials and national registry data showing reductions in mortality associated with TRA use. This study evaluates regional changes in access site practice in England and Wales over time, examines whether changes in access site practice have been uniform nationally and across different patient subgroups, and provides national estimates for the potential number of lives saved or lost associated with regional differences in access site practice. Methods and Results— Using the British Cardiovascular Intervention Society database, we investigated outcomes for growth of TRA in different regions in England and Wales in 448 853 patients who underwent percutaneous coronary intervention from 2005 to 2012. Multiple logistic regression was used to quantify the effect of TRA on 30-day mortality and quantify lives saved and lost by differences in TRA adoption. TRA use increased from 14.0% to 58.6% in 417 038 PCI patients with large variations in different parts of the country. TRA was independently associated with a decreased risk of 30-day mortality (odds ratio=0.70; 95% confidence interval=0.66–0.74), with significant but small differences observed across different regions. The number of estimated lives saved was 450 (95% confidence interval=275–650), and we estimate that an additional 264 (95% confidence interval=153–399) lives would have been saved if TRA adoption were uniform nationally. Conclusions— TRA has become the dominant percutaneous coronary intervention approach in the United Kingdom, with a wide variation in different parts of the country. Changes in practice have contributed to mortality reductions, and inequalities have resulted in missed opportunities for further improvements.

Although ultrasound (US) guidance for venous access is becoming the “standard of care” for preventing access site complications, its feasibility for arterial access has not been fully investigated, especially in the neuro-interventional population. We conducted the first prospective cohort study on US-guided femoral artery access during neuro-interventional procedure. This study included 64 consecutive patients who underwent US-guided femoral artery access through 66 arterial access sites for diagnostic and/or neuro-interventional purposes. The number of attempts required for both the sheath insertion and the success of anterior wall puncture were recorded. In addition, the occurrence of major complications and hematoma formation on the arterial access site examined by US were statistically analyzed. The median number of attempts was 1 (1–2) and first-pass success rate was 63.6%. Anterior wall puncture was achieved in 98.5%. In one case (1.5%), a pseudoaneurysm was observed. In all cases, US clearly depicted a common femoral artery (CFA) and its bifurcation. Post-procedural hematoma was detected in 13 cases (19.7%), most of which were “tiny” or “moderate” in size. Low body mass index and antiplatelet therapy were the independent risk factors for access site hematoma. The US-guided CFA access was feasible even in neuro-interventional procedure. The method was particularly helpful in the patients with un-palpable pulsation of femoral arteries. To prevent arterial access site hematoma, special care should be taken in patients with low body mass index and who are on antiplatelet therapy.

Background There are little available contemporary real-world data in the era of third-generation P2Y12-receptor inhibitors, examining the association between glycoprotein IIb/IIIa inhibitors (GPI) and outcomes in patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI), according to arterial access site. Objectives We sought to investigate this association in a contemporary cohort of real-world patients. Methods Clinical and follow-up data for all patients undergoing PPCI in Leeds General Infirmary between 01–01–2009 and 31–12–2011, and 01–01–2013 and 31–12–2013 were collected prospectively. Patients included in this analysis had pre-procedural Thrombolysis in Myocardial Infarction (TIMI)−0 flow and post-procedural TIMI-3 flow in their infarct-related artery. Clinical endpoints were 30 day and 12 month mortality, and 30 day HORIZONS-major bleeding. Patients were analysed according to arterial access site with Cox-regression models, to assess the association between GPI use and outcomes in each group (transfemoral PPCI and transradial PPCI), adjusting for confounding variables. Results A total of 2369 patients were included in this analysis, of whom 821 (34.7%) underwent transfemoral PPCI and 1548 (65.3%) underwent transradial PPCI (Figure 1). GPI was used in 169 (20.6%) patients undergoing transfemoral PPCI, and 179 (11.6%) patients undergoing transradial PPCI. In transfemoral PPCI, GPI use was independently associated with 30 day mortality (HR 2.04 (1.05–3.94); p=0.03) and 30 day bleeding (HR 2.05 (1.07–3.93); p=0.03), particularly arterial access site bleeding (HR 2.71 (1.00–7.37); p=0.05), with no significant difference in 12 month mortality (HR 1.48 (0.82–2.67); p=0.20) (Table 1; Figures 2 (A)-(C)). However, in transradial PPCI, GPI use was not associated with 30 day (HR 1.27 (0.39–4.16); p=0.69) or 12 month (HR 1.21 (0.58–2.51); p=s0.62) mortality, or 30 day bleeding (HR 1.93 (0.73–4.76); p=0.16) (Figures 3 (A)-(C)). Conclusion In transfemoral PPCI, GPI use was independently associated with worse 30 day mortality and 30 day bleeding, particularly access-site bleeding. This association was not observed in transradial PPCI.

