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6 Principles, Sites andTechniques ofVascular Access
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53
lating wires and catheters. Predictors of such an event
include radial artery anomaly, small radial artery diameter, female sex, multiple prior interventions, multiple
access puncture attempts, and pain during radial artery
cannulation [24–26]. The condition is often resolved
with the administration of nitrates. Second alternative
access should be used if the spasm does not resolve
optimally despite the drugs. Further manipulation
against resistance may result in rare and serious complications such as perforation, sheath entrapment, or an
avulsion endarterectomy [27].
Fig. 6.5 Radial artery anatomy at the wrist demonstrating the access
sites at the proximal (solid black arrow) and distal (dotted arrow) site at
the anatomical snuff box distal to the supercial radial artery take-off
(white arrow). Adapted by permission from Springer Nature: Springer
Nature, CardioVascular and Interventional Radiology, Left Distal
Transradial Access (ldTRA): A Comparative Assessment of
Conventional and Distal Radial Artery Size, Anastasia Hadjivassiliou
etal, License number: 5391931202441(2020)
Local anaesthetic (lignocaine) mixed with some isosorbide dinitrate (or Glyceyl Trinitrate) is typically administered to reduce vasospasm during access. A short bevelled
21G needle usually found in dedicated radial access sets
should be used. The needles found in routine micropuncture
access typically have longer bevels, making them unsuitable
for radial arteries with small diameters. Single-wall access is
recommended under direct US guidance. The guidewire is
advanced slowly and no resistance to advancing it should be
encountered. If resistance is encountered, the guidewire
should be removed and the needle bevel adjusted to conrm
satisfactory pulsatile ow. Dedicated radial access sheaths
do not require a skin incision for insertion over the guidewire. Once the sheath is in situ a cocktail of drugs is given to
prevent radial artery spasm and thrombosis. At our institute,
the “radial cocktail” consists of 3000IU of heparin, 400 ug
of Isosorbide Dinitrate and 2.5mg of Verapamil. The cocktail is drawn up in a 20 mL luer lock syringe. Blood is rst
aspirated into the syringe to allow haemodilution of up to 20
mL total volume and then very slowly injected through the
sheath.
On completion, a radial access closure device is placed to
achieve haemostasis. A protocol for the gradual deation of
the balloon is determined.
Tips andProblem Solving
Approximately 15% of patients experience radial artery
spasms, which are almost always transient [23]. It manifests as forearm discomfort and difficulty in manipu-
Brachial Artery Access
The brachial artery offers all the advantages of radial access,
as well as the possibility of inserting a larger sheath.
However, it has a high risk of complications. This is because
the axillary and brachial arteries are in an enclosed space
called the medial brachial fascial compartment [28]. Within
this compartment are the median and ulnar nerves which
often get compressed when a hematoma forms in the compartment. Access of the brachial artery in the antecubital
fossa may be safer as the nerves are further apart from the
brachial artery at this level [28]. Reported rates of brachial
artery access major complications are approximately 5%
[29]
Technique
Radial and ulnar pulses should be checked before the procedure. Again, the left brachial is preferred due to the
straighter course for body interventions and the avoidance
of the arch. Nevertheless, the right side may be preferred
if the patient is left-handed, has a subclavian occlusion, or
because it is easier to access for the operator. A 21G
micropuncture needle is used to puncture the artery overlying the humerus a few centimetres above the antecubital
crease. Single wall puncture should be used, and multiple
attempts avoided to prevent bleeding risk that may lead to
compartment syndrome. After the procedure haemostasis
is usually achieved by manual compression. Closure
devices can be used if the artery is of large calibre but it
increases the risk of occlusion [30]. We apply a compression bandage after haemostasis is obtained for four hours,
checking the pulses in the brachial and radial arteries at
regular intervals. It is important to educate the patients to
report any swelling, pulsatile mass, pain at the puncture
site or arm, tingling or weakness they may experience.
