Practices and complications of vascular closure devices and manual compression in patients undergoing elective transfemoral coronary procedures

Totally Extravascular Bioresorbable Closure Reduces Access Complications After Endovascular Peripheral Intervention

OBJECTIVE

Percutaneous closure of the access artery has become commonplace after endovascular intervention. In patients with peripheral vascular occlusive disease, however, control of the puncture site is more problematic as the access artery is frequently plaque-laden and stenotic. Ischemic complications in the access extremity are more common in these cases, particularly when using devices that depend on the deployment of prosthetic material within the compromised arterial lumen. The purpose of this retrospective clinical study was to assess the efficacy of totally extravascular/bioresorbable closure (TEBC) of the femoral artery puncture sites after percutaneous peripheral intervention (PPI).

METHODS

Consecutive PPIs performed at single institution between 2015-2020 were studied. Demographic characteristics and the incidence of access complications were recorded. The complication rate of TEBC and manual compression were analyzed with multivariate regression analysis. Major complications were defined as the composite of acute arterial ischemia, major bleeding and/or pseudoaneurysm requiring operation. Minor complications were defined as the aggregate of transient hypotension, groin hematoma and/or arteriovenous fistula.

RESULTS

A total of 507 PPIs were performed in 345 patients during the study period. The mean age was 74 years; comorbidities were prevalent including diabetes (57%), obesity (28%) and end-stage renal failure requiring dialysis (10%). Indications for PPI were either chronic limb-threatening ischemia (68%) or claudication (32%). All procedures were performed using femoral artery access in a retrograde (93%) or antegrade (7%) fashion with ≤5 Fr (21%), 6 Fr (18%) or ≥7 Fr (61%) sheaths. Control of the femoral artery puncture site was achieved by either manual compression (MC, 75%), or totally extravascular/bioresorbable closure (TEBC, 25%). TEBC became the exclusive closure method in 2019. Acute arterial ischemia rarely complicated MC (1.3%) but was not observed in any patient undergoing TEBC. Bleeding and/or pseudoaneurysms requiring reoperation were also rare (MC 0.3% vs. TEBC 1.6%; p=0.64). On multivariate analysis there was no difference in major access complications between MC and TEBC (OR=1.45 [0.27-7.79]; p=0.66), while minor access complications were significantly reduced with the use of TEBC (OR=0.39 [0.19-0.75]; p<0.01).

CONCLUSIONS

TEBC after PPI for peripheral arterial disease is safe and effective. There were no instances of acute arterial ischemia following TEBC in this series, and TEBC significantly reduced the incidence of minor access complications compared to MC. Given the bioresorbable design of the device, and the lack of an intraluminal component of any kind, TEBC may be the ideal closure device for patients with peripheral arterial disease undergoing endovascular intervention.

Ultrasound-guided versus fluoroscopy-guided large-bore femoral access in PCI of complex coronary lesions: the international, multicentre, randomised ULTRACOLOR Trial

BACKGROUND

Transfemoral access is often used when large-bore guide catheters are required for percutaneous coronary intervention (PCI) of complex coronary lesions, especially when large-bore transradial access is contraindicated. Whether the risk of access site complications for these procedures may be reduced by ultrasound-guided puncture is unclear.

AIMS

We aimed to show the superiority of ultrasound-guided femoral puncture compared to fluoroscopy-guided access in large-bore complex PCI with regard to access site-related Bleeding Academic Research Consortium 2, 3 or 5 bleeding and/or vascular complications requiring intervention during hospitalisation.

METHODS

The ULTRACOLOR Trial is an international, multicentre, randomised controlled trial investigating whether ultrasound-guided large-bore femoral access reduces clinically relevant access site complications compared to fluoroscopy-guided large-bore femoral access in PCI of complex coronary lesions.

RESULTS

A total of 544 patients undergoing complex PCI mandating large-bore (≥7 Fr) transfemoral access were randomised at 10 European centres (median age 71; 76% male). Of these patients, 68% required PCI of a chronic total occlusion. The primary endpoint was met in 18.9% of PCI with fluoroscopy-guided access and 15.7% of PCI with ultrasound-guided access (p=0.32). First-pass puncture success was 92% for ultrasound-guided access versus 85% for fluoroscopy-guided access (p=0.02). The median time in the catheterisation laboratory was 102 minutes versus 105 minutes (p=0.43), and the major adverse cardiovascular event rate at 1 month was 4.1% for fluoroscopy-guided access and 2.6% for ultrasound-guided access (p=0.32).

CONCLUSIONS

As compared to fluoroscopy-guided access, the routine use of ultrasound-guided access for large-bore transfemoral complex PCI did not significantly reduce clinically relevant bleeding or vascular access site complications. A significantly higher first-pass puncture success rate was demonstrated for ultrasound-guided access.

CLINICALTRIALS

gov identifier: NCT04837404.

Post-procedural structural heart CT imaging: TAVR, TMVR, and other interventions

Transcatheter valve replacement has experienced substantial growth in the past decade and this technique can now be used for any of the four heart valves. Transcatheter aortic valve replacement (TAVR) has overtaken surgical aortic valve replacement. Transcatheter mitral valve replacement (TMVR) is often performed in pre-existing valves or after prior valve repair, although numerous devices are undergoing trials for replacement of native valves. Transcatheter tricuspid valve replacement (TTVR) is similarly under active development. Lastly, transcatheter pulmonic valve replacement (TPVR) is most often used for revision treatment of congenital heart disease. Given the growth of these techniques, radiologists are increasingly called upon to interpret post-procedural imaging for these patients, particularly with CT. These cases will often arise unexpectedly and require detailed knowledge of potential post-procedural appearances. We review both normal and abnormal post-procedural findings on CT. Certain complications-device migration or embolization, paravalvular leak, or leaflet thrombosis-can occur after replacement of any valve. Other complications are specific to each type of valve, including coronary artery occlusion after TAVR, coronary artery compression after TPVR, or left ventricular outflow tract obstruction after TMVR. Finally, we review access-related complications, which are of particular concern due to the requirement of large-bore catheters for these procedures.

Ultrasound-guided femoral access in patients with vascular closure devices: a prespecified analysis of the randomised UNIVERSAL trial

BACKGROUND

Whether ultrasound (US)-guided femoral access compared to femoral access without US guidance decreases access site complications in patients receiving a vascular closure device (VCD) is unclear.

AIMS

We aimed to compare the safety of VCD in patients undergoing US-guided versus non-US-guided femoral arterial access for coronary procedures.

METHODS

We performed a prespecified subgroup analysis of the UNIVERSAL trial, a multicentre randomised controlled trial of 1:1 US-guided femoral access versus non-US-guided femoral access, stratified for planned VCD use, for coronary procedures on a background of fluoroscopic landmarking. The primary endpoint was a composite of major Bleeding Academic Research Consortium 2, 3 or 5 bleeding and vascular complications at 30 days.