Background Patients' intra and post procedural comfort, quick recovery, as well as procedure success, are key elements for choosing the right arterial access site. Radial artery access has been of increasing interest since it was first described. Advanced treatments of coronary lesions, from primary percutaneous interventions during ST elevation myocardial infarction cases to chronic total occlusion cases, have been increasingly done through the radial access. Distal left trans radial artery (dlTRA) is a new technique first described by Kiemineij. We report the first documented US experience of the left distal radial artery access for coronary angiography and interventions. Methods dlTRA was attempted on 22 consecutive patients, consented for a cardiac catheterization . 7 patients underwent percutaneous coronary intervention. The left hand is prepped in the usual fashion, exposing the anatomical snuff box. Under ultrasound guidance, the artery is punctured and the sheath is inserted carefully. The cardiac catheterization is completed using standard diagnostic and guiding catheters, that are typically chosen for femoral artery access. Hemostasis was achieved with a radial band. Patients had the ability to use the right hand as well as bend their left wrist post procedure. Results dlTRA was successful in all 22 patients. 7 patients underwent PCI through this approach. Two patients required a multivessel complex PCI with multiple stents and additional equipment. There were no conversions to the right radial or femoral approach. All patients had excellent hemostasis with a radial band, with no complications. Pre discharge radial pulses were intact in the wrist as well as in the anatomical snuff box. Conclusion Distal left trans radial access is feasible and safe in patients that are carefully selected and are deemed good candidates. There is a learning curve for developing such program, as is the case with conventional radial access.

Optimal management of vascular access sites to assure hemostasis while minimizing the risk of vascular injury or complication has been a primary challenge of all endovascular techniques. While manual compression of the arterial access site had been the standard approach to hemostasis for many procedures, tools and techniques for mechanical compression and the development of implantable vascular closure devices now provide a variety of options for the management of vascular access sites. Given the many options for vascular access site management, it is encumbant on the endovascular expert to incorporate available evidence, as well as their own experience and expertise, in the selection of a access site management strategy. In this chapter, we review the evidence for the use of various vascular access site management techniques including manual compression, mechanical compression and vascular closure devices, and explore the unique advantages and disadvantages of each approach.

Shared decision-making (SDM) has become a cornerstone of patient-centered medicine. In order to better understand SDM related to arterial access site choices, we studied patient understanding of risks and benefits associated with transradial (TRA) and transfemoral (TFA) cardiac catheterization. A

Transradial access for cardiac catheterisation results in lower bleeding and vascular complications than the traditional transfemoral access route. However, the increased radiation exposure potentially associated with transradial access is a possible drawback of this method. Whether transradial access is associated with a clinically significant increase in radiation exposure that outweighs its benefits is unclear. Our aim was therefore to compare radiation exposure between transradial access and transfemoral access for diagnostic coronary angiograms and percutaneous coronary interventions (PCI).We did a systematic review and meta-analysis of the scientific literature by searching the PubMed, Embase, and Cochrane Library databases with relevant terms, and cross-referencing relevant articles for randomised controlled trials (RCTs) that compared radiation parameters in relation to access site, published from Jan 1, 1989, to June 3, 2014. Three investigators independently sorted the potentially relevant studies, and two others extracted data. We focused on the primary radiation outcomes of fluoroscopy time and kerma-area product, and used meta-regression to assess the changes over time. Secondary outcomes were operator radiation exposure and procedural time. We used both fixed-effects and random-effects models with inverse variance weighting for the main analyses, and we did confirmatory analyses for observational studies.Of 1252 records identified, we obtained data from 24 published RCTs for 19 328 patients. Our primary analyses showed that transradial access was associated with a small but significant increase in fluoroscopy time for diagnostic coronary angiograms (weighted mean difference [WMD], fixed effect: 1·04 min, 95% CI 0·84-1·24; p0·0001) and PCI (1·15 min, 95% CI 0·96-1·33; p0·0001), compared with transfemoral access. Transradial access was also associated with higher kerma-area product for diagnostic coronary angiograms (WMD, fixed effect: 1·72 Gy·cm(2), 95% CI -0·10 to 3·55; p=0·06), and significantly higher kerma-area product for PCI (0·55 Gy·cm(2), 95% CI 0·08-1·02; p=0·02). Mean operator radiation doses for PCI with basic protection were 107 μSv (SD 110) with transradial access and 74 μSv (68) with transfemoral access; with supplementary protection, the doses decreased to 21 μSv (17) with transradial access and 46 μSv (9) with transfemoral. Meta-regression analysis showed that the overall difference in fluoroscopy time between the two procedures has decreased significantly by 75% over the past 20 years from 2 min in 1996 to about 30 s in 2014 (p0·0001). In observational studies, differences and effect sizes remained consistent with RCTs.Transradial access was associated with a small but significant increase in radiation exposure in both diagnostic and interventional procedures compared with transfemoral access. Since differences in radiation exposure narrow over time, the clinical significance of this small increase is uncertain and is unlikely to outweigh the clinical benefits of transradial access.None.

