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102
Key Point
The CFA should be accessed at the level of the femoral
head. Access above the femoral head risks retroperitoneal hemorrhage and below the femoral head risks
thigh hematoma.
In patients who are obese or who have hard-to-palpate
arterial pulses, a combination of uoroscopy and ultrasound
should be used to locate the midpoint of the femoral head as
a landmark for arterial puncture and to visualize entry into
the artery with real-time guidance [3, 4]. Many endovascular
specialists advocate using ultrasound guidance for every
arterial puncture to ensure safe access [5]. Randomized trials
have demonstrated lower complication rates with routine use
of ultrasound [6, 7]. Marking the locations of the inguinal
ligament and CFA bifurcation can also be helpful in avoiding
high or low punctures. When utilizing ultrasound, a highfrequency probe should be used, typically 9 or 12MHz, in
order to obtain the best-quality images possible. Depending
on the type of intervention, an antegrade (in the direction of
blood ow) or retrograde (against the direction of blood
ow) access may be chosen.
V. L. Bishay et al.
The interventionalist is able to perform a wide variety of
procedures and treat a broad spectrum of disease from an
arterial access point including but not limited to thrombectomy/thrombolysis for stroke, aortic aneurysm repair, embolization for acute bleeding, transarterial delivery of chemo- and
radiotherapeutics, uterine and prostatic artery embolization
for symptomatic broids and benign prostatic hyperplasia,
and treatment of peripheral artery disease, all of which will
be discussed in subsequent chapters. Nearly all arterial interventions can be performed from a common femoral artery
approach although relative contraindications for femoral
artery catheterization exist, including therapeutic anticoagulation that cannot be reversed, thrombocytopenia, and extensive atherosclerosis at the access site [8] (Table8.1). While
generally considered safe, CFA access site complications do
occur including hematoma, pseudoaneurysm, hemorrhage,
limb ischemia related to a thromboembolic event, and stula
formation with the adjacent femoral vein [9].
Key Point
Arterial access complications
• Hematoma/hemorrhage
• Pseudoaneurysm
• Thromboembolic event leading to limb ischemia
Key Point
Radial andBrachial Artery Access
• Antegrade puncture=in the direction of blood ow
• Retrograde puncture = against the direction of
blood ow
Table 8.1 Hemostasis management in percutaneous vascular interventions
Lab/Drug Bleeding risk
Low (venography, non-tunneled central
line)
INR Recommend if receiving
anticoagulation or
suspected liver disease
aPTT Not routinely
recommended
Plt Not routinely
recommended
H&H Not routinely
recommended
Plavix Optional 5 day
Aspirin Continue
LMWH Hold 1 dose Hold 1 dose Hold 24h or 2
Abbreviations: INR, international normalized ratio; aPTT, activated partial thromboplastic time; Plt, platelets; H&H, hemoglobin and hematocrit;
LMWH, low molecular weight heparin
Correct if >2.0 Recommended Correct if >1.5 Recommended
hold
therapeutic dose
Moderate (angiography (≤7F sheath),
venous intervention, tunneled central line
placement)
Recommended if
receiving IV
unfractionated heparin
Not routinely
recommended
Not routinely
recommended
Depending on patient and procedure-specic factors,
alternative arterial access sites may be more appropriate.
The transbrachial approach provides a reasonable access site
High (TIPS, arterial intervention (>7F
sheath))
Correct to ≤1.5
Correct if >1.5×
control
Transfuse if
<50k/μL
No threshold Recommended No threshold
Optional 5 day
hold
Continue
therapeutic dose
Recommended if
receiving IV
unfractionated heparin
Recommended Transfuse if
Correct if
>1.5× control
<50k/μL
Hold 5days
Hold 5days
doses
8 Vascular Access Techniques andClosure Devices
103
a
b
Common digital
arteries
Superficial
palmar arch
Deep palmar
arch
Ulnar artery
Radial artery
Fig. 8.4 Schematic and digital subtraction angiography of the ulnopalmar arches. A patent arch allows for safe radial artery access
alternative that is still used today. Several disadvantages
exist with this approach including increased total uoroscopy
time and radiation dose relative to CFA access, risk of brachial plexus injury, and postoperative compartment syndrome
[8, 10, 11]. More recently, interventionalists have begun to
adopt the radial artery as the upper extremity access point of
choice for arterial intervention.