Any neurological symptoms should be taken seriously
and acted on immediately to prevent long-term sequelae.
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Popliteal Access
The popliteal artery is usually used as an alternate method
to cross a chronic total occlusion when antegrade approach
fails. Its disadvantages include the need to often place the
patient in a prone position, difculties in achieving haemostasis, and inability to use most closure devices. As
newer techniques such as tibial access have emerged that
do not present these issues, popliteal access should be
reserved for exceptional situations. It can also be accessed
when there is a single vessel run-off to the foot. US is
mostly needed as it is difcult to palpate and to avoid
injury to the sciatic and tibial nerves which run in close
relation to the vessel. Haemostasis can be usually obtained
by manual compression and use of closure devices is offlabel currently.
D. Manoharan and N. Karunanithy
Fig. 6.6 Pedal access set from Cook Medical Inc. (Limerick, IR)
Tibial/Pedal Access
In 1990, Iyer etal. described the use of retrograde access of
the tibial vessels using surgical cut down when conventional
antegrade access to cross the occlusion failed [31]. Surgical
cut down has been superseded by percutaneous approaches.
The rate of major complications is reported to be 2–3% and
is higher when larger sheaths are used [32].
Technique
Tibial and pedal vessels are small and often calcied in the
cohort of patients where use is necessitated. Hence the vessel
tends to slip away from the puncture needle. Additionally,
overuse of local anaesthetic should be avoided to prevent
vessel compression. US is vital although uoroscopy may be
helpful in most cases in heavily calcied vessels. Posterior
tibial artery near the ankle may be straightened with dorsiexion, while dorsalis pedis and anterior tibial arteries may
be straightened by plantar exion. As far as possible, access
should be gained to the tibial and pedal vessels in a nondiseased segment.
The use of a short-bevelled needle with an echogenic tip
facilitates good needle visualization. They are usually available as part of a pedal access kit (Cook Medical Inc.
(Limerick, Ireland) (Fig.6.6). A short bevelled echogenic tip
21G needle with a 4 cm length is used. After obtaining
access, a 0.018 wire is advanced under uoroscopic guidance followed by the insertion of a 4F sheath or dilator. As
the access is only required to cross the occlusion, larger
sheaths are avoided as intervention is then performed from
the antegrade access [33]. After the occlusion is crossed and
antegrade access obtained, the dilator can be removed, and
haemostasis is typically achieved with gentle manual com-
pression only. Occasionally additional prolonged ination of
a balloon across the access site may be required.
Tips andTricks
Heparinization of the patient is essential during pedal/tibial
access to prevent vessel occlusion. Target Activated clotting
time should be more than 200s. Although the benet of giving a spasmodic agent is unproven, we believe that such an
agent (Nitroglycerin and/or verapamil) may be administered
when it is necessary to insert a sheath [34]. Upon removal of
the sheath, some amount of spasm is common, so an antispasmodic medication may be administered just before
removal.
Venous Access
Venous access can be obtained in the periphery or central
site. Central access is needed when peripheral access is inadequate or when there is a need for long-term administration
of drugs, parenteral nutrition, dialysis etc. Venous access is
also used to perform various interventions such as venoplasties, transjugular intrahepatic portosystemic shunt creations,
etc. Some common sites of venous access are described in
this chapter.
Internal Jugular Vein
The internal jugular vein (IJV) arises at the base of the skull
and terminates at the level of the clavicle where it joins the
subclavian vein. It lies within the carotid sheath in close
proximity to the common carotid artery. The relation of the
6 Principles, Sites andTechniques ofVascular Access
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55
IJV to the carotid artery is important, as inadvertent arterial
injury is a relatively common complication. Right IJV has a
straighter course to the heart and is usually preferred for
venous access compared to the left.
Technique
Blind access to the IJV without image guidance is possible but
fraught with complications and not recommended [35, 36].