To intra-individually compare discomfort levels and patient satisfaction after arterial access closure using the ExoSeal® vascular closure device (VCD) and manual compression (MC) in a prospective study design. Patients undergoing two planned interventions from 07/2013 to 09/2014 could participate in the study. Access closure was performed with an ExoSeal®-VCD in one and MC in the other intervention. Patients were clinically and sonographically examined and were given questionnaires 1 day after intervention [groin- and back-pain during bedrest (100-point visual analog scale; 0: no pain); comfortability of bedrest (10-point Likert scale, 1: comfortable), satisfaction with closure (10-point Likert scale, 1: very satisfied)]. Results were analyzed in a cross-over design. 48 patients (29 male, median age 62.5 (32–88) years) were included. An ExoSeal®-VCD was used first in 25 cases. As four of these subsequently refused MC as second intervention, data from 44 patients could be analyzed. All closures were technically successful (successful device deployment) without major complications. Groin- and back-pain after VCD-use/MC was 0 (0–15) vs. 10 (0–80) and 0 (0–75) vs. 25 (0–90), respectively (p

Background Transradial (TR) access for percutaneous coronary intervention (PCI) reduces bleeding compared with transfemoral (TF) access, and may reduce mortality in specific patient subsets. However, switching from TF to TR access is associated with a learning curve and it is unclear whether benefits observed in randomized trials translate into practice. We sought to characterize the trends in bleeding and mortality rates at our institution, as we changed from being a TF to predominantly TR center over a 5-year period. Methods and Results 10,213 consecutive patients presenting for PCI were included (mean age 65.0 ± 11.6 years, 76.1% male, 48.0% PCI for acute coronary syndrome) over 5 years at a single center with PCI volume >2,000 cases per annum. Patients were stratified by initial arterial access site (TR or TF) and outcome measures included temporal trends in TR procedural failure, 30-day bleeding complications and all-cause 1-year mortality. TR procedural failure fell to a consistently low rate within 1 year (11.8% in 2008 to 2.9% in 2009, P

Aims To review the safety and feasibility of a transradial (TR) approach during transcatheter structural or congenital heart disease interventions when utilized as either as a primary or secondary arterial access site. Methods and Results Studies and case reports published between 2002 and 2014 utilizing the TR access during transcatheter structural and congenital heart disease interventions during alcohol septal ablation (ASA), ventricular septal defect (VSD), renal denervation (RD), paravalvular leak (PVL) closure, transcatheter aortic valve implantation (TAVI, secondary access) and endovascular repair of aortic coarctation (ERAC, secondary access) were evaluated. Access-site (femoral vs. TR) vascular and bleeding complications were assessed. Femoral access complications ranged from 0·16% to 40%, with an overall incidence of 2·2% (56/2521). There were 18 reports or studies specifically evaluating the utility of TR access in the context of transcatheter structural heart disease interventions (ASA: 3; VSD: 1; RD: 3; PVL closure: 1; TAVI: 7, ERAC: 3). The use of TR access either as primary or secondary access site was feasible and allowed the completion of the procedure in all cases. The overall incidence of access-site complications following a TR approach was 0·5% (2/406 patients), with no major vascular or bleeding complications. Conclusions A TR approach during transcatheter structural heart disease interventions appears to be a safe, effective means of delivering high procedural success accompanied by lower bleeding complications compared with the transfemoral approach.

This study sought to determine the relationships among access site practice, clinical presentation, and procedural outcomes in a large patient population.Transradial access (TRA) has been associated with improved patient outcomes in selected populations in randomized trials. It is unclear whether these outcomes are achievable in clinical practice.Using the BCIS (British Cardiovascular Intervention Society) database, we investigated outcomes for percutaneous coronary intervention procedures undertaken between 2007 and 2012 according to access site practice. Patients were categorized as stable, non-ST-segment elevation acute coronary syndrome (NSTEACS) and ST-elevation acute coronary syndrome (STEACS). The impact of access site on 30-day mortality, major adverse cardiac events, bleeding, and arterial access site complications was studied.Data from 210,260 TRA and 229,687 transfemoral access procedures were analyzed. Following multivariate analysis, TRA was independently associated with a reduction in bleeding in all presenting syndromes (stable odds ratio [OR]: 0.24, p0.001; NSTEACS OR: 0.35, p0.001; STEACS OR: 0.47, p0.001) as well as access site complications (stable OR: 0.21, p0.001; NSTEACS OR: 0.19; STEACS OR: 0.16, p0.001). TRA was associated with reduced major adverse cardiac events only in patients with unstable syndromes (stable OR: 1.08, p = 0.25; NSTEACS OR: 0.72, p0.001; STEACS OR: 0.70, p0.001). TRA was associated with improved outcomes compared with a transfemoral access (TFA) with a vascular closure device in a propensity matched cohort.In this large study, TRA is associated with reduced percutaneous coronary intervention-related complications in all patient groups and may reduce major adverse cardiac events and mortality in ACS patients. TRA is superior to transfemoral access with closure devices. Use of TRA may lead to important patient benefits in routine practice. TRA should be considered the preferred access site for percutaneous coronary intervention.

Since the introduction of transradial coronary intervention (TRI) by Kiemeneij, its advantages over transfemoral coronary intervention (TFI) have been shown in many clinical situations. TRI can reduce the incidence and severity in the bleeding complications through arterial access site [1], which result in the reduction in mortality, length of hospital stay and cost after percutaneous coronary intervention (PCI). Since TRI is more patients’ friendly, most of the patients, who have received both TRI and TFI, prefer to the former from next session.