First described by Lucien Campeau in 1989 for percutaneous coronary angiography, radial artery catheterization
has become an important tool for an interventionalist [12].
The hand is perfused by a dual blood supply via the radial
and ulnar arteries which often form a complete collateral
pathway via the deep and supercial palmar arches. Assessing
patency of both the radial and ulnar artery is needed prior to
using a transradial approach to ensure maintenance of blood
ow to the hand (Fig.8.4). Traditionally, the modied Allen
test has been used to ensure adequate perfusion of the hand.
To perform the modied Allen test, the operator applies pressure to both the radial and ulnar artery until the hand turns a
bluish hue. Then, the ulnar artery is released, and if the hand
achieves normal tone after 5–9s, it is assumed that cannulating the radial artery will not impact perfusion of the hand.
However, this test leads to many false positives and false
negatives due to its subjective nature.
The Barbeau test has been shown to be more accurate
and sensitive as compared to the modied Allen test [13].
The Barbeau test is performed by applying a pulse oximeter
to the thumb, the digit furthest away from the ulnar artery,
and then applying compressive force to the radial artery only.
The operator then observes for changes to the amplitude of
the pulse waveform and oxygen saturation value. The degree
of waveform alteration gives the operator important information about perfusion of the hand. The Barbeau test assigns
the patient a waveform of type A through D based on degree
of collateral ow between the radial and ulnar arteries
(Fig.8.5). The most concerning waveform is type D, which is
considered by many to be an absolute contraindication to radial
access due to the elevated risk of hand ischemia if the radial
artery becomes damaged or occluded. However, some believe
that even in the event of a radial artery occlusion in a patient
with a Barbeau D waveform, the interosseous artery may be
sufcient to adequately perfuse the palmar circulation.
The radial artery has several key advantages compared to
other access sites, including the traditional transfemoral
approach [14]. The radial artery is a supercial structure,
allowing easy palpation and visualization by ultrasound.
There are few surrounding vital structures that may be inadvertently damaged during arterial access. If injury to the ves-
104
++
++
–+
––
V. L. Bishay et al.
Barbeau
type
ANormal
B
C
D
Fig. 8.5 Barbeau test waveforms A through D based on degree of col-
lateral ow between the radial and ulnar arteries. Type A shows no
change in the waveform with compression of the radial artery, type B is
blunted in amplitude with return of the initial waveform within 2min,
type C waveform indicates complete loss with eventual return of a
Waveform apperance Interpretation
Excellent collaterals
Initially blunted, returns
to normal after 2 mins
Complete loss initially with
return of dampened waveform
after 2 mins
No waveform which persists
beyond 2 mins
Good collaterals
Not well collateralized
but still a candidate
No collaterals, absolute
contraindication to radial access
sel does occur in a patient with a Barbeau type A–C
waveform, the operator can be assured that there will be no
critical hand ischemia due to the dual supply of the hand via
the ulnar artery.
Following preoperative assessment with the Barbeau test,
ultrasound should be utilized to identify and measure the
caliber of the radial artery [15]. A paste containing nitroglycerin and local analgesic can be applied to the wrist in advance
of any intervention to maximally dilate the artery and minimize pain during access. In most cases, vessel diameter< 2mm is contraindicated; however, with small sheaths
and even sheathless guiding catheters, radial arteries down to
1.5mm can be used in certain circumstances. Additionally,
the radial artery should not be accessed if an intervention
will require a sheath size greater than 7F.The radial artery is
accessed using ultrasound guidance, and the Seldinger technique with a short 21-gauge echogenic-tipped needle until
pulsatile blood ow is seen. An 0.018-inch oppy-tipped
wire is then advanced into the radial artery via the access
needle. If resistance is felt, the wire can be retracted and
repositioned. If the wire is unable to be advanced, uoroscopy and contrast injection can be used to identify any anatomic variations. Once the artery has been accessed, a
hydrophilic sheath should be used to maintain radial artery
access throughout the procedure. Hydrophilic sheaths have
been shown to decrease pain, artery spasm, and radial artery
occlusion [16] (Fig. 8.6). Hydrophilic sheaths utilizing a
tapered 0.018-inch inner dilator allow sheath insertion over
the existing access wire without need for wire exchange or
dermatotomy.
