Analysis of vascular closure devices after transbrachial artery access

Transbrachial Artery as Single or Combined Approach for Complex Interventions in Patients with Peripheral Artery Disease

BACKGROUND

This study aimed to assess the safety and efficacy of the transbrachial approach as a single or combined procedure for complex interventions in peripheral artery disease (PAD).

METHODS

Between March 2011 and April 2021, 169 patients with PAD underwent endovascular therapy via the transbrachial approach as a single or dual procedure. Univariate and multivariate analyses were performed to evaluate the predictors of adverse events at the brachial puncture site. All demographic, clinical, and perioperative data were acquired from electronic medical records and retrospectively analyzed.

RESULTS

Brachial artery access was used alone and in combination in 87 and 82 patients, respectively. Patients in the combined-approach group underwent more intraoperative stent implantations and had more vascular closure devices (VCD). Multivariate logistic regression analysis revealed that hypertension was an independent factor for higher rates of brachial puncture site adverse events (odds ratio, 4.76; 95% confidence interval, 1.33-16.97; P = 0.016). Brachial artery access-site complications occurred in 26 patients, including 6 (23.1%) major and 20 (76.9%) minor entry-site complications. Entry-site complications were observed in 21 (16.8%) and 5 (11.4%) patients assigned to manual compression and VCD groups, respectively. There were no significant intergroup differences in the incidence of major or minor complications. Interestingly, patients assigned to the VCD group did not experience major entry-site complications.

CONCLUSIONS

The transbrachial approach, as a single or combined procedure, is a safe alternative to complex interventions in patients with PAD. Complications of brachial access progressively decrease with improved blood pressure control.

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

BACKGROUND

There are many percutaneous coronary approaches. The most commonly used one is the radial artery because of its lowest risk of adverse vascular events. However, it could not be an option in some situations as congenital radial artery hypoplasia and spasm. In these cases, the second most common access is the femoral artery. The current literature over the brachial artery access is controversial. Thus, the aim of this study was to verify the brachial artery approach's effectiveness and safety.

RESULTS

We studied 300 patients who underwent elective coronary angiography and angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients with brachial access and 150 with femoral access. Access, procedural and fluoroscopy times were recorded. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, P = 0.05), but no significant difference noted regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not significantly differ (P = 0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ± 1.1 vs. 3.4 ± 0.7 min, P = 0.05) and hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, P < 0.001). Regarding major and minor complications (especially hematomas), they were significantly less in the brachial arm (P = 0.04 and P = 0.05, respectively).

CONCLUSIONS

Brachial access is a safe, efficient and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

The Use of Vascular Closure Devices for Brachial Artery Access: A Systematic Review and Meta-Analysis

PURPOSE

To estimate the rates of technical success and adverse events of vascular closure devices (VCDs) in the brachial artery and compare the rates of adverse events with manual compression.

MATERIALS AND METHODS

MEDLINE and Embase were searched for observational studies examining VCDs in the brachial artery. Meta-analyses were performed using random effects for the following outcomes: (a) technical success, (b) hematoma at the access site, (c) pseudoaneurysm, (d) local neurological adverse events, and (e) total number of adverse events. A pairwise meta-analysis compared VCD with manual compression for the outcomes of hematoma and the total number of adverse events.

RESULTS

Of 1,761 eligible records, 16 studies including 510 access sites were included. Primary procedures performed were peripheral arterial disease interventions, percutaneous coronary intervention, and endovascular thrombectomy for ischemic stroke. The technical success rate was 93% (95% CI, 87%-96%; I² = 47%). Data on the following adverse events were obtained via meta-analysis: (a) hematoma, 9% (5%-15%; I² = 54%); (b) stenosis or occlusion at access site, 3% (1%-14%; I² = 51%); (c) infection, 0% (0%-5%; I² = 0%); (d) pseudoaneurysm, 4% (1%-13%; I² = 61%); (e) local neurological adverse events, 5% (2%-13%; I² = 54%); and (f) total number of adverse events, 15% (10%-22%; I² = 51%). Angio-Seal success rate was 96% (93%-98%; I² = 0%), whereas the ExoSeal success rate was 93% (69%-99%; I² = 61%). When comparing VCD and manual compression, there was no difference in hematoma formation (relative risk, 0.75; 95% CI, 0.35-1.63; I² = 0%; P = .47) or the total number of adverse events (relative risk, 0.75; 95% CI, 0.35-1.58; I² = 76%; P = .45).