RESULTS

Of 621 patients, 328 (52.8%) received a VCD (86% ANGIO-SEAL, 14% ProGlide). In patients who received a VCD, those randomised to US-guided femoral access compared to non-US-guided femoral access experienced a reduction in major bleeding or vascular complications (20/170 [11.8%] vs 37/158 [23.4%], odds ratio [OR] 0.44, 95% confidence interval [CI]: 0.23-0.82). In patients who did not receive a VCD, there was no difference between the US- and non-US-guided femoral access groups, respectively (20/141 [14.2%] vs 13/152 [8.6%], OR 1.76, 95% CI: 0.80-4.03; interaction p=0.004).

CONCLUSIONS

In patients receiving a VCD after coronary procedures, US-guided femoral access was associated with fewer bleeding and vascular complications compared to femoral access without US guidance. US guidance for femoral access may be particularly beneficial when VCD are used.

ULTrasound-guided TRAnsfemoral puncture in COmplex Large bORe PCI: study protocol of the UltraCOLOR trial

INTRODUCTION

Although recently published evidence favours transradial access (TRA) when using large-bore guiding catheters for percutaneous coronary intervention (PCI) of complex coronary lesions, the femoral artery will still be used in a considerate proportion of patients undergoing complex PCI, especially in PCI of chronic total occlusions (CTO). Ultrasound-guided puncture of the femoral artery may reduce clinically relevant access site complications, but robust evidence is lacking up to date.

METHODS AND ANALYSIS

A total of 542 patients undergoing complex PCI, defined as PCI of CTO, complex bifurcation, heavy calcified lesion or left main, in which the 7-F or 8-F transfemoral access is required, will be randomised to ultrasound-guided puncture or fluoroscopy-guided puncture. The primary outcome is the incidence of the composite end-point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Access site complications and major adverse cardiovascular events up to 1 month will also be compared between both groups.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee ('Medisch Ethische Toetsing Commissie Isala Zwolle') for all Dutch sites, 'Comité Medische Ethiek Ziekenhuis Oost-Limburg' for Hospital Oost-Limburg, 'Comité d'éthique CHU-Charleroi-ISPPC' for Centre Hospilatier Universitaire de Charleroi and 'Ethik Kommission de Ärztekammer Nordrhein' for Elisabeth-Krankenhaus). The trial outcomes will be published in peer-reviewed journals of the concerned literature. The ultrasound guided transfemoral access in complex large bore PCI trial has been administered in the ClinicalTrials.gov database, reference number: NCT03846752.

REGISTRATION DETAILS

ClinicalTrials.gov identifier: NCT03846752.

Femoral Artery Closure Devices vs Manual Compression During Cardiac Catheterization and Percutaneous Coronary Intervention

Background

Femoral arterial access remains widely used despite recent increase in radial access for cardiac catheterization and percutaneous coronary intervention (PCI). Various femoral artery closure devices have been developed and are commonly used to shorten vascular closure times, with variable rates of vascular complications observed in clinical trials. We sought to examine the rates of contemporary outcomes during diagnostic catheterization and PCI with the most common femoral artery closure devices.

Methods

We identified patients who had undergone either diagnostic catheterization alone (n = 14,401) or PCI (n = 11,712) through femoral artery access in the Indiana University Health Multicenter Cardiac Cath registry. We compared outcomes according to closure type: manual compression, Angio-Seal, Perclose, or Mynx. Access complications and bleeding outcomes were measured according to National Cardiovascular Data ​Registry standard definitions.

Results

The use of any vascular closure device as compared to manual femoral arterial access hold was associated with a significant reduction in vascular access complications and bleeding events in patients who underwent PCI. No significant difference in access-site complications was observed for diagnostic catheterization alone. Among closure devices, Perclose and Angio-Seal had a lower rate of hematoma than Mynx.

Conclusions

The use of femoral artery access closure devices is associated with a reduction in vascular access complication rates as compared to manual femoral artery compression in patients who undergo PCI.

Transradial versus Transfemoral Approaches in Diagnostic and Therapeutic Neuroendovascular Interventions: A Meta-Analysis of Current Literature

BACKGROUND

The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures.

METHODS

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures.

RESULTS

Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P < 0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P < 0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P < 0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P < 0.01).

CONCLUSIONS

Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.

Watchman Device Procedure Complicated by Rare Perclose ProGlide Embolization: Case Report and Literature Review

Atrial fibrillation (AF) is the most common cardiac arrhythmia with significant morbidity and mortality. In this case, we present a 69-year-old man with a past medical history of atrial fibrillation on warfarin who came to the hospital for placement of the Watchman device (Boston Scientific Corporation, Marlborough, Massachusetts, United States). His procedure was complicated by Perclose ProGlide™ Suture-Mediated Closure system (Abbott Laboratories Inc., Chicago, Illinois, United States) embolism. The vascular surgery department was consulted STAT in the electrophysiology lab and was unable to fully visualize the vessel. The patient was then brought emergently to a hybrid operating room where venotomy was made. He tolerated the procedure well and was eventually discharged home.

Access Site Related Vascular Complications following Percutaneous Cardiovascular Procedures

Vascular access site complications (ASC) are among the most frequent complications of percutaneous cardiovascular procedures (PCP) and are associated with adverse outcome and high resources utilization. In this prospective study, we investigated patients with postprocedural clinical suspicion of ASC evaluated by duplex ultrasound (DUS) for the presence of ASC. We assessed the incidence, in-hospital outcome, treatment of complications and predictors for ASC. Overall, 12,901 patients underwent PCP during a 40 months period. Of those, 2890 (22.4%) patients had postprocedural clinical symptoms of ASC and were evaluated using DUS. An ASC was found in 206 of the DUS examined patients (corresponding to 7.1% of the 2890 DUS examined patients). In 6.7% of all valvular/TAVI procedures, an ASC was documented, while coronary, electrophysiological and peripheral PCP had a comparable and low rate of complications (1.2–1.5%). Pseudoaneurysm (PSA) was the most frequent ASC (67.5%), followed by arteriovenous fistula (13.1%), hematoma (7.8%) and others (11.7%). Of all PSA, 84 (60.4%) were treated surgically, 44 (31.6%) by manual compression and 11 (7.9%) conservatively. Three (0.02%) patients died due to hemorrhagic shock. In conclusion, femoral ASC are rare in the current era of PCP with PSA being the leading type of ASC. Nonetheless, patients with predisposing risk factors and postprocedural suspicious clinical findings should undergo a DUS to early detect and mitigate ASC-associated outcome.

Incidence of and predisposing factors for pseudoaneurysm formation in a high-volume cardiovascular center

Purpose

To evaluate factors associated with pseudoaneurysm (PSA) development.

Methods

Between January 2016 and May 2020, 30,196 patients had invasive vascular radiological or cardiac endovascular procedures that required arterial puncture. All patients with PSA were identified. A matched (age, gender, and type of the procedure) control group of 134 patients was created to reveal predictors of PSA formation.