The femoral artery has been the primary percutaneous-based arterial access site for coronary artery catheterizations for more than three decades. Noncardiac percutaneous-based procedures have also been performed primarily with femoral access and have increased in number exponentially by vascular specialists in past decades. Groin complications are infrequent in incidence after femoral arterial access for cardiac and peripheral diagnostic and interventional cases, with groin hematomas and pseudoaneurysms being the most common. Until ultrasound-based treatment modalities became the mainstay of treatment, vascular surgeons were the primary specialty managing pseudoaneurysms, but now other specialties also manage these cases. This review outlines the clinical implications and current issues relevant to understanding the ideal treatment strategy for this common complication.

The history of cardiac catheterization began in 1711 with an equine biventricular catheterization and progressed through the centuries.1 In 1929, German physician Forssmann boldly performed a right heart catheterization on himself, and subsequently shared the 1956 Nobel Prize in Medicine with Columbia University physicians Cournand and Richards for the development of cardiac catheterization.1 The actions of these medical pioneers paved the way for modern interventions of the heart and coronary arteries, prompting the advent of interventional cardiology.1 In 1989 Campeau was able to perform the first diagnostic cardiac catheterization via the radial artery, and in 1993 Kemeneij and Laarman were able to complete a radial access percutaneous coronary artery intervention, a procedure involving angioplasty and stenting.2 With regards to arterial access site, the femoral artery and radial artery are routinely selected. For patients in whom radial and femoral access is impossible, the brachial method is sometimes employed, though less desirable due to the risk of complications, including neuropathy.3 4 Rarely, experienced operators opt for axillary entrance.3 Unfortunately, major weaknesses of catheter-based procedures are the risks of acute vessel closure, restenosis, bleeding, and pseudoaneurysm.1 3 Overall analysis of complications in 200,000 patients undergoing diagnostic cardiac catheterization indicates that less than 1% of patients experience vascular complications such as thrombosis, pseudoaneurysms, or bleeding requiring transfusion.3 Much research in the last 30 years has been devoted to determining which access site is best suited for particular patients and circumstances; as technological advances expand the boundaries of possibilities, this work continues. In spite of the efficacy of femoral catheterizations for cardiac procedures, vascular bleeding complications give rise to increased morbidity and duration of hospitalization, especially when aggravated by aggressive anticoagulation and antiplatelet treatment.5 6 The femoral approach has been compared with the radial approach for both diagnostic and interventional procedures in multiple randomized trials and observational studies. An important advantage of the radial artery is that unlike the brachial and femoral arteries, it is not an end artery, so even in the event of occlusion, blood from collateral arteries will prevent ischemia of the territory that it supplies. Current literature suggests lower rates of vascular and neurological complications in radial access procedures since the artery is more compressible, facilitating sheath removal, and not immediately associated with a nerve. Numerous studies also report earlier patient discharge, earlier time to ambulation, patient preference for the procedure, and a shorter recovery period associated with radial access.7 A potential complication with the procedure is radial artery occlusion, which hinders future radial access and use of the artery for dialysis fistulas and bypass grafts.8 The reported rates of radial artery occlusion vary widely, spanning 5 to 40% depending on institution and study specific protocol.9 10 However, hand ischemia is largely preventable if the patient's ulnar supply to the palmar arch is assessed before the procedure by Allen test.8 We aim to review praxes and trends of transradial catheterization procedures across the globe, paying particular attention to metrics of cost-effectiveness, procedural safety, complications, and effectiveness across a variety of clinical scenarios.

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.

Objectives Aim of this study was to analyze feasibility, efficacy, and safety of a double-ProGlide preclose technique for access site closure after transfemoral transcatheter aortic valve implantation (TAVI). Background An effective and safe transcutaneous closure device is advantageous in transfemoral TAVI to avoid surgical cut down of the large caliber sheath insertion site. The use of two ProGlide sutures has not been described in this context in a large patient cohort. Methods ProGlide closure was used between 2010 and 2012 in 162 patients. ProGlide sutures were deployed in a preclose technique prior to insertion of the large caliber sheath. Success of the closure technique was defined as effective hemostasis and no further access site-related vascular or bleeding complications during the index hospitalization. Results Patients were 82 ± 5 years old with a logistic EuroSCORE of 16.7 ± 12.5. Edwards SAPIEN valves were used in 81.5% and Medtronic CoreValves in 18.5%. The overall success rate of the double-ProGlide technique was 93.9%. Success rate was only 40.0% under circumstances of prolonged high-dose heparinization. Success rate was 96.8% among the patients on dual-antiplatelet therapy (DAPT). All 10 ProGlide failures could effectively be managed by either percutaneous angioplasty or surgical reconstruction. The rate of VARC major vascular complications was 4.3%. Thirty-day mortality was 5.6%. Conclusion The double-ProGlide preclose technique offers a simple, highly effective, and safe method for closure of the arterial access site after transfemoral TAVI. The double-ProGlide strategy results in low rates of major vascular complications and translates into favorable early outcome. © 2013 Wiley Periodicals, Inc.