The neck is gently extended, and the head is turned to the
opposite side. It is important not to ex the neck by placing
large pillows underneath since this will shorten the neck and
make access more difcult. Generally, the puncture site is at
the triangle formed by the two heads of the sternocleidomastoid and the clavicle. Since the IJV is supercial and often
collapsible with minimal pressure, it is often necessary to
place the US probe gently and to use less local anaesthesia.
Intraluminal access is conrmed by gentle aspiration of blood.
Standard Seldinger’s technique is then used to insert a sheath
or a catheter. It is important to conrm the passage of the
guidewire into the vein under US as inadvertent carotid or vertebral access may lead to stroke. Advancing the guidewire into
the IVC is recommended before placing the sheath or catheter
to prevent arrhythmias and inadvertent cardiac injury.
Tips andTricks
When a patient is dehydrated or malnourished, the vein may
be collapsed and difcult to access. In such cases placing the
patient completely supine or even in a slight Trendelenburg
position or Valsalva might help distend the vein. In the event
of an accidental puncture of the carotid artery, the needle
should be withdrawn immediately, and manual pressure
should be applied. If a sheath or catheter has been inserted, it
should be left in place and only removed after careful consideration of the optimum endovascular or surgical method for
doing so [37].
Femoral Vein
The common femoral vein is accessed over the femoral head.
This can be done by inserting the needle just medial to the
maximum femoral artery pulsation in emergencies. However,
in most instances, US-guided access is the standard. Asking
the patient to perform a Valsalva manoeuvre or placing them
in a reverse Trendelenburg position may help in distending
the vein. Standard Seldinger’s technique is then used. It was
previously thought that insertion of non-tunnelled lines in
the femoral vein was associated with increased risk of
Central Line-Associated Bloodstream Infection (CLABSI);
however, recent studies have questioned this notion [38].
Multiple studies have now shown that femoral and internal
Juglar lines have similar higher infection rates compared to
subclavian lines [39, 40].
Subclavian Vein
The use of US has signicantly improved the chance of
success and reduced complication rates with subclavian
vein access [41]. Subclavian vein lines do have lower infection rates as the exit site is away from the oral mucosa [38–
40]. However, the concern with subclavian vein lines is the
mechanical sheer-stress the line will be subject to at the
thoracic inlet and the potential for accelerating subclavian
vein stenosis making future arm venous access (e.g. haemodialysis) complex. In addition, there is a small but signicant risk of pneumothorax and inadvertent arterial
injury.
Technique
There are two main approaches for subclavian access via
either supra or infraclavicular approaches. The infraclavicular approach is commonly used and the subclavian
vein is accessed just below the middle one-third of the
clavicle. Technically this segment of the subclavian vein
overlies the 1st rib or just lateral to it (axillary vein).
Access here has less chance of pneumothorax because of
the protection from the underlying rib. The supraclavicular approach is underlying the medial one-third of the
clavicle.
A recent systematic review by Nazir etal showed that
supraclavicular approach has a higher success rate [42].
However, most of the studies in this review did not use
ultrasound for access. A recent randomized trial by Kim
et al. concluded that supraclavicular approach took less
time to attain a puncture and the complication rate was
similar as well [43]. However, we feel that accessing the
supraclavicular portion of the subclavian vein should be
done with due caution. Unlike infraclavicular approaches,
the subclavian vessels are within the thoracic cavity at this
site and in direct relation to the adjacent low-pressure
pleural cavity [44]. Therefore, if the underlying vein is
torn or the artery punctured there is no tamponade effect
from the underlying tissues. Moreover, this site cannot be
manually compressed or easily accessed by a surgical cutdown. There is also an added risk of pericardial tamponade
as the pericardium often extends over the proximal
branches of aorta [45].