Results

Single PSAs were found in 134 patients. Fifty-three PSAs developed after radiological procedures (53/6555 [0.8%]), 31 after coronary artery procedures (31/18038 [0.2%]), 25 after non-coronary artery cardiac procedures (25/5603 [0.4%]), and 25 due to procedures in which the arterial puncture was unintended. Thirty-four PSAs (25.4%) were localized to the upper extremity arteries (vascular closure device [VCD], N = 0), while 100 (74.6%) arose from the lower extremity arteries (VCD, N = 37). The PSA prevalence was 0.05% (10/20478) in the radial artery, 0.1% (2/1818) in the ulnar artery, 1.2% (22/1897) in the brachial artery, and 0.4% (99/22202) in the femoral artery. Treatments for upper and lower limb PSAs were as follows: bandage replacement (32.4% and 14%, respectively), ultrasound-guided compression (11.8% and 1%, respectively), ultrasound-guided thrombin injection (38.2% and 78%, respectively), and open surgery (17.6% and 12%, respectively). Reintervention was necessary in 19 patients (14.2%). The prevalence of PSA for the punctured artery with and without VCD use was 37/3555 (1%) and 97/27204 (0.4%), respectively (OR, 2.94; 95% CI, 1.95–4.34; P<0.001). The effect of red blood cell (RBC) count (P<0.001), hematocrit value (P<0.001), hemoglobin value (P<0.001), international normalized ratio (INR; P<0.001), RBC count—INR interaction (P = 0.003), and RBC count—VCD use interaction (P = 0.036) on PSA formation was significant.

Conclusion

Patients in whom the puncture site is closed with a VCD require increased observation. Preprocedural laboratory findings are useful for the identification of patients at high risk of PSA formation.

Randomized Comparison Between Radial and Femoral Large-Bore Access for Complex Percutaneous Coronary Intervention

OBJECTIVES

The aim of this study was to investigate whether transradial (TR) percutaneous coronary intervention (PCI) is superior to transfemoral (TF) PCI in complex coronary lesions with large-bore guiding catheters with respect to clinically relevant access site-related bleeding or vascular complications.

BACKGROUND

The femoral artery is currently the most applied access site for PCI of complex coronary lesions, especially when large-bore guiding catheters are required. With downsizing of TR equipment, TR PCI may be increasingly applied in these patients and might be a safer alternative compared with the TF approach.

METHODS

An international prospective multicenter trial was conducted, randomizing 388 patients with planned PCI for complex coronary lesions, including chronic total occlusion, left main, heavy calcification, or complex bifurcation, to either 7-F TR access (TRA) or 7-F TF access (TFA). The primary endpoint was defined as access site-related clinically significant bleeding or vascular complications requiring intervention at discharge. The secondary endpoint was procedural success.

RESULTS

The primary endpoint event rate was 3.6% for TRA and 19.1% for TFA (p < 0.001). The crossover rate from radial to femoral access was 3.6% and from femoral to radial access was 2.6% (p = 0.558). The procedural success rate was 89.2% for TFA and 86.0% for TRA (p = 0.285). There was no difference between TFA and TRA with regard to procedural duration, contrast volume, or radiation dose.

CONCLUSIONS

In patients undergoing PCI of complex coronary lesions with large-bore access, radial compared with femoral access is associated with a significant reduction in clinically relevant access-site bleeding or vascular complications, without affecting procedural success. (Complex Large-Bore Radial Percutaneous Coronary Intervention [PCI] Trial [Color]; NCT03846752).

Early radial artery occlusion following the use of a transradial 7-French sheath for complex coronary interventions in Chinese patients

OBJECTIVES

We aimed to explore the impact of 7-Fr sheaths on the incidence of early radial artery occlusion (RAO) after transradial coronary intervention (TRI) in Chinese patients.

BACKGROUND

RAO precludes future use of the vessel for vascular access. Transradial catheterization is usually performed via 5-Fr or 6-Fr catheters; 7-Fr sheath insertion enables complex coronary interventions but may increase the RAO risk.

METHODS

We prospectively enrolled 130 consecutive patients undergoing complex TRI using 7-Fr sheaths. Radial artery ultrasound assessment was performed before and after TRI. Early RAO was defined as the absence of flow on ultrasound within 6-24 hr after TRI. Multivariate logistic regression was used to determine the factors related to early RAO after TRI.

RESULTS

7-Fr sheaths were mainly used for chronic total occlusion (44.6%), bifurcation (30.0%), and tortuous calcification (25.4%) lesions. All patients were successfully sheathed. Percutaneous coronary intervention (PCI) procedural success was 96.2%; 119 patients (91.5%) had preserved radial artery patency after TRI. All 11 RAO cases (8.5%) were asymptomatic. The radial artery diameter was significantly larger postoperatively (3.1 ± 0.4 mm) than preoperatively (2.6 ± 0.5 mm) (p < .001). No parameters significantly differed between patients with and without RAO. TRI history was the only independent risk factor of early RAO (odds ratio: 6.047, 95% confidence interval: 1.100-33.253, p = .039).

CONCLUSIONS

7-Fr sheath use after transradial access for complex PCI is feasible and safe. Evaluating the radial artery within 24 hr after TRI allows timely RAO recognition, important for taking measures to maintain radial artery patency and preserve access for future TRIs.

Ultrasound-guided puncture reduces bleeding-associated complications, regardless of calcified plaque, after endovascular treatment of femoropopliteal lesions, especially using the antegrade procedure: A single-center study

Background

A common complication of endovascular treatment for femoropopliteal lesions is bleeding at the vascular access site. Although risk factors of bleeding-associated complications at the approach site have been reported, the results have been inconclusive. Hence, this study aimed to assess the predictors of bleeding-associated complications at the approach site in patients undergoing endovascular treatment for femoropopliteal lesions.

Methods

This retrospective, single-center, observational study included consecutive patients who underwent endovascular treatment (n = 366, 75% male, 72.4±9.9 year) for peripheral arterial disease with claudication and critical limb ischemia in our hospital from January 2010 to December 2017. We divided the patients into bleeding and non-bleeding groups, depending on whether bleeding-associated complications occurred at the approach site. Bleeding-associated complications were defined according to the Bleeding Academic Research Consortium criteria types 2, 3, and 5.

Results

Altogether, 366 endovascular treatment procedures and 404 arterial accesses were performed for femoropopliteal lesions in 335 peripheral arterial disease patients with claudication and 69 critical limb ischemia patients. We recorded 35 postprocedural bleeding-associated complications at the approach site (9%), all of which were hematomas. The predictors of increased bleeding-associated complications were age ≥ 80 years (bleeding vs. non-bleeding group, 43% vs. 25%, p<0.05) and antegrade cannulation of the common femoral artery (48% vs. 69%, p<0.05). Ultrasound-guided puncture reduced bleeding-associated complications (odds ratio, 0.28; 95% confidence interval, 0.004–0.21; p<0.05). In contrast, there was no significant difference in puncture site calcification between the groups (bleeding vs. non-bleeding groups, 29% vs. 21%, p = 0.29).