Radial artery compression
StartAfter 2 min.
Oxymetry Oxymetry
dampened waveform within 2min from compression, and type D waveform with at line in the pulse oximeter waveform which persists
beyond 2min, indicating no collateral supply to the radial side of the
hand from the ulnar artery
Key Point
Radial access is limited to a sheath size of ≤7F.
Immediately following artery access, an antithrombotic
and antispasmodic medication solution is delivered into the
artery via the sheath, further promoting patency during intervention. Based on the PCI literature, this cocktail consists of
3000 IU of heparin, 200 micrograms of nitroglycerin, and
2.5 milligrams of verapamil. The 5mL solution is prepared
in a 20-mL syringe and delivered following hemodilution
with 15cc of the patient’s blood via the sheath side port in an
effort to minimize discomfort experienced by the patient
from intra-arterial injection of verapamil. In cases of active
bleeding or existing coagulopathy, the heparin component of
the cocktail may be reduced or omitted. The pulse oximeter
remains secured on the patient’s thumb throughout the duration of the procedure to monitor hand perfusion. A change
in the pulse oximetry waveform can alert the operator to
evaluate the left upper extremity.
Radial artery access is appealing for several patientspecic factors. The transradial approach has also been
shown to have decreased time to hemostasis and lower access
site complication rates as compared to other access sites
[17]. Post-procedurally, patients are able to ambulate immediately, use the restroom, and sit up in bed. In contrast,
following transfemoral puncture, patients must lay at for
several hours. The patient experience and recovery suite
workow have the potential to be improved following tran-
8 Vascular Access Techniques andClosure Devices
105
Fig. 8.6 Setup and access of the radial artery. (a) The left hand is
afxed to an arm board with pulse oximeter placed on the thumb. (b)
The arm is adducted allowing for use of standard femoral drape and
easy catheter and wire exchange across the patient’s body in similar
fashion to that with a femoral artery approach (some operators prefer an
abducted position to bring the arm away from the radiation source and
sradial intervention. Some operators discharge patients faster
owing to immediate ambulation and decreased incidence of
signicant access site complications. Additionally, patients
may prefer radial site access rather than groin access due to
an improved sense of privacy.
Key Point
Advantages to radial artery access
• Increased patient mobility post-procedurally
• Potential for earlier discharge
• No need for expensive closure devices
• Lower access site complication rates
minimize operator exposure). (c) Ultrasound-guided puncture of the
radial artery. (d) Transverse ultrasound view of the radial artery with
needle tip in artery lumen, note the distal radial head deep to the radial
artery. (e–f) Seldinger technique with hydrophilic sheath for radial
artery access
Although considered more technically challenging than
other approaches given small artery size, difculties in
negotiating the aortic arch and the long catheter lengths
required, a radial artery approach can provide many advantages over other access sites for infradiaphragmatic interventions. Anatomic variants including radial loops can
potentially lead to catheterization failure. Transradial
access carries its own particular risks that should be discussed with the patient. Upper extremity access introduces
the risk of stroke not seen with typical CFA access due to
the need to cross the aortic arch vessels. When available,
previous imaging of the chest should always be reviewed to
evaluate for atherosclerotic disease and tortuosity of the
subclavian artery and aortic arch, which may increase the
technical difculty of the procedure. The devastating com-
106
V. L. Bishay et al.
plication of hand ischemia can be minimized with appropriate preoperative Barbeau assessment of ulnopalmar
patency. Other rare radial access site complications include
pseudoaneurysm, hematoma, hemorrhage, spasm, pain,
and radial artery occlusion [18]. Some complications may
occur more frequently in females, as women tend to have
signicantly smaller radial arteries when compared to their
male counterparts [19]. However, several peer-reviewed
articles have shown the transradial approach to be safer and
have decreased morbidity as compared to the transfemoral
approach [9, 20–22].