Objectives This study sought to investigate the influence of access site utilization on mortality, major adverse cardiac and cardiovascular events (MACCE), bleeding, and vascular complications in a large number of patients treated by primary percutaneous coronary intervention (PPCI) in the United Kingdom over a 5-year period, through analysis of the British Cardiovascular Intervention Society database. Background Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing PPCI. A significant proportion of such bleeding complications are related to the access site, and adoption of radial access may reduce these complications. These benefits have not previously been studied in a large unselected national population of PPCI patients. Methods Mortality (30-day), MACCE (a composite of 30-day mortality and in-hospital myocardial re-infarction, target vessel revascularization, and cerebrovascular events), and bleeding and access site complications were studied based on transfemoral access (TFA) and transradial access (TRA) site utilization in PPCI STEMI patients. The influence of access site selection was studied in 46,128 PPCI patients; TFA was used in 28,091 patients and TRA in 18,037. Data were adjusted for potential confounders using Cox regression that accounted for the propensity to undergo radial or femoral approach. Results TRA was independently associated with a lower 30-day mortality (hazard ratio [HR]: 0.71, 95% confidence interval [CI]: 0.52 to 0.97; p Conclusions This analysis of a large number of PPCI procedures demonstrates that utilization of TRA is independently associated with major reductions in mortality, MACCE, major bleeding, and vascular complication rates.

Background Vascular complications associated with transfemoral transcatheter aortic valve insertion (TAVI) are a frequent untoward consequence of arterial sheath insertion. We report the prevalence of anatomic arterial injury with open artery access TAVI. Methods This review consisted of 53 consecutive patients who received transfemoral Sapien 23 or 26 mm TAVI via the 22- or 24-French sheath through open artery access from November 2008. The median age of the patients was 83 years (range, 59 to 94), and there were 31 males (58%). All arteries were examined to determine the optimal point of access and then explored after removal of the sheath to document injury. Results The accessed artery had a minimal lumen diameter of 8.9 mm (7.2 to 14.7) and a sheath-to-artery ratio of 1.0 (0.6 to 1.2). The point of access was the common femoral artery in 33 patients (62%) and the external iliac artery in 20 (38%). Exploration of the artery demonstrated localized arterial injury in 22 patients (42%). Female gender was predictive of injury (p = 0.03), but arterial access site location, presence of arterial access calcification, sheath-to-artery ratio, and sheath size were not. Techniques of artery repair included primary closure in 34 patients (64%), pericardial patch angioplasty in 15 (28%), and graft interposition in 4 (8%). There was one minor groin wound complication. Conclusions Open artery access allows for direct examination and optimal access site choice of the vessel during transfemoral TAVI. Localized arterial injury was commonly encountered after 22- and 24-French sheath insertion, but the associated artery repair complication rate was low. doi: 10.1111/jocs.12140 (J Card Surg 2013;28:348–352)

Percutaneous arterial closure devices have increasingly entered clinical practice to assist in achieving femoral arterial access site hemostasis. Prior studies have demonstrated the safety and efficacy of several arterial closure devices in adults. To evaluate the efficacy of using an arterial closure device in children. A retrospective review of all children (defined as younger than 18 years) undergoing device-assisted closure of their percutaneous femoral arterial access site was conducted. Patient demographics, the clinical indications for use of the arterial closure device and pre-procedural laboratory parameters were noted. The accessed common femoral artery diameter and largest procedural sheath size were recorded. The technical success rate for device deployment and rates of immediate and delayed complications including hemorrhage, access site or retroperitoneal hematoma, access site infection, arterial thromboembolism, pseudoaneurysm or arteriovenous fistulae were documented. Between June 2009 and June 2011, an arterial closure device was deployed with intent to achieve hemostasis in percutaneous femoral arterial access punctures in 38 consecutive children. The mean common femoral artery diameter was 0.70 ± 0.13 cm. Device deployment was technically successful in 37/38 (97.4%) procedures. There was a single complication (2.6%), a small access site hematoma. No other immediate or delayed complications occurred. The use of a percutaneous arterial closure device can be an efficacious method for achieving immediate femoral arterial access site hemostasis with few complications in children who have undergone percutaneous femoral arterial access procedures.

The volume of cardiac diagnostic procedures involving the use of ionizing radiation has increased rapidly in recent years, and the radiation exposure experienced by patients undergoing any medical imaging procedure has recently obtained a growing attention. Transradial (TR) access is being increasingly used worldwide for diagnostic coronary angiography (CA), and percutaneous coronary interventions, since it offers several benefits as compared to transfemoral (TF) access, such as by reducing hemostasis time and vascular complications, increased patient comfort, reduced hospital stay, and lower cost. In contrast, TR CA is thought to be associated with increased radiation exposure parameters compared with the traditional TF access. Although experienced operators may almost counterbalance this shortcoming, the increase in radiation exposure associated with TR approach seems not to be present in most clinical settings.