Conclusion

Ultrasound-guided puncture is associated with a decrease in bleeding-associated complications at the approach site, regardless of the presence of calcified plaque. It is particularly effective and should be more actively used in patients aged ≥80 years and for antegrade cannulation of the common femoral artery.

Practical tips for performing resuscitative endovascular balloon occlusion of the aorta

Background:

Hemorrhage is the leading cause of death in trauma settings. Non-compressible torso hemorrhage, which is caused by abdominopelvic and thoracic injuries, is an important cause of subsequent organ dysfunction and poor outcomes in multiple trauma patients. The management of hemodynamically unstable patients with non-compressible torso hemorrhage has changed, and the concept of damage control resuscitation has been developed in the last decades. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) as a method of temporary stabilization is the modern evolution of bleeding control, and it is in the middle of a paradigm shift as a treatment for non-compressible torso hemorrhage. Despite its effectiveness in patients with hemorrhagic shock, the application of REBOA remains limited because of lack of experience and troubleshooting guidelines.

Objectives:

The aim of study was to provide useful tips for the implementing a step-by-step procedure for REBOA in various hospital settings and capabilities.

Methods:

We introduced REBOA procedures using a REBOA-customized 7 Fr balloon catheter through the animation models or radiography from preparation to access, catheter management, and device removal after procedure completed.

Results:

We have described REBOA procedures as follows: identification of the common femoral artery, arterial access for placement of a guidewire, precautions during a sheath insertion, guidewire and balloon positioning in the aorta, occlusion zones and adjustment of balloon location, REBOA strategy for extending the occlusion time, balloon deflation and removal, sheath removal, and medical records.

Conclusion:

We believe that the practical tips mentioned in this article will help in performing the REBOA procedure systematically and developing an effective REBOA framework.

Perclose ProGlide embolization as a complication: case report and review of literature

Background: Vascular closure devices have replaced mechanical compression for closure of femoral access sites after endovascular procedures. Case: We present an 87-year old male with symptomatic infrarenal aortic aneurysm measuring 4.8 cm presenting for elective endovascular repair of the aortic aneurysm. A Perclose ProGlide Suture-Mediated Closure was used for closure. The closure was complicated by a separation of the ProGlide device resulting in the migration of the footplate to the descending aorta. Correction required snare retrieval via radial access, and the patient recovered without complications. Discussion: We highlight an important complication of the Perclose ProGlide Suture-Mediated Closure device that is rare but important to know when performing endovascular closures with this device.

Brain abscess – A rare complication of endovascular treatment for acute ischemic stroke

Background:

Brain abscess is a neurosurgical emergency, which can arise through direct bacterial seeding or hematogenous spread. Rarely, brain abscess formation has been reported following ischemic stroke. An increasingly utilized therapy for stroke is mechanical thrombectomy, and within this report, we present a case of brain abscess formation following this procedure.

Case Description:

A 78-year-old female presented to our center with a right total anterior circulation stroke (TACS) secondary to terminal internal carotid artery occlusion. An emergent mechanical thrombectomy was performed and the patient’s initial postoperative recovery was good. In the 3^rd week after the procedure, however, the patient became more confused and following the onset of fever, an MRI brain was performed, which demonstrated an extensive multiloculated right-sided brain abscess. Burr hole drainage of the abscess was subsequently undertaken and pus samples obtained grew Proteus mirabilis, presumed secondary to a urinary tract infection, and the patient was started on prolonged antibiotic therapy. To date, the infection has been eradicated and the patient survives albeit with persistent neurological deficits.

Conclusion:

To the best of our knowledge, this is the first reported UK case of brain abscess following mechanical thrombectomy for stroke. Endovascular interventions can lead to increased incidence of ischemia-reperfusion injury in stroke with increased blood–brain barrier damage and risk of microbial seeding. This case highlights the need for rigorous asepsis and proactive treatment of systemic infections in the acute phase following endovascular treatment and consideration of brain abscess in all patients who present with new-onset confusion and unexplained fever following stroke.

Complex Large-Bore Radial percutaneous coronary intervention: rationale of the COLOR trial study protocol

INTRODUCTION

The radial artery has become the standard access site for percutaneous coronary intervention (PCI) in stable coronary artery disease and acute coronary syndrome, because of less access site related bleeding complications. Patients with complex coronary lesions are under-represented in randomised trials comparing radial with femoral access with regard to safety and efficacy. The femoral artery is currently the most applied access site in patients with complex coronary lesions, especially when large bore guiding catheters are required. With slender technology, transradial PCI may be increasingly applied in patients with complex coronary lesions when large bore guiding catheters are mandatory and might be a safer alternative as compared with the transfemoral approach.

METHODS AND ANALYSIS

A total of 388 patients undergoing complex PCI will be randomised to radial 7 French access with Terumo Glidesheath Slender (Terumo, Japan) or femoral 7 French access as comparator. The primary outcome is the incidence of the composite end point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Procedural success and major adverse cardiovascular events up to 1 month will also be compared between both groups.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee at each recruiting center ('Medisch Ethische Toetsing Commissie Isala Zwolle', 'Commissie voor medische ethiek ZNA', 'Comité Medische Ethiek Ziekenhuis Oost-Limburg', 'Comité d'éthique CHU-Charleroi-ISPPC', 'Commission cantonale d'éthique de la recherche CCER-Republique et Canton de Geneve', 'Ethik Kommission de Ärztekammer Nordrhein' and 'Riverside Research Ethics Committee'). The trial outcomes will be published in peer-reviewed journals of the concerned literature.

TRIAL REGISTRATION NUMBER

NCT03846752.

Endovascular Stroke Interventions: Procedural Complications and Management

Endovascular mechanical thrombectomy has evolved significantly and has become the mainstay and most effective currently available treatment for acute ischemic stroke patients due to large vessel occlusion. Mechanical thrombectomy is presently performed using a stent retriever or stent-like device, an aspiration catheter, or a combination of the two. Much of the literature has focused on the benefits of endovascular mechanical thrombectomy with only limited data about procedural complications and management. Awareness of risk factors and early recognition of these complications can potentially reduce complication rates, improve management, and yield better overall outcomes. In this review, the authors present a description of intraprocedural complications and strategies to prevent and treat these complications.

Comparison of the effect of manual compression and closure pad on postangiography complications: A randomized controlled trial

BACKGROUND

Different methods are available for the closure of the femoral artery after catheterization. The present study aimed at comparing the effect of manual compression (MC) and closure pad (CP) on vascular complications (hematoma and bleeding) of coronary angiography.