Key Point
Radial access site specic complications
• Vessel spasm
• Access site hematoma
• Pseudoaneurysm
• Radial artery occlusion
Alternative Arterial Access Sites
Other access sites that may be considered for arterial interventions include access via the supercial femoral artery, popliteal artery, pedal artery, tibial artery, or direct aortic puncture.
Few interventions are performed via the axillary artery, due to
the risk of brachial plexus injury, which would require surgical
repair [23]. However, these approaches may be used in
patients with extensive atherosclerotic disease who fail interventions via other approaches. The tibial and pedal arteries
may be accessed for patients who have infrainguinal atherosclerotic occlusive disease and have failed antegrade procedures via the femoral artery [24, 25]. Translumbar, direct
aortic puncture was historically an important arterial access.
More recently there has been a resurgence for this technique:
following repair of an abdominal aortic aneurysm (AAA)
with a covered stent, the aneurysm sac may remain pressurized by collateral arterial supply, such as from the lumbar or
inferior mesenteric artery. This condition, known as a type II
endoleak, is often repaired via direct, translumbar, aortic
puncture (refer to Chap. 19 for more information) [26].
Venous Access
Many endovascular procedures within an interventionalist’s
armamentarium begin with venous access. While certain
large conduit vessels with a more direct (i.e., shorter or more
linear course to the central venous system) route, such as the
internal jugular and common femoral veins, are routinely
employed as the starting point for a wide array of venous
interventions, virtually any vein can be accessed depending
on procedure indication. The principles of venous access
remain the same regardless of the vein used.
Key Point
Five tricks to identify a vein versus artery on US
• Arteries are pulsatile.
• Veins are compressible.
• Direction of Doppler ow.
• Veins have valves.
• Internal jugular vein is lateral to the common
carotid artery, common femoral vein medial to the
common femoral artery.
Veins are thin-walled and perfuse at a low pressure making
the technique of puncturing a vein slightly different from that
of puncturing an artery. Ultrasound should be used whenever
possible to identify neighboring vital structures such as arteries and nerves and to ensure entry into the vein lumen under
real time visual guidance [27]. Veins may not be palpable
depending on their location and depth. Furthermore, depending on the patient’s intravascular uid status, veins may be
nearly or entirely collapsed making access more challenging.
Minimal or no blood return may be seen if the patient’s central venous pressure is low. At the interventionalist’s preference, a syringe can be attached to the back of the needle and
drawn back on to aspirate blood and conrm entry into the
lumen. If the vein of access is located in an upper extremity,
applying a tourniquet to the upper arm or axilla can help distend the vein making puncture easier. Improving central
venous distention can be achieved by ensuring adequate
patient hydration prior to the procedure. Tricks for increasing venous return such as placing the patient in Trendelenburg
position or asking him or her to perform a Valsalva maneuver
or to hum can also help.
The ultrasound probe can be oriented longitudinally along
the vein providing a sagittal view of the vein with visualization of the entire needle as it enters the scan plane. Depending
on the location of the vein of access, a longitudinal orientation may not be possible, in which case the probe can be
placed transversely across the skin providing a crosssectional view of the vein. In this orientation, only a portion
of the needle will be seen as the operator sweeps across the
tissue plane with the ultrasound probe as he or she advances
8 Vascular Access Techniques andClosure Devices
107
Fig. 8.7 Right internal jugular vein access. (a) A puncture using an
ultrasound view in plane with the needle allows continuous visualization of the needle during vein puncture (patient’s head is on image left).