As interventional cardiologists, we often decide at the end of a procedure whether to close the femoral arterial access site with a vascular closure device (VCD). We make this decision based on a multitude of factors, including the extent of calcification of the femoral artery, the location and quality of the arterial puncture site, and whether the patient requires continued arterial pressure monitoring because of a tenuous condition, or conversely, might benefit from earlier ambulation with a VCD to facilitate same day discharge. As clinical investigators, we have learned that the inability to capture the clinical nuances that govern treatment decisions create the preconditions for confounding of observational studies, particularly when these variables may themselves be associated with …

The femoral artery pseudoaneurysm is a disturbing groin complication associated with the femoral arterial access site used for invasive cardiovascular interventions. We present a 39 year old man who developed a huge right common femoral artery pseudoaneurysm, following diagnostic coronary artery catheterization, which was successfully managed with stent-assisted coiling, an emerging and narrative option in invasive percutaneous approaches to femoral artery pseudoaneurysm.

Background Published data relating to arterial access site selection and radiation exposure during coronary procedures suggest radial access may lead to increased radiation exposure, but this is based on poorly controlled studies. We sought to measure radiation exposure to patients and operators during elective coronary angiography (CA) according to access site, with other procedure related variables controlled for. We also investigated the specific effect of operator expertise in relation to radiation exposure. Methods 100 consecutive patients undergoing first time elective CA were recruited prospectively. An expert transradial (TR) and an expert transfemoral (TF) operator performed 25 cases each via their default route. A trainee cardiologist with intermediate experience in both access sites performed 25 cases via each route. Angiographic projections were standardised and optimised radiation protection was utilised for all procedures. The primary endpoints were operator and patient exposure, quantified by effective dose (ED) and dose area product (DAP) respectively. Secondary endpoints included fluoroscopy time (FT) and time to patient ambulation. Results The trainee operator recorded higher values for radiation exposure in radial and femoral cases when compared to the expert operators. There were no significant differences in radiation exposure during CA to operator or patient according to access site when standardised by operator experience. For the trainee, ED for TR and TF procedures was 8.8 ± 4.3 μSv and 8.5 ± 6.5 μSv ( P = .86) and DAP was 25.4 ± 4.8 Gycm 2 vs 25.2 ± 8.3 Gycm 2 ( P = .9). For the expert TR and TF operators, ED was 6.4 ± 4.7 μSv vs 6.1 ± 5.6 μSv ( P = .85) and DAP was 21.7 ± 6.5 Gycm 2 vs 22.4 ± 8.0 Gycm 2 , ( P = .74). There was no significant difference in FT in relation to access site. Time to ambulation was significantly longer with TF access. Conclusion The use of TR access has no adverse effect on radiation exposure or FT for diagnostic CA, but does allow for quicker ambulation compared to TF access. The magnitude of radiation exposure is related to operator expertise for both access sites. The results of previous studies reflect the effect of uncontrolled patient and operator variables and not access site selection.

Objectives To evaluate feasibility, safety and efficacy of percutaneous arterial access site closure after transfemoral, transcatheter aortic valve implantation (TF-TAVI) using a single, commercially available six French monofilament suture-mediated vascular closure device (VCD) in “preclosure” technique. Background Currently, TF-TAVI is evolving into a completely percutaneous procedure. However, percutaneous access site closure still remains a major technical challenge with room for improvement. Methods 94 of 144 consecutive patients underwent completely percutaneous TF-TAVI using following technique for access site closure: After puncture of the common femoral artery using fluoroscopy and contralateral angiography for guidance, the VCD was deployed prior further predilatation of the vessel and insertion of the large-bore introducer sheath. At the end of the procedure, the preloaded sutures were tied for final hemostasis and crossover angiography was used for postprocedural evaluation of the access vessel. Results Application of the VCD was technically successful in all cases, resulting in an efficient hemostasis with cessation of any bleeding within 10 min of final knot-tying in 83 of the 94 patients, and there was only one closure-failure with continuous bleeding despite prolonged manual compression requiring endovascular treatment. In addition, we observed four closure-related access vessel stenoses of hemodynamic relevance requiring endovascular treatment in three and surgical repair in one patient. However, interventional and surgical repair was not associated with death or irreversible end-organ damage and all patients recovered without sequelae. Conclusion “Preclosure” of the arterial access site with a single six French suture-mediated VCD is relatively easy, safe and efficient method for access site closure after TF-TAVI which, along with ongoing profile reductions of TAVI devices, should further simplify and broaden the way toward a routine, completely percutaneous procedure. © 2012 Wiley Periodicals, Inc.

Trans-radial cardiac catheterization has lower rates of arterial access site complications. Hydrophilic-coated sheaths designed specifically for trans-radial procedures have resulted in numerous reports of a foreign body reaction to retained material. Although this is a self-limited condition that should be managed expectantly, it is often confused with an infected pseudoaneurysm, resulting in unnecessary surgery. We searched the FDA MAUDE (Manufacturer and User Facility Device Experience) database to determine which brands of sheath have been associated with this complication. In addition, we performed a literature search for all reported cases of this complication. Only one brand of sheath has been associated with this condition. As trans-radial procedures become more common in the US, knowledge of such complications, which appear to be specific to the Cook radial hydrophilic-coated sheaths, is imperative for all radial interventionalists to prevent unnecessary surgical procedures. © 2010 Wiley-Liss, Inc.