METHODS

In the current clinical trial, a total of 238 patients who were candidates for angiography were randomly assigned to the MC and CP groups. In the MC group, after removal of the arterial sheath, the arterial puncture site was manually compressed for 5-10 minutes and hemostasis was achieved. In the CP group, after removal of the arterial sheath, the arterial puncture site was first manually compressed for 5-10 minutes and initial coagulation was achieved. Then, to continue the coagulation process, a CP was attached to the artery puncture site. Postangiography complications including bleeding and hematoma were monitored in both groups immediately and up to 24 hours after hemostasis. Data were analyzed by SPSS-18 software.

RESULTS

After angiography, 7 (9.5%) and 5 (2.4%) patients had hematoma in the MC and CP groups, respectively; however, no significant difference was found between the groups. Rebleeding after hemostasis was observed in 2 (7.1%) patients in the MC group, but none of the subjects in the CP group had rebleeding. There was no significant difference in bleeding volume between the groups.

CONCLUSION

The results indicated the same efficacy of MC and CP methods in the prevention of postangiography vascular complications. Given the advantages of CP such as the possibility of changing the position in bed and increased physical comfort in the patient, this method is recommended for angiography and catheterization.

Brachiocephalic artery stenting through the carotid artery: A case report and review of the literature

BACKGROUND

As the population ages and people's living standards gradually improve, the incidence of cerebrovascular disease in China is increasing annually, posing a serious threat to people's health. The incidence of brachiocephalic artery stenosis in ischemic cerebrovascular disease is relatively low, accounting for 0.5% to 2% of patients, but its consequences are very serious. Herein, we report a case of brachiocephalic artery stenting through the carotid artery.

CASE SUMMARY

The patient was a 66-year-old man. He came to our hospital because of repeated dizziness and was diagnosed with ischemic cerebrovascular disease (stenosis at the beginning of the brachiocephalic artery). Cerebral angiography suggested that the stenosis of the brachiocephalic artery had almost occluded it. Contrast agent threaded a line through the stenosis, and there was reversed blood flow through the right vertebral artery to compensate for the subclavian steal syndrome in the right subclavian artery. To improve the symptoms, we placed an Express LD (8 mm × 37 mm) balloon expanding stent in the stenosis section. After the operation, the patient's dizziness significantly improved. However, after 6 mo, the patient was re-admitted to the hospital due to dizziness. A computed tomography scan of the head revealed multiple cerebral infarctions in bilateral basal ganglia and the right lateral ventricle. An auxiliary examination including computerized tomography angiography of the vessels of the head and cerebral angiography both showed severe stenosis in the brachiocephalic artery stent. During the operation, the guidewire and catheter were matched to reach the opening of the brachiocephalic artery. Therefore, we decided to use a right carotid artery approach to complete the operation. We sutured the neck puncture point with a vascular stapler and then ended the operation. After the operation, the patient recovered well, his symptoms related to dizziness disappeared, and his right radial artery pulsation could be detected.

CONCLUSION

In patients with brachial artery stenosis, when the femoral artery approach is difficult, the carotid artery is an unconventional but safe and effective approach. At the same time, the use of vascular suturing devices to suture a carotid puncture point is also commendable. Although it is beyond the published scope of the application, when used cautiously, it can effectively avoid cerebral ischemia caused by prolonged artificial compression, and improper suturing can lead to stenosis of the puncture site and improper blood pressure, resulting in the formation of a hematoma. Finally, satisfactory hemostasis can be achieved.

Safety and efficacy of using vascular closure devices for hemostasis on sheath removal after a transfemoral artery percutaneous coronary intervention

AIM

To determine the efficacy of vascular closure devices (VCDs) for hemostasis following transfemoral percutaneous coronary interventions (PCIs).

METHODS

This two-group pre-post-test observational study with purposive sampling enrolled 73 patients between January, 2014 and February, 2015. The patients were allocated to either the intervention (vascular closure devices group, n = 34) or the control group (manual compression [MC] group, n = 39). Questionnaires were used to assess their demographic and clinical characteristics, vascular complications, visual analogue scale score for pain, and discomfort levels. Pain and discomfort were measured before and after the PCI.

RESULTS

Vascular complications were observed in 15 (44.1%) VCD patients and 13 (33.3%) MC patients, with no significant between-group difference. However, the VCD patients had a higher relative risk of bruising, hematomas, and need for further treatment. After the PCI, the pain scores and discomfort levels increased significantly in both groups, but the VCD patients had more successful hemostasis, less pain, and less physical and psychological discomfort (lower-limb numbness, shoulder pain, restlessness, and worrying about walking ability, being unable to lift heavy objects in the future, and taking time off from work).

CONCLUSION

The VCDs seem to be superior to the MCs, providing more successful hemostasis, less pain and discomfort, and earlier ambulation after a transfemoral PCI. These findings aid clinical nurses in understanding the risk of vascular complications, discomfort, and pain that are associated with VCD use for improving the quality of clinical care and help clinicians in determining the appropriate hemostatic method for patients undergoing a transfemoral PCI, particularly in the Chinese population.

Multidetector CT of iatrogenic and self-inflicted vascular lesions and infections at the groin

Abstract

The number and complexity of endovascular procedures performed via either arterial or venous access are steadily increasing. Albeit associated with higher morbidity compared to the radial approach, the traditional common femoral artery remains the preferred access site in a variety of cardiac, aortic, oncologic and peripheral vascular procedures. Both transarterial and venous cannulation (for electrophysiology, intravenous laser ablation and central catheterisation) at the groin may result in potentially severe vascular access site complications (VASC). Furthermore, vascular and soft-tissue groin infections may develop after untreated VASC or secondarily to non-sterile injections for recreational drug use. VASC and groin infections require rapid diagnosis and appropriate treatment to avoid further, potentially devastating harm. Whereas in the past colour Doppler ultrasound was generally used, in recent years cardiologists, vascular surgeons and interventional radiologists increasingly rely on pelvic and femoral CT angiography. Despite drawbacks of ionising radiation and the need for intravenous contrast, multidetector CT rapidly and consistently provides a panoramic, comprehensive visualisation, which is crucial for correct choice between conservative, endovascular and surgical management. This paper aims to provide radiologists with an increased familiarity with iatrogenic and self-inflicted VASC and infections at the groin by presenting examples of haematomas, active bleeding, pseudoaneurysms, arterial occlusion, arterio-venous fistula, endovenous heat-induced thrombosis, septic thrombophlebitis, soft-tissue infections at the groin, and late sequelae of venous injuries.

Teaching Points

• Complications may develop after femoral arterial or venous access for interventional procedures.

• Arterial injuries include bleeding, pseudoaneurysm, occlusion, arteriovenous fistula, dissection.

• Endovenous heat-induced thrombosis is a specific form of iatrogenic venous complication.

• Iatrogenic infections include groin cellulitis, abscesses and septic thrombophlebitis.

• CT angiography reliably triages vascular access site complications and groin infections.