(b) Transverse ultrasound view of the internal jugular vein with jugular
the needle (Fig.8.7). The operator must consider the depth of
the vein along with the angle of entry in order to effectively
triangulate the needle tip as it is advanced through the soft
tissues toward the vein. Multiple passes into small veins
should be avoided as they can easily get compressed by a
perivenous hematoma or thrombose, making lumen entry
more difcult. Many practitioners will blindly puncture the
femoral vein after palpating the femoral artery and advancing a needle just medial to the pulse. In obese patients or
cases where the femoral pulse is weak, ultrasound guidance
can be used to localize the vein.
Central venous access is the starting point for many interventions. One of the most routinely performed procedures is
central venous catheter placement (see Chap. 9 for more
information). The most commonly accessed veins for central venous procedures are the internal jugular vein and
femoral vein.
Prior to jugular central venous access, available preoperative imaging of the patient’s neck and chest should be
reviewed to assess for access site pitfalls. The patient should
be placed supine on the table, in Trendelenburg position if
possible, and with their head turned away from the side being
accessed. A quick scan of the neck can provide clues to central venous occlusion that can make access more challenging, such as numerous collateral veins. After adequate local
anesthetic administration to the skin and soft tissue, a small
dermatotomy is made. Using the technique described above,
a 21-gauge hollow needle is advanced under ultrasound
guidance into the internal jugular vein. Care should be taken
to identify and avoid inadvertent entry into the adjacent
vein lateral to the carotid artery and needle within the vessel lumen. (c)
Longitudinal ultrasound view of vein with complete course of needle
demonstrated with tip in vessel lumen
The How to : Venous Access
1.
2.
a dermatotomy with blunt soft tissue dissection;
many operators prefer to perform the dermatotomy
after vessel access.
3. Advance the needle to just outside of the vein wall
under ultrasound guidance, ideally seeing the needle tenting the vessel wall.
4. Perform single wall puncture of the vessel. Some
advocate doing this with a quick motion. Blood
return may be poor in veins and a syringe on the
back of the needle may be used to aspirate blood to
5.
into vein lumen.
6. Remove the needle using the pin-pull technique.
7. Advance a sheath or catheter over the wire.
carotid artery. Once conrmed within the lumen, a 0.018inch oppy-tipped wire is advanced through the needle,
and the needle is removed leaving only the wire within the
vein. A 4 or 5 Fr introducer with inner dilator tapered to the
0.018- inch wire can be advanced over the wire and eventually
used to transition to a larger sheath over a stiff 0.035-inch
guidewire.
108
V. L. Bishay et al.
Fig. 8.8 Adrenal vein sampling. (a) SIM1 catheter in the right adrenal
vein which drains directly into the IVC. (b) Contrast CT performed
from the angiosuite table (cone beam CT) via the right adrenal vein
Fluoroscopic guidance is used to visualize passage of the
guidewire from the access site into the central venous system.
Ideally the operator is able to place the guidewire into the
inferior vena cava (IVC). This may require asking the patient
to take a deep breath in and hold it which allows the wire to
more easily follow the straight course from the superior vena
cava (SVC) into the IVC rather than entering the right atrium.
A catheter may be needed to direct the wire away from the
right atrium and into the IVC.Placing the wire within the IVC
provides a stiff and stable “rail” over which larger gauge catheters or sheaths can be safely advanced without risk of prolapsing the sheath or catheter into an extra-venous space such
as the lung or mediastinum.
Beyond central venous catheter placement, the jugular
vein can be the entry point for a variety of procedures including the placement of IVC lters, access into the hepatic veins
for the purposes of liver biopsy or transjugular intrahepatic
portosystemic shunt (TIPS) placement, and access into the
adrenal veins for the purposes of adrenal vein sampling
(Fig. 8.8). For the majority of patients requiring central
venous catheter placement, a jugular or common femoral
vein will prove suitable for access. In patients with severe
acute or chronic renal insufciency who will likely require
impending renal replacement therapy, venous access via the
supercial and deep upper extremity veins is contraindicated
as these veins are reserved for eventual AV stula or graft
creation. In those patients receiving hemodialysis chronically via central venous catheters, less commonly used veins
catheter demonstrates opacication of the right adrenal gland conrming correct position for right adrenal vein sampling
may be needed when the common veins listed above become
occluded or thrombosed from chronic use and frequent catheter exchange. Alternative central venous access sites include
through the liver parenchyma into a hepatic vein and directly
into the IVC via a right translumbar approach.