Background: Access site complications requiring emergent surgery following femoral catheterization expose patients to additional morbidities and mortality. We observed a significant decrease in such surgeries after the Mynx device was introduced. Methods: A retrospective review of surgeries performed as a complication of 6F & 7F femoral cardiac and peripheral catheterization was done. Rates of surgeries among 3 closure methods were compared during the study period July 2006 to July 2008 (Mynx, AngioSeal, and manual/mechanical compression). Results: Of 11 006 6F &7F transfemoral catheterization procedures, 26 (0.24%) surgeries secondary to access complications resulted. Surgeries were done in 14 (0.61%) AngioSeal patients, 10 (0.19%) manual/mechanical compression, and 2 (0.06%) Mynx patients (P < .0001 vs AngioSeal, P = .14 vs compression). Conclusions: Significant reduction in surgeries was seen in the Mynx vs Angioseal patients, no difference was noted in compression subset. Further analysis is warranted to prospectively evaluate these findings.

Femoral arterial access site complications are responsible for a substantial proportion of the bleeding complications that occur in patients undergoing percutaneous coronary intervention (PCI). Because bleeding is associated with an increase in morbidity and mortality, pharmacologic and nonpharmacologic strategies associated with lower bleeding risk may improve outcomes. From this perspective, radial artery access, which is associated with a similar rate of success as femoral artery access with lower rates of bleeding, might become the "gold standard" for PCI. Although transradial technique requires a specific skill set and significant learning curve, success rates comparable to those of the femoral approach may be achieved. The benefits of radial access may be further enhanced by using antithrombotic strategies that maintain efficacy but limit bleeding risk. Indeed, a substantial proportion of bleeding complications unrelated to the access site occur, a finding that supports the use of safer antithrombotic regimens to optimize patient outcomes.

Background Dual antiplatelet treatment with aspirin and a thienopyridine is the antithrombotic treatment recommended after coronary stenting. Such strategy is generally not applicable in most patients with an indication for oral anticoagulation (OAC), for whom however, information about the optimal antithrombotic regimen is currently limited. Methods In order to derive some practical indications for the clinicians who are requested to care for these patients, the available evidence on the use, safety and efficacy of the various antithrombotic strategies was reviewed. Results A substantial variability in the choice of treatment was observed in current practice where, however, standardized management protocols are seldom used. Triple therapy with OAC, aspirin and a thienopyridine is the most frequently adopted regimen, although its safety appears suboptimal, due to an apparent increased incidence of major hemorrhagic complications. Conversely, the efficacy of the combination of OAC and aspirin is suboptimal, so that such regimen should be considered only for patients at very high hemorrhagic risk, and in association with the implantation of more "biocompatible" stents. Conclusions While waiting for further studies to generate more consistent evidence, the choice of the antithrombotic treatment for patients with an indication for OAC undergoing coronary stenting should be guided by careful stratification of both thrombotic/thromboembolic and hemorrhagic risks. In general, however, the implantation of drug-eluting stents should be avoided, due to the prolonged need for dual antiplatelet administration, and the radial approach preferred, due to the virtual elimination of bleeding complications at the arterial access site.

The removal of arterial cannulas using a Perclose device (Abbott Vascular, Clonmel, Tipperary, Ireland) has not been reported in patients undergoing venoarterial extracorporeal membrane oxygenation (ECMO). We investigated the procedural outcomes and complications of percutaneous device closure vs surgical repair for hemostatic control of the arterial access site in weaning from venoarterial ECMO.Between September 2012 and December 2014, 115 patients with ECMO weaned by percutaneous or surgical access were enrolled. The percutaneous technique used two ProGlide devices (Abbott Vascular) by direct puncture of an arterial cannula at the time of weaning off ECMO. The primary outcomes were composite complications of open repair at the insertion site, limb ischemia after removal of the arterial cannula, removal site infection, pseudoaneurysm, distal part embolization, and 10 minutes or more manual compression at the weaning site.The percutaneous technique was performed on 56 patients, and the surgical exposure technique was performed on 59. Technical success was not significantly different between the percutaneous and surgical groups (85.7% vs 86.4%; P = 1.0) although the procedure duration (17.15 ± 9.38 minutes vs 64.33 ± 31.67 minutes; P .001) was shorter in the percutaneous access group. A composite of procedure-related complications and length of stay in the intensive care unit after weaning was not significantly different between groups (17.9% vs 28.8%; P = .19 and 16.82 ± 38.53 days vs 19.69 ± 21.40 days; P = .62).Percutaneous access using two Perclose ProGlide devices was a feasible and safe strategy for weaning from ECMO.