Do not underestimate the femoral pseudoaneurysm

Abstract. In addition to haematoma and arteriovenous fistula, the iatrogenic pseudoaneurysm is a common complication of vascular access that is caused by a perforation in the arterial wall. Iatrogenic pseudoaneurysms can progress in size and lead to rupture and active bleeding. Over the previous few decades, therapeutic methods have evolved from surgical repair to less invasive options, such as ultrasound-guided compression therapy (UGCT) and ultrasound-guided thrombin injection (UGTI). This paper presents an overview of the diagnostic and treatment modalities used in femoral pseudoaneurysms as well as a comprehensive summary of previous studies that analysed the success and complication rates of UGCT and UGTI.

Pivotal Study of a Next-Generation Balloon-Expandable Stent-Graft for Treatment of Iliac Occlusive Disease

Purpose: To evaluate the safety and efficacy of a next-generation balloon-expandable stent-graft for the treatment of arterial occlusive disease in patients with de novo or restenotic lesions in the common and/or external iliac arteries. Methods: A prospective, multicenter, single-arm safety and efficacy study ( ClinicalTrials.gov identifier: NCT02080871) of the VBX Stent Graft for treatment of de novo or restenotic lesions in the iliac arteries was conducted under an Investigational Device Exemption at 26 US sites and 1 New Zealand center. The study eligibility criteria were established with the aim of enrolling more “real-world” patients compared with previous iliac stent studies supporting Food and Drug Administration approval. The study enrolled 134 patients (mean age 66±9.5 years; 79 men) with 213 iliac lesions. Three-quarters of the population (101, 75.4%) had Rutherford category 3 ischemia, and 43 (32.1%) patients presented with TASC II C/D lesions. The primary endpoint was a composite of device- or procedure-related death within 30 days, myocardial infarction within 30 days, target lesion revascularization (TLR) within 9 months, and amputation above the metatarsals in the treated leg within 9 months. Results: In all, 234 devices were implanted in 213 lesions with 100% technical success; 57 (42.5%) patients received kissing stents at the aortic bifurcation. No devices exhibited a discernable change in length after final deployment as determined by independent core laboratory quantitative angiographic analysis. At 9 months, 3 (2.3%) of 132 patients (1 lost to follow-up, 1 unrelated death) experienced a major adverse event (3 TLRs) related to the primary endpoint. At 9 months, there were no device-related serious adverse events or unanticipated adverse device effects. Conclusion: The next-generation balloon-expandable stent-graft demonstrated notable 9-month safety and efficacy in treating iliac occlusive disease in patients reflecting common clinical practice.

ANMCO/GICR-IACPR/SICI-GISE Consensus Document: the clinical management of chronic ischaemic cardiomyopathy

Stable coronary artery disease (CAD) is a clinical entity of great epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions. Stable CAD encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity, and diet. Adherence to therapy as an emerging risk factor is also discussed.

Effects of position change on lumbar pain and discomfort of Korean patients after invasive percutaneous coronary intervention: a RCT study

[Purpose] This study sought to examine the effects of position change on lumbar pain and discomfort of Korean patients after invasive percutaneous coronary intervention. [Subjects and Methods] The participants consisted of 48 patients (experimental: n=24, control: n=24) who underwent invasive coronary intervention (Percutaneous Coronary Intervention) in K hospital, Seoul, Korea. A randomized controlled trial design was used. Position changes as the experimental treatment were sequenced as follows: supine position for one hour after removal of the catheter; 30-degree bed-elevated lateral position for one hour; 30-degree bed elevation for one hour; and finally 30-degree bed-elevated lateral position for one hour. The thirty degree bed-elevated lateral position was intended to press on the surgical site. Measures used were the general characteristics form, Visual Analogue Scale for lumbar pain, and discomfort scale. [Results] There were significant differences on lumbar pain and discomfort of Korean patients after invasive coronary intervention between the experimental and control groups. [Conclusion] Position change was an effective intervention for decreasing lumbar pain and discomfort of Korean patients after invasive coronary intervention. Health professionals need to consider an array of methods including position change for patients after invasive coronary intervention.

Vascular closure devices for femoral arterial puncture site haemostasis

BACKGROUND

Vascular closure devices (VCDs) are widely used to achieve haemostasis after procedures requiring percutaneous common femoral artery (CFA) puncture. There is no consensus regarding the benefits of VCDs, including potential reduction in procedure time, length of hospital stay or time to patient ambulation. No robust evidence exists that VCDs reduce the incidence of puncture site complications compared with haemostasis achieved through extrinsic (manual or mechanical) compression.

OBJECTIVES

To determine the efficacy and safety of VCDs versus traditional methods of extrinsic compression in achieving haemostasis after retrograde and antegrade percutaneous arterial puncture of the CFA.

SEARCH METHODS

The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (April 2015) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 3). Clinical trials databases were searched for details of ongoing or unpublished studies. References of articles retrieved by electronic searches were searched for additional citations.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials in which people undergoing a diagnostic or interventional procedure via percutaneous CFA puncture were randomised to one type of VCD versus extrinsic compression or another type of VCD.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the methodological quality of trials. We resolved disagreements by discussion with the third author. We performed meta-analyses when heterogeneity (I(2)) was < 90%. The primary efficacy outcomes were time to haemostasis and time to mobilisation (mean difference (MD) and 95% confidence interval (CI)). The primary safety outcome was a major adverse event (mortality and vascular injury requiring repair) (odds ratio (OR) and 95% CI). Secondary outcomes included adverse events.