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ad e
b
c
D. Manoharan and N. Karunanithy
Fig. 6.7 (a) US image of the left radial artery at the wrist showing suit-
able calibre for safe access. Ultrasound guided access of was performed
using a 21G needed in the centre of the artery (b) and guidewire was
Upper Arm Veins
The basilic and cephalic veins are commonly accessed for
insertion of peripherally inserted central catheter placements. They may also be used for performing interventions
such as central venoplasties and testicular vein embolization.
Access to these vessels is usually straightforward using US
and Seldinger’s technique.
Conclusion
Performing vascular access is a core skill every interventionalist should be familiar with. To achieve safe and successful
vascular access, it is crucial to have a thorough understanding of anatomy, be familiar with the use of imaging, and be
able to manage complications.
Case Presentation
Continued from page 49
Morphine patient controlled analgesia infusion was started
and the entire procedure was performed using local anaesthesia alone. An ultrasound assessment of the left proximal radial
artery at the wrist revealed a diameter of 2.63mm which was
suitable for the hardware to be used (Fig. 6.7a). A type-A
curve was observed in the Barbeau test. A mixture containing
2 mL of 1% lignocaine and Glyceryl trinitrate was administered around the radial artery and skin as local anaesthetic. A
short bevelled 21G needle found in the Terumo RadifocusTM
inserted (c). After insertion of a 6 F sheath, the radial access was used
to successfully stent the superior mesenteric artery (d and e)
Introducer II Transradial Kit was used to puncture the artery
in the centre using ultrasound guidance (Fig.6.7b). Following
this, a 6 Fr sheath was placed and access was secured. We
administered the radial cocktail as described above. Through
the radial access, the superior mesenteric artery was successfully stented (Fig.6.7c and d). The sheath was then removed
and the haemostasis was secured with a radial band. Upon
discharge, she was no longer in pain and her radial access site
was alright with good radial pulse.
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Coronary Disease for Cardiac Minimally
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Invasive Techniques
S.A.Salazar andA.S.Niekamp
7
Case Presentation
A 73-year-old male presents for elective repair of a 6.5cm
infrarenal abdominal aortic aneurysm (AAA) diagnosed on a
surveillance CT-scan from an outpatient interventional radiology clinic. The patient weighs 82 kilograms and after review
of the CT-scan, it was noted that the common femoral arteries
were widely patent bilaterally without signicant atherosclerotic disease. The arteries are also located 7mm from the skin
surface. The patient also has a history of chronic obstructive
pulmonary disease, coronary artery disease, diabetes, hypertension, and hyperlipidemia. Vascular surgery was consulted
for evaluation for potential open surgical repair. The patient
was deemed not a surgical candidate and the decision was
made to proceed with endovascular repair of the AAA. The
decision for percutaneous access was made as opposed to a
surgical cutdown due to the patient’s favorable anatomy.
Background
With the widespread adoption and evolution of minimally
invasive techniques, hemostasis following percutaneous vascular access is an important consideration for interventionists, such as interventional radiologists, interventional
cardiologists, and vascular surgeons. For any vascular portof- entry, appropriate measures are necessary to ensure the
proper closure of the vessel and mitigate the incidence of
complications. Historically, the gold standard for achieving
hemostasis after vessel puncture has always been manual
compression of the access site. However, there is a variety of
factors that limit the utility of manual compression, including time demands for healthcare staff, the need for extended
bedrest, and in some cases large patient body habitus.
Successful hemostasis with manual compression requires
labor-intensive, consistent pressure applied at the access site
often for upwards of 15–20min and patient bedrest in the
range of 4–8h, with time dependent on the use of anticoagulation or size of the vascular sheath deployed. However,
though manual compression is considered a safe option and
remains the standard of care [1], alternatives exist in the
modern era to help avoid these drawbacks.
Vascular closure devices (VCDs) were rst introduced in
the 1990s, with the rst of these devices VasoSeal (St. Jude
Medical, St. Paul, MN) receiving FDA approval in 1995 [2].