The common femoral vein is accessed for IVC lter
placement, for iliocaval access in patients with deep venous
thrombosis or iliac vein stenosis, and for retrograde transvenous gastric varix obliteration in those with a patent gastrorenal shunt. In a patient with extensive and symptomatic
deep vein thrombosis of the iliocaval or iliofemoral veins,
thrombolysis and thrombectomy can be performed via a
common femoral, popliteal, or posterior tibial vein access
depending on how far into the leg thrombosis extends.
Ideally, venous access is obtained in a patent segment of the
deep venous system of the aficted leg. For varicose vein
treatment, the specic vein targeted for ablation may be
accessed directly.
Key Point
Venous access complications
• Pneumothorax/hemothorax
• Air embolism
• Arterial puncture/injury
• Catheter malposition
8 Vascular Access Techniques andClosure Devices
109
Complications of venous access include accidental arterial puncture or injury, pneumothorax, hemothorax, air
embolism, and catheter malposition [28]. Proper use of ultrasound and uoroscopy can mitigate many of these complications. The risk of pneumothorax and hemothorax are
signicantly more common in subclavian versus jugular vein
access. Air embolism is a potentially fatal medical emergency resulting from aspiration of air into the central venous
system which can propagate into the heart and pulmonary
arteries. This is best prevented by keeping any large-bore
needles, catheters, or introducers to the central venous system covered. If air embolism is suspected, the patient should
be immediately placed in a left lateral decubitus or headdown position.
Key Point
Suspect air embolism? Immediately place the patient
left side down or head down.
Hemostasis andClosure Devices
Manual Compression
and is monitored by nursing staff, all factors which must be
considered when considering practice cost and workow.
Patients also report discomfort associated with several hours
of strict bedrest and restrictions on their ability to ambulate,
void, and eat. Patients with musculoskeletal disorders,
orthopnea, and signicant abdominal pain or cramping, such
as is typical following uterine broid embolization, can be
negatively affected by this post-procedure recumbency. The
success of MC relies both upon the success of the arteriotomy and the integrity of the patient’s intrinsic clotting cascade to form thrombus at the puncture site. If the operator
makes the puncture in the external iliac artery, retroperitoneal hematoma may not be detected until the patient develops signs of signicant intravascular volume depletion. In
many instances, peri- and post-procedural anticoagulation is
required resulting in prolonged MC time as well as a
prolonged period spent in a non-ambulatory position in order
to decrease the risk of hematoma or pseudoaneurysm formation. The use of larger artery access sheaths further increases
these risks.
Venous hemostasis is achieved with manual compression
for all access sites. Closure devices may be rarely utilized for
very large common femoral vein accesses. Bedrest for
venous access varies per institution however is typically
shorter than arterial access sites.
Achieving hemostasis after arterial endovascular intervention is readily achieved with manual compression (MC).
With CFA access, major complications can occur in approximately 2% of cases. MC has a high rate of success and a low
rate of major access site complication, particularly when an
arteriotomy is well performed (center of the vessel wall in an
area without calcication). A drawback of MC is that it can
require a signicant amount of time to achieve hemostasis
depending on patient characteristics and clinical status.
Under ideal circumstances, 15–25min of rm, non- occlusive
pressure is typically required for a common femoral arteriotomy, though it may require more time depending on the
size of the arteriotomy or coagulopathic state. The patient
must then remain non-ambulatory with the access leg immobilized for up to 6h [29].