MAIN RESULTS

We included 52 studies (19,192 participants) in the review. We found studies comparing VCDs with extrinsic compression (sheath size ≤ 9 Fr), different VCDs with each other after endovascular (EVAR) and percutaneous EVAR procedures and VCDs with surgical closure after open exposure of the artery (sheath size ≥ 10 Fr). For primary outcomes, we assigned the quality of evidence according to GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria as low because of serious imprecision and for secondary outcomes as moderate for precision, consistency and directness.For time to haemostasis, studies comparing collagen-based VCDs and extrinsic compression were too heterogenous to be combined. However, both metal clip-based (MD -14.81 minutes, 95% CI -16.98 to -12.63 minutes; five studies; 1665 participants) and suture-based VCDs (MD -14.58 minutes, 95% CI -16.85 to -12.32 minutes; seven studies; 1664 participants) were associated with reduced time to haemostasis when compared with extrinsic compression.For time to mobilisation, studies comparing collagen-, metal clip- and suture-based devices with extrinsic compression were too heterogeneous to be combined. No deaths were reported in the studies comparing collagen-based, metal clip-based or suture-based VCDs with extrinsic compression. For vascular injury requiring repair, meta-analyses demonstrated that neither collagen (OR 2.81, 95% CI 0.47 to 16.79; six studies; 5731 participants) nor metal clip-based VCDs (OR 0.49, 95% CI 0.03 to 7.95; three studies; 783 participants) were more effective than extrinsic compression. No cases of vascular injury required repair in the study testing suture-based VCD with extrinsic compression.Investigators reported no differences in the incidence of infection between collagen-based (OR 2.14, 95% CI 0.88 to 5.22; nine studies; 7616 participants) or suture-based VCDs (OR 1.66, 95% CI 0.22 to 12.71; three studies; 750 participants) and extrinsic compression. No cases of infection were observed in studies testing suture-based VCD versus extrinsic compression. The incidence of groin haematoma was lower with collagen-based VCDs than with extrinsic compression (OR 0.46, 95% CI 0.40 to 0.54; 25 studies; 10,247 participants), but no difference was evident when metal clip-based (OR 0.79, 95% CI 0.46 to 1.34; four studies; 1523 participants) or suture-based VCDs (OR 0.65, 95% CI 0.41 to 1.02; six studies; 1350 participants) were compared with extrinsic compression. The incidence of pseudoaneurysm was lower with collagen-based devices than with extrinsic compression (OR 0.74, 95% CI 0.55 to 0.99; 21 studies; 9342 participants), but no difference was noted when metal clip-based (OR 0.76, 95% CI 0.20 to 2.89; six studies; 1966 participants) or suture-based VCDs (OR 0.79, 95% CI 0.25 to 2.53; six studies; 1527 participants) were compared with extrinsic compression. For other adverse events, researchers reported no differences between collagen-based, clip-based or suture-based VCDs and extrinsic compression.Limited data were obtained when VCDs were compared with each other. Results of one study showed that metal clip-based VCDs were associated with shorter time to haemostasis (MD -2.24 minutes, 95% CI -2.54 to -1.94 minutes; 469 participants) and shorter time to mobilisation (MD -0.30 hours, 95% CI -0.59 to -0.01 hours; 469 participants) than suture-based devices. Few studies measured (major) adverse events, and those that did found no cases or no differences between VCDs.Percutaneous EVAR procedures revealed no differences in time to haemostasis (MD -3.20 minutes, 95% CI -10.23 to 3.83 minutes; one study; 101 participants), time to mobilisation (MD 1.00 hours, 95% CI -2.20 to 4.20 hours; one study; 101 participants) or major adverse events between PerClose and ProGlide. When compared with sutures after open exposure, VCD was associated with shorter time to haemostasis (MD -11.58 minutes, 95% CI -18.85 to -4.31 minutes; one study; 151 participants) but no difference in time to mobilisation (MD -2.50 hours, 95% CI -7.21 to 2.21 hours; one study; 151 participants) or incidence of major adverse events.

AUTHORS' CONCLUSIONS

For time to haemostasis, studies comparing collagen-based VCDs and extrinsic compression were too heterogeneous to be combined. However, both metal clip-based and suture-based VCDs were associated with reduced time to haemostasis when compared with extrinsic compression. For time to mobilisation, studies comparing VCDs with extrinsic compression were too heterogeneous to be combined. No difference was demonstrated in the incidence of vascular injury or mortality when VCDs were compared with extrinsic compression. No difference was demonstrated in the efficacy or safety of VCDs with different mechanisms of action. Further work is necessary to evaluate the efficacy of devices currently in use and to compare these with one other and extrinsic compression with respect to clearly defined outcome measures.

Safety and Feasibility of Transradial Access for Visceral Interventions in Patients with Thrombocytopenia

PURPOSE

Transradial access (TRA) has shown lower morbidity and decreased bleeding complications compared to transfemoral access. This study evaluates the safety and feasibility of TRA in thrombocytopenic patients undergoing visceral interventions.

METHODS AND MATERIALS

Patients who underwent visceral interventions via the radial artery with platelet count less than or equal to 50,000/µL were included in the study. Outcome variables included technical success, access site, bleeding, transfusion, and neurological complications.

RESULTS

From July 1, 2012, to May 31, 2015, a total of 1353 peripheral interventions via TRA were performed, of which 85 procedures were performed in 64 patients (mean age 62.2 years) with a platelet count <50,000/µL (median 39,000/µL). Interventions included chemoembolization (n = 46), selective internal radiation therapy (n = 30), and visceral embolization (n = 9). Technical success was 97.6% with two cases of severe vessel spasm requiring ipsilateral femoral crossover. There was no major access site, bleeding, or neurological adverse events at 30 days. Minor access site hematomas occurred in five cases (5.9%) and were treated conservatively in all cases. Pre-procedural platelet transfusions were administered in 23 (27.1%) cases. There was no statistically significant difference in access site or bleeding complications between the transfused and nontransfused groups.

CONCLUSIONS

Transradial visceral interventions in patients with thrombocytopenia are both feasible and safe, possibly without the need for platelet transfusions.

Risk Factors for Puncture Site Complications After Endovascular Procedures in Patients With Peripheral Arterial Disease

OBJECTIVE

To compare femoral access site closure techniques and to highlight risk factors for puncture site complications after lower extremity endovascular procedures.

METHODS

This retrospective study included 787 patients. Procedures were performed according to a standardized protocol. Puncture site complications within 24 hours were regarded as study end points.

RESULTS

Ninety (11.5%) puncture site complications were registered. Conventional manual compression (n = 87, 11.1%) was significantly associated with puncture site complications (odds ratio [OR] 2.08, P = .03). Body mass index > 25 kg/m(2) (OR 0.54, P = .01) and prothrombin time > 70% (OR 0.38, P = .04) were protective. All bleeding occurred in procedures >45 minutes. Blood pressure >200 mm Hg and below the knee (BTK) procedures were strong predictors for access site complications (OR 4.21, P = .01 and OR 3.33, P = .02).

CONCLUSIONS

We observed an inferiority of conventional manual compression. Age, procedure duration > 45 minutes, BTK procedures, uncontrolled hypertension, and impaired coagulation were risk factors.

Comparison of Exo-Seal(®) and Angio-Seal (®) for arterial puncture site closure: A randomized, multicenter, single-blind trial

BACKGROUND

The use of extravascular femoral closure devices in patients undergoing coronary angiography/intervention has not been sufficiently evaluated. We sought to define the impact of an extravascular polyglycolic acid (PGA) plug for the closure of a femoral access site in patients undergoing coronary angiography and/or percutaneous coronary intervention.

METHODS

In this prospective, single-blind, multicenter trial we randomly assigned 319 patients to vessel closure with Angio-Seal(®) or Exo-Seal(®). We hypothesized that the use of an extravascular closure device is not inferior to an anchor/plug-mediated device regarding the occurrence of the composite primary endpoint: hematoma > 5 cm, significant groin bleeding (TIMI major bleed), false aneurysm, and device failure.