Since then, they have become increasingly popular among
interventionists. This class of devices allow for the closure of
arteriotomy sites following percutaneous vascular access
using several different mechanisms of action. Although various studies have shown that VCDs do not signicantly
decrease the risk of vascular complications, their main benets lie in the reduction of time needed for hemostasis and
patient bedrest [3]. This is thought to result in decreased
healthcare costs and time demands on healthcare staff, as
well as improvement in patient comfort and satisfaction in
the postoperative period [4].
Today, a large variety of VCDs are available on the market. As such, it is important for any interventionist to be
aware of the indications of available devices and to know
which patients would benet most from their use.
S. A. Salazar (*)
Florida International University Herbert Wertheim College of
Medicine, Miami, FL, USA
e-mail: ssala060@med.u.edu
A. S. Niekamp (*)
Miami Cardiac and Vascular Institute, Baptist Health South
Florida, Miami, FL, USA
e-mail: AndrewSN@baptisthealth.net
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_7
Indications forIntervention
Application of VCDs is indicated in any patient requiring
percutaneous vascular access closure who would benet
from reduction in time to hemostasis and ambulation. In
patients undergoing procedures requiring large bore access,
such as endovascular aortic aneurysm repair (EVAR), thoracic endovascular aortic aneurysm repair (TEVAR), and
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transcatheter aortic valve replacement (TAVR), these devices
are routinely used and are particularly benecial due to the
larger diameter of the vascular sheath complicating closure
[5–7]. Patients treated with anticoagulation are also excellent
candidates for VCD use due to medication effects prolonging
time to hemostasis with manual compression [1]. Individuals
in which extended bed-rest is difcult, such as patients with
musculoskeletal pain, pressure ulcers, orthopnea, or dementia, may benet from the decreased time to ambulation as
well [3].
Preoperative Preparation
Timing ofIntervention
Needless to say, vessel closure in the setting of endovascular
procedures is performed once all necessary aspects of the
case are complete and the interventionist deems it is appropriate to close. However, it is important to note that some
commonly used VCDs, such as the suture-mediated Perclose
ProGlide and Prostar XL (Abbott Vascular, IL, USA), must
be deployed prior to the procedure (“preclose” technique),
with the subsequent suture knot tightened after completion
of the case [8, 9]. In contrast, other devices such as AngioSeal (Terumo Medical, BE, EU) are able to be applied postprocedurally [10]. Thus, it is necessary for the interventionist
to have a suitable plan for vessel closure prior to the procedure, become familiar with the devices at their disposal, and
understand how they are meant to be deployed.
Imaging
The most commonly selected site to obtain peripheral vascular access remains the common femoral artery, although
alternative access sites are becoming increasingly popular.
For patients undergoing diagnostic or interventional procedures, evaluation of the access site with angiography is typically recommended prior to VCD deployment [11].
Information obtained via angiography, such as the presence
of vessel calcication, small luminal diameter at the access
site, and vessel tortuosity, are all important considerations to
assess if VCD usage is safe. In addition to understanding the
target anatomy, patients undergoing large bore intervention
such as EVAR or TAVR may also have a pre-operative CT to
assist in vascular mapping and determining approach to vascular access [12].
Ultrasound capability should be available in the procedure room to assist with proper vascular access (i.e. to avoid
multiple sticks, conrm location) and to guide appropriate
VCD placement post-procedurally. With certain VCDs, such
as the Manta Vascular Closure Device (Teleex, PA, USA),
radio-opaque markers are present to help demarcate the
access site [13].
Risk Assessment
Among patients in whom a VCD is being considered, there
are many factors affecting successful device deployment and
rate of vascular complications. Proper patient selection is
essential and the interventionist should exercise their own
clinical judgement based on the instructions for use (IFU)
and prole of the device being implemented, their own experience with the particular device, and nally individual case
characteristics. Overall though, given the number of VCDs
currently available, there are no absolute contraindications
for most devices and they are each better tailored for certain
cases. Relative contraindications for the usage of VCDs
include access site above the inguinal ligament, vessel wall
calcication, severe peripheral arterial disease, or small
luminal diameter at the access site (i.e. distal to the common
femoral artery bifurcation). In most existing evidence,
patients with these access site characteristics are excluded
due to their presumed high-risk [3]. Use of VCDs should also
be avoided in patients who develop an overlying hematoma
during the procedure.