A distinct benet of MC over use of a closure device for
achieving hemostasis is that no implanted device is left
behind. In spite of this benet, MC requires an investment of
time and labor by the primary operator or assistant performing vessel compression. The location in which compression
is performed, be it the angiography suite or recovery room,
remains occupied during MC.Furthermore, for several hours
following MC, the patient typically occupies a recovery bay
Closure Devices
Given the time and resource utilization with MC, various
closure devices have been developed to minimize time to
hemostasis. Some devices may provide suture closure, while
others implant devices that promote coagulation. These will
remain in the patient, either within or outside the artery for
varying lengths of time after artery closure has been performed. Placement of closure devices naturally carries the
potential for complication. Closure devices may be malpositioned, fail to deploy, embolize distally, cause occlusion of
the access artery, or act as a nidus for infection.
Key Point
Closure device complications
• Malpositioning
• Failure to deploy
• Distal embolization
• Occlusion of the access vessel
• Nidus for infection
110
V. L. Bishay et al.
Closure-assist devices are increasingly utilized by many
interventionalists. Some series within the vascular and interventional literature support the use of closure devices quoting
decreased access site bleeding complications, time to discharge,
and overall cost, although large meta-analyses have not supported such conclusions [30, 31]. Still, specic technical and
clinical factors may favor their use. Arterial interventions requiring a 7F or greater sheath size may be challenging to close with
MC alone. Critically ill patients or those requiring therapeutic
levels of anticoagulation after an intervention will often fail MC
as their intrinsic coagulation pathway is inhibited. Obese
patients with a large pannus and those unable to tolerate bedrest
may also be good candidates for use of a closure device.
Contraindications to closure device use are few and include
small (<5mm) vessel size, large arteriotomy unless a pre-close
technique is performed, severe atherosclerosis, need for repeat
arterial access, and allergy to a device component.
Key Point
Relative contraindications to use of a closure device
• Vessel <5mm.
• Large arteriotomy unless a pre-close technique is
performed.
• Severe atherosclerosis.
• Need for repeat access.
• Allergy to a device component.
A variety of closure devices are available each with
specic indications, benets, and drawbacks. They may be
categorized broadly into compression devices, topical agents,
and invasive devices.
Compression Devices
Compression devices achieve hemostasis without requiring
an operator to manually apply force over a period of time. An
inatable cuff or C-clamp is used to apply pressure to an
access site. There are specic devices available for a variety
of access sites, including the radial and femoral arteries.
These compression devices have very high rates of success,
similar or superior to invasive closure devices [30]. It is
important that such devices only apply enough pressure to
tamponade bleeding at the arteriotomy without completely
occluding the artery which can lead to ischemia [31]. A clear
benet of such devices is that they leave nothing behind
within the patient. With regard to CFA access in particular,
MC or compression devices still require bedrest following
achievement of hemostasis.
Radial arterial hemostasis is easily achieved via compression of the artery against the radial head or distal radial
shaft. Patent hemostasis (hemostasis without artery occlusion) can be achieved with a purpose-specic insufation
cuff applied to the wrist that provides only enough radial
pressure to occlude the arteriotomy, but not enough to
occlude the artery helping to reduce the risk of post-procedure radial artery occlusion. Palpation of the radial pulse
proximal and distal to the cuff should be performed after
cuff ination. Palpation of a radial pulse distal to the
access site may not always indicate artery patency since
backlling from the ulnar artery via the ulnopalmar arch
may occur. Assessment of the radial pulse with simultaneous compression of the ulnar artery ensures that patent
hemostasis has been achieved. The patient is immediately
able to ambulate and use the arm to eat and drink with this
method (Fig.8.9).