Background— In European Ambulance Acute Coronary Syndrome Angiography (EUROMAX), bivalirudin improved 30-day clinical outcomes with reduced major bleeding compared with heparins plus optional glycoprotein IIb/IIIa inhibitors. We assessed whether choice of access site (radial or femoral) had an impact on 30-day outcomes and whether it interacted with the benefit of bivalirudin. Methods and Results— In EUROMAX, choice of arterial access was left to operator discretion. Overall, 47% of patients underwent radial and 53% femoral access. Baseline risk was higher in the femoral access group. Unadjusted proportions for the primary outcome (death or noncoronary artery bypass graft protocol major bleeding at 30 days) were lower with radial access, however, without differences in major or major plus minor bleeding proportions. After multivariable adjustment, ischemic outcomes were no longer different between access site groups, except for a lower risk of stroke in radial patients. Bivalirudin was associated with lower proportions of the primary outcome in both the radial (odds ratio, 0.58; 95% CI, 0.33–1.03; P =0.058) and the femoral groups (odds ratio, 0.59; 95% CI, 0.37–0.93; P =0.022; interaction P =0.97). Bleeding was significantly lower in the bivalirudin group both in the radial- and femoral-treated patients but no significant difference was observed in ischemic outcomes. In multivariable analysis, bivalirudin emerged as the only independent predictor of reduced major bleeding (odds ratio, 0.45; 95% CI, 0.27–0.74; P =0.002). Conclusions— In this prespecified analysis from EUROMAX, radial access was preferred in lower risk patients and did not improve clinical outcomes. Bivalirudin was associated with less bleeding irrespective of access site. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01087723.

Complications of vascular access are common after diagnostic coronary angiography and percutaneous coronary intervention (PCI), and include bleeding from the arterial access site, hematoma and pseudoaneurysm formation, and retroperitoneal hemorrhage [(1)][1]. These complications are uncomfortable

According to data reported by the American Heart Association, more than 5 million diagnostic and therapeutic catheterizations are performed each year in the United States. The number of catheterizations has tripled since 1979. It has been estimated that complications related to the access site result in more than 75,000 surgical procedures annually. Thus, improved management of the access site itself is essential to achieve the greater goals of improved care and reduced cost. Manual compression directly over the site of arterial puncture usually results in adequate hemostasis but has several significant drawbacks. Manual compression is uncomfortable for the patient, is fatiguing and time-consuming for staff, and necessitates several hours of costly in-hospital observation. In addition, it may be ineffective in achieving hemostasis, especially in the setting of systemic anticoagulation or following the use of large-bore devices. Based on the perceived need for an improved method of managing the arterial access site following catheterization, various vascular sealing devices have been developed. There are at least 8 (and the number is increasing) hemostatic vascular closure devices that are currently approved by the FDA for access site closure after femoral arterial catheterization. The chief advantage attributed to vascular sealing devices is accelerated access site hemostasis, even in the setting of anticoagulation, leading to earlier ambulation and hospital discharge following arterial catheterization. The most important drawbacks related to vascular sealing devices include the cost of the devices and the possibility of increased access site complications. Despite the paucity of properly designed studies supporting their use, it is estimated that over one million vascular sealing devices are used annually in the United States, a number that has increased dramatically in the past 5 years.In this review, we present a brief description of the design and function of the most widely used devices, describe the most common mechanisms of failure, and recommend strategies for management of access site complications including hemorrhage, arterial obstruction, and infection.

Objectives: Our objective was to analyze the impact of arterial access site, sheath size, timing of sheath removal, and use of access site closure devices on high-risk patients with acute coronary syndromes (ACS). Background: In the SYNERGY trial, 9,978 patients with ACS were randomly assigned to receive enoxaparin or unfractionated heparin. Methods: This analysis includes 9,404 patients for whom sheath access information was obtained for the first PCI procedure or diagnostic catheterization. Comparisons of baseline, angiographic, and procedural characteristics were carried out according to access site and sheath size. Results: Overall, 9,404 (94%) patients underwent angiography at a median of 21 hr (25th and 75th percentiles: 5, 42) and 4,687 (50%) underwent PCI at a median of 23 hr (6,49) of enrollment. The access site was femoral for 94.9% of cases, radial for 4.4%, and brachial for 0.7%. Radial access was associated with fewer transfusions than femoral access (0.9% vs. 4.8%, P = 0.007). For femoral access, the rates of noncoronary artery bypass grafting (CABG)-related TIMI major bleeding by sheath size was 1.5% for 4 or 5 French (Fr), 1.6% for 6 Fr, 3.3% for 7 Fr, and 3.8% for ≥ 8 Fr (P < 0.0001). After adjustment for baseline characteristics, femoral access site, larger sheath size, and delayed sheath removal were independent predictors of need for transfusion. Conclusions: Smaller sheaths, radial access, and timely sheath removal may mitigate the bleeding risk associated with potent antithrombotic/platelet therapy and early catheterization. © 2006 Wiley-Liss, Inc.

Percutaneous techniques are routinely used in the diagnosis and treatment of cardiovascular disease. The transfemoral route is the most frequently used arterial access site for performing these procedures To describe a technique to gain arterial access via the radial artery to perform diagnostic and invasive procedures. Patient selection is key to establishing a successful transradial service. There is a significant vascular complication rate when using the transfemoral route. Transfemoral access can also be difficult in patients with peripheral vascular disease. Arterial access via the right radial artery represents a realistic alternative to the transfemoral route for performing diagnostic and therapeutic coronary procedures. The radial artery offers a safe and effective alternative access site for performing diagnostic and interventional coronary procedures.The need for alternatives to femoral artery access is critical in patients with severe peripheral vascular disease.The establishment and ongoing provision of radial artery intervention allows for a significant reduction in major vascular complication rates, earlier patient ambulation, increased patient comfort and the potential to establish day case coronary intervention.