The following are characteristics that may predispose to
complications or adverse outcomes associated with VCDs:
Patient
• Obesity.
• Female gender.
• Peripheral vascular disease (PVD).
• Tortuous vessels.
• Presence of vessel calcication at the access site.
• Development of overlying hematoma.
• Emergency procedure.
• Undergoing multiple procedures (i.e. long procedure
time).
Operator/Center
• Operator inexperience.
• Forceful manipulation of access site.
• Multiple attempts at vascular access.
• Access obtained through the lateral vessel wall.
• Inappropriate access in the iliac arteries (i.e. above the
inguinal ligament).
• Small luminal diameter at the access site.
• Lack of presence of a multidisciplinary team (i.e. surgery,
anesthesia).
• Lack of availability of blood products.
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Other
• Large bore vascular access for EVAR, TAVR, etc. (sheath
diameter>8F).
• Inaccurate vessel measurement (i.e. pre-operative CT).
• Safety prole of VCD.
• Device failure.
Endovascular Strategy andTechnique
Basic Endovascular Toolkit
• Specic vascular closure device kit.
• Vascular sheath.
• Guidewire.
• Hollow needle.
A list of suggested materials is included in Table7.1.
Currently, there are sixteen VCD products available on
the market. The two broadest categories into which these
devices can be sorted include those with passive or active
mechanisms. Passive VCDs use methods to mechanically
assist with manual compression or to apply pro-thrombotic
factors to the access site and adjacent tissue tract. In contrast,
active VCDs involve the placement of implanted materials
such as sutures or vessel clips in order to obtain hemostasis.
With the exception of a few, all of these devices are indicated
Table 7.1 Suggested endovascular toolkit for management of vascular
closure following EVAR
Manufacturer Size/length
Vascular closure device
Perclose Proglide or Prostyle Abbott
vascular
Prostar XL Abbott
Manta vascular closure device
18F
Wires
Standard access wire Any
Sheaths
Standard large-bore access
sheath
Stent-graft Any Sized to access
Thrombolytic catheters Any
Thrombectomy devices Any
This list is based on the author’s experience and includes items needed
during device deployment and treatment of possible major
complications
vascular
Teleex 15–18F (max OD
Any 18–24F
5–21F (max OD
26F)
8.5–24F
25F)
≤0.035″
vessel
for closure of femoral artery access sites– although their use
has been described in other locations with varying degrees of
success.
The majority of VCDs are indicated for the closure of
5–8F puncture sites. In cases of large bore access, there are
currently ve devices indicated to close puncture sites greater
than 8 F. These include the Perclose ProGlide, Perclose
Prostyle, Prostar XL, Vascade MVP Venous Vascular Closure
System (VVCS), and Manta Vascular Closure Device. A
review of available devices and decision-making regarding
technique will be discussed in this section.
Suture-Based Closure Device: Perclose
ProGlide andPerclose ProStyle
The Perclose ProGlide (Abbott Vascular, IL, USA; Fig.7.1)
device delivers a single pre-tied polypropylene monolament suture at the arteriotomy site [3, 10]. Puncture sizes in
the range of 5–8F can be closed using a single device; however, multiple devices can be employed to close sites greater
than 8 and up to 21F by arterial sheaths and up to 24F by
venous sheaths– allowing it to be applied in cases necessitating large bore access. The device uses a “pre-close” system,
where the sutures are deployed prior to the procedure and
subsequently tightened upon completion, and allows for
maintenance of guidewire access.