Fig. 8.9 Pneumatic compression device for patent hemostasis of the radial artery. (a) Wrist cuff and insufator syringe (Terumo Interventional
Systems). (b) Cuff is secured around left wrist with green marker indicating air reservoir that is placed over the radial arteriotomy
8 Vascular Access Techniques andClosure Devices
111
Table 8.2 Vascular access closure devices
Maximum
Device
name Manufacturer Closure mechanism
Invasive device, no foreign material deposition
Axera Arstasis,
Catalyst (II
and III)
Invasive device using foreign body deposition/active closure
Perclose AT
glide
ProStar XL Abbott vascular
StarClose SEAbbott vascular
Mynx Access closure,
EXOSEAL Cordis Corp.,
FISH Morris
Angio-seal St. Jude
Redwood City,
CA
Cardiva medical,
Sunnyvale, CA
Abbott vascular
devices, Abbott
Park, IL
devices, Abbott
Park, IL
devices, Abbott
Park, IL
mountain view,
CA
Bridgewater, NJ
innovative,
Bloomington, IN
Medical, St.
Paul, MN
Guides and extends
arterial puncture
tract within artery
wall
Temporary umbrella
deployed within the
artery to promote
hemostasis
Suture 8 French
Suture 10 French
Nitinol clip 6 French
Occlusion balloon/
polyethylene glycol
polymer injection at
arteriotomy
Polyglycolic acid
plug
Porcine
bioabsorbable patch
Collagen plug in
arteriotomy with
intravascular anchor
arteriotomy
size
6 French
6 French
7 French
7 French
8 French
8 French
Topical Agents
Topical agents (Table8.2), such as collagen or thrombin, can
be directly deposited on top of the arteriotomy, providing a
source of procoagulant material to achieve hemostasis. These
agents are suited for supercial artery punctures using small
diameter puncture such as in cases of dialysis access. These
agents are not typically utilized independently and may be
helpful to augment manual compression in the setting of
coagulopathy.
Invasive Devices
Invasive closure devices (see Table 8.2) are inserted into the
arteriotomy at the completion of a procedure. There are several closure devices currently available that achieve hemostasis by either utilizing a procoagulant solution, mechanical
balloon occlusion, suture closure of the arteriotomy, or a combination thereof. Invasive closure devices are designed for use
in the common femoral artery. Complications may arise if
deployed within another vessel or when antegrade arteriotomy
is used. A femoral arteriogram is useful prior to deployment of
a closure device to ensure that the puncture was performed in
a good location and adequate vessel size and to assess for atherosclerotic calcication, which may lead to device failure.
Many of these devices deploy a foreign substance (collagen
plug, footplate, or suture) at the puncture site. Depending on
the substance deployed, these can tether the front and back
artery walls together, causing dissection or resulting in artery
injury when malpositioned or deployed improperly. They may
also act as a nidus for infection when sterile procedure is not
strictly adhered to including re-preparing the operative site
and replacing sterile gloves prior to deployment. Certain closure devices are also painful to the patient when deployed and
administration of additional anesthetic around the access
artery is recommended.
Key Point
Most closure devices require a 5-mm vessel.
Various closure devices exist that place sutures across the
arteriotomy to achieve immediate hemostasis. These devices
range from placement of a single suture across the arteriotomy to placement of several sutures across the arteriotomy
with a footplate left within the artery for complete closure
and hemostasis. Procedures, such as percutaneous endovascular aneurysm repair (EVAR), requiring larger arteriotomies (9F–24F), pose a challenge for successfully achieving
hemostasis. Access historically required cutdown to the
common femoral artery for direct visualization of sheath
placement and artery closure. Newer techniques utilizing
devices placing multiple sutures (Prostar XL and Perclose
ProGlide, Abbott Vascular) prior to large femoral artery
sheath placement (pre-close technique) have been successful
for achieving hemostasis at large arteriotomies required for
EVAR and TEVAR placement (refer to Chap. 17 for more
information). In this particular setting, access site complication including bleeding following closure device deployment
is associated with larger sheath diameters, smaller CFA
diameter, and larger sheath size to CFA diameter ratios [32].
Finally, there are closure devices that utilize both sutures and
a procoagulation solution. Several studies have compared
these invasive closure devices to manual or device-assisted
compression.
Although results vary, it appears that these invasive closure devices achieve hemostasis more rapidly where the
median time to hemostasis was 1min in the invasive closure
group and 10 min in manual compression group [33].
Complication rates are similar between closure and compressive devices, with signicant heterogeneity between