RESULTS

There was no significant difference in patient baseline characteristics or procedural results. After 24 h the primary endpoint occurred in nine patients (5.6 %) in the Angio-Seal(®) group and in 13 patients (8.2 %) inthe Exo-Seal(®) group (p = 0.38). Hematoma > 5 cm was noted in three patients (1.9 %) receiving Angio-Seal(®) vs. two patients (1.3 %) receiving Exo-Seal(®) (p = 0.99). In one patient (0.6 %) of the Exo-Seal(®) group, TIMI major bleeding occurred, requiring transfusion (p = 0.49). There were four (2.5 %) false aneurysms found in patients treated with Angio-Seal(®) and two (1.3 %) in patients treated with Exo-Seal(®) (p = 0.68). There was a trend for a higher incidence of device failure in the Exo-Seal(®) group (1.2 vs. 5.2 %, p = 0.06). At telephone interview after 30 days, there was no significant difference found regarding the events readmission with surgery of puncture site, infection, bleeding, hematoma, or pain.

CONCLUSION

In the present study, there were no significant differences found regarding the occurrence of hematoma > 5 cm, major bleeding, false aneurysm, and device failure between Angio-Seal(®) and Exo-Seal(®) 24 h after device implantation.

Groin complications in endovascular mechanical thrombectomy for acute ischemic stroke: a 10-year single center experience

Background

The increasing utilization of balloon guide catheters (BGCs) in thrombectomy therapy for ischemic stroke has led to concerns about large-bore sheaths causing vascular groin complications.

Objective To retrospectively assess the impact of large large-bore sheaths and vascular closure devices on groin complication rates at a comprehensive stroke center over a 10-year period.

Methods

Radiological and clinical records of patients with acute ischemic stroke who underwent mechanical endovascular therapy with an 8Fr or larger sheaths were reviewed. A groin complication was defined as the formation of a groin hematoma, retroperitoneal hematoma, femoral artery pseudoaneurysm, or the need for surgical repair. Information collected included size of sheath, type of hemostatic device, and anticoagulation status of the patient. Blood bank records were also analyzed to identify patients who may have had an undocumented blood transfusion for a groin hematoma.

Results

A total of 472 patients with acute ischemic stroke who underwent mechanical thrombectomy with a sheath and BGC sized 8Fr or larger were identified. 260 patients (55.1%) had tissue Plasminogen Activator (tPA) administered as part of stroke treatment. Vascular closure devices were used in 97.9% of cases (n=462). Two patients were identified who had definite groin complications and a further two were included as having possible complications. There was a very low rate of clinically significant groin complications (0.4–0.8%) associated with the use of large-bore sheaths.

Conclusions

These findings suggest that concerns for groin complications should not preclude the use of BGCs and large-bore sheaths in mechanical thrombectomy for acute ischemic stroke.

Spontaneous iliopsoas haematoma: a complication of hypertensive urgency

Iliopsoas haematoma is a rare clinical entity which can be life threatening in extreme cases. We are reporting a case of iliopsoas haematoma as a complication of hypertensive urgency. A 67-year old woman presented to emergency room with hypertensive urgency and hip pain. During hospitalisation, her haemoglobin was decreasing and on further evaluation, she did not have any signs of external bleeding and laboratory results were not suggestive of haemolysis. CT scan of abdomen and pelvis revealed a spontaneous iliopsoas haematoma. A likely explanation for this presentation in the absence of coagulopathy and trauma is very high blood pressure. Patient was on low-dose aspirin at home which could have further aggravated her bleeding due to platelet dysfunction. She was managed conservatively with blood transfusions and blood pressure was reduced to target after which she recovered.

Routine use of ultrasound guidance in femoral arterial access for peripheral vascular intervention decreases groin hematoma rates

BACKGROUND

Use of fluoroscopy and bone landmarks to guide percutaneous common femoral artery (CFA) access has decreased access site complications compared with palpation alone. However, only limited case series have examined the benefits of ultrasound to guide CFA access during peripheral vascular intervention (PVI). We evaluated the effect of routine vs selective use of ultrasound guidance (UG) on groin hematoma rates after PVI.

METHODS

The Vascular Study Group of New England database (2010-2014) was queried to identify the complication of postprocedural groin hematoma after 7359 PVIs performed through CFA access. Hematoma (including pseudoaneurysms) was defined as minor (requiring compression or observation), moderate (requiring transfusion or thrombin injection), and major (requiring operation). Both procedure-level and interventionalist-level analyses were performed. Multivariable Poisson regression models were used to compare hematoma rates of interventionalists based on routine (≥80% of PVIs) and selective (<80%) utilization of UG in the adjusted overall sample and in multiple subgroups.

RESULTS

The overall postprocedural groin hematoma rate after PVI was 4.5%, and the rate of combined moderate and major hematoma was 0.8%. Among 114 interventionalists with ≥10 PVI procedures, routine and selective UG was used by 31 (27%) and 83 (73%) interventionalists, respectively. Routine UG was protective against hematoma (rate ratio [RR], 0.62; 95% confidence interval [CI], 0.46-0.84; P < .01). Subgroup analysis revealed that routine UG was also protective against hematoma under the following circumstances: age >80 years (RR, 0.47; 95% CI, 0.27-0.85; P = .01), body mass index ≥30 (RR, 0.51; 95% CI, 0.29-0.90; P = .02), and sheath size >6F (RR, 0.43; 95% CI, 0.23-0.79; P < .01).

CONCLUSIONS

Routine UG may potentially protect against the complication of hematoma for both modifiable and nonmodifiable patient and procedural characteristics. Encouraging routine UG is a feasible quality improvement opportunity to decrease patient morbidity after PVI.

Systematic review and cost-benefit analysis of radial artery access for coronary angiography and intervention

BACKGROUND

Radial artery access for coronary angiography and interventions has been promoted for reducing hemostasis time and vascular complications compared with femoral access, yet it can take longer to perform and is not always successful, leading to concerns about its cost. We report a cost-benefit analysis of radial catheterization based on results from a systematic review of published randomized controlled trials.

METHODS AND RESULTS

The systematic review added 5 additional randomized controlled trials to a prior review, for a total of 14 studies. Meta-analyses, following Cochrane procedures, suggested that radial catheterization significantly increased catheterization failure (OR, 4.92; 95% CI, 2.69-8.98), but reduced major complications (OR, 0.32; 95% CI, 0.24-0.42), major bleeding (OR, 0.39; 95% CI, 0.27-0.57), and hematoma (OR, 0.36; 95% CI, 0.27-0.48) compared with femoral catheterization. It added approximately 1.4 minutes to procedure time (95% CI, -0.22 to 2.97) and reduced hemostasis time by approximately 13 minutes (95% CI, -2.30 to -23.90). There were no differences in procedure success rates or major adverse cardiovascular events. A stochastic simulation model of per-case costs took into account procedure and hemostasis time, costs of repeating the catheterization at the alternate site if the first catheterization failed, and the inpatient hospital costs associated with complications from the procedure. Using base-case estimates based on our meta-analysis results, we found the radial approach cost $275 (95% CI, -$374 to -$183) less per patient from the hospital perspective. Radial catheterization was favored over femoral catheterization under all conditions tested.

CONCLUSIONS

Radial catheterization was favored over femoral catheterization in our cost-benefit analysis.