Perclose ProStyle (Abbott Vascular, IL, USA) represents
a newer iteration of the popular Perclose ProGlide device.
Changes include higher tensile strength needles and differences in design to improve ease of use; however, it employs
the same suture deployment mechanism as described in its
predecessor. The maximum guidewire compatibility for both
of these devices is 0.038 inches.
Fig. 7.1 Arteriotomy site with a single pre-tied suture knot deployed
using Perclose ProGlide device
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Suture-Based Closure Device: Prostar XL
The Prostar XL device (Abbott Vascular, IL, USA) deploys
two braided polyester sutures at the access site and is indicated for closure of common femoral access sites between
8.5–10 F with a single use [3, 14, 15]. Unlike Perclose
ProGlide, the suture deployment mechanism can be repeated
to place more sutures at the access site without the need for
additional devices. ProStar XL can be applied for up to 24F
vascular sheaths and employs a similar “pre-close” technique to the Perclose devices. The maximum guidewire compatibility is 0.035 inches.
Clip-Based Closure Device: StarClose SE
StarClose SE (Abbott Vascular, IL, USA; Fig.7.2) is a clipbased VCD that closes the arteriotomy site using an implantable 4mm nitinol clip [3, 14, 15]. The disc-shaped metal clip
left behind remains extravascular. The device results in
immediate mechanical closure of the site without inammatory response, allowing for hemostasis to be conrmed on
the table. Considered simple to use relative to other devices,
it can be used to close 5–6F access sites– although it has
been used in up to 8F access sites- and has a maximum wire
compatibility of 0.035 inches.
Plug-Based Closure Device: Exoseal
Exoseal (Cordis Corp., NJ, USA) is a plug-based device that
deploys a synthetic, bioabsorbable polyglycolic acid (PGA)
plug [3, 15]. This device is delivered through a preexisting
procedural sheath (with a maximum length up to 12cm) and
has a visual marker to ensure the plug is placed in the
intended location extravascular to the femoral artery access
site. There is no intravascular component to this device and
the plug is typically resorbed within 60–90days. This device
is indicated for closure of 5–7F puncture sites.
Plug-Based Closure Devices: MynxGrip
andMynx Control Vascular Closure Devices
The MynxGrip and Mynx Control Vascular Closure Devices
(Cordis Corp, NJ, USA; Fig.7.3) both function by delivering
a polyethylene glycol (PEG) based sealant to the extravascular space above the access site [16, 17]. Simultaneously, a
semi-compliant balloon is inated in the vessel lumen, promoting hemostasis and allowing the sealant to expand across
the puncture surface and tissue tract. The sealant is completely reabsorbed within 30days. Both devices can be utilized with 5–7F puncture sites and procedural sheaths up to
a length of 12cm. The Mynx Control includes a streamlined
deployment system, whereas the MynxGrip can be used for
both arteriotomy and venotomy sites.
Manual Assistive Closure Devices: Cardiva
Catalyst II andIII
Cardiva Catalyst II (Haemonetics, MA, USA; Fig.7.4) is a
manual assistive device available for closure of 5–7F puncture sites [3, 15]. After introduction through the pre-existing
vascular sheath, the device houses a disc technology that is
retracted and opposed to the arteriotomy site to provide temporary hemostasis. Afterwards, a hemostatic coating on the
wire is exposed to the site and tissue tract, activating the
coagulation cascade and promoting platelet aggregation.
A version of Catalyst II, the Catalyst III (Haemonetics,
MA, USA) is intended for use in patients receiving intraprocedural heparin. With this device, the same technology is
employed with the addition of protamine sulfate, allowing
for heparin deactivation [3, 15]. Both of these devices,
Fig. 7.2 Extravascular clip deployed at femoral arteriotomy site using
StarClose SE device
Fig. 7.3 MynxGrip device with semi-compliant balloon inated in
vessel lumen and delivery of PEG-based sealant above vessel
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