CONCLUSIONS

Despite being off-label, studies suggest that VCDs in the brachial artery have a high technical success rate. There was no significant difference in adverse events between VCDs and manual compression in the brachial artery.

Vascular Closure Devices versus Manual Compression in Cardiac Interventional Procedures: Systematic Review and Meta-Analysis

Backgrounds

Manual compression (MC) and vascular closure device (VCD) are two methods of vascular access site hemostasis after cardiac interventional procedures. However, there is still controversial over the use of them and a lack of comprehensive and systematic meta-analysis on this issue.

Methods

Original articles comparing VCD and MC in cardiac interventional procedures were searched in PubMed, EMbase, Cochrane Library, and Web of Science through April 2022. Efficacy, safety, patient satisfaction, and other parameters were assessed between two groups. Heterogeneity among studies was evaluated by I² index and the Cochran Q test, respectively. Publication bias was assessed using the funnel plot and Egger's test.

Results

A total of 32 studies were included after screening with inclusion and exclusion criteria (33481 patients). This meta-analysis found that VCD resulted in shorter time to hemostasis, ambulation, and discharge (p < 0.00001). In terms of vascular complication risks, VCD group might be associated with a lower risk of major complications (p = 0.0001), but the analysis limited to randomized controlled trials did not support this result (p = 0.68). There was no significant difference in total complication rates (p = 0.08) and bleeding-related complication rates (p = 0.05) between the two groups. Patient satisfaction was higher in VCD group (p = 0.002). Meta-regression analysis revealed no specific covariate as an influencing factor for above results (p > 0.05).

Conclusions

Compared with MC, the use of VCDs significantly shortens the time of hemostasis and allows earlier ambulation and discharge, meanwhile without increase in vascular complications. In addition, use of VCDs achieves higher patient satisfaction and leads cost savings for patients and institutions.

Transbrachial Access Site Complications in Endovascular Interventions: A Systematic Review of the Literature

The transfemoral approach (TFA) or transradial approach (TRA) serves as the primary technique for most endovascular cases; however, the transbrachial (TBA) route is an alternative access site used when TFA and TRA are contraindicated. Although TBA has advantages over TRA, such as the ability to accommodate large guide catheters and devices, there is some apprehension in implementing TBA due to perceived access site complication rates. This article aims to glean the rate of access site complication from current literature.

Relevant studies were identified using the following search terms: ((access site complications) AND ((endovascular AND brachial) OR (percutaneous brachial access) OR (brachial))) OR (endovascular AND (percutaneous brachial access)); endovascular + brachial artery; endovascular + brachial artery + access site; and endovascular + brachial artery + access site complications. Articles published after 2008 addressing major complication rates from percutaneous TBA interventions were included.

Fifteen studies out of 992 total articles met the inclusion criteria. The major access site complication rate was 75/1,424 (5.27%). Patients who underwent hemostasis with a vascular closure device (VCD) had a major complication rate of 13/309 (4.21%) compared to a major complication rate of 65/1122 (5.79%) for patients who underwent hemostasis with manual compression (MC).

The major access site complication rate associated with TBA was 5.27%, which is relatively high compared to the complication rate in TFA or TRA. More prospective trials are needed to fully understand the access site complication rate in TBA interventions.

Transbrachial Secondary Vascular Access in Transcatheter Aortic Valve Replacement Procedures: A Single-Centre Retrospective Analysis

BACKGROUND

Transfemoral transcatheter aortic valve replacement (TAVR) procedures require secondary vascular access for inserting accessory catheters and performing percutaneous repair of femoral artery injury. Use of the transbrachial approach for secondary vascular access in TAVR procedures has not been reported.

METHODS

This study identified 48 patients at the current institution who had undergone transfemoral TAVR utilising transbrachial secondary vascular access. Efficacy and safety of this strategy for achieving a successful totally percutaneous procedure were examined. Study endpoints were occurrence of vascular complications and bleeding related to transbrachial access, as well as periprocedural and 1-year mortality.

RESULTS

Mean patient age was 80±7 years and Society of Thoracic Surgeons Predicted Risk of Mortality score was 10.6±3.1. Sizes of sheaths inserted into the brachial artery were 6 Fr (85%), 8 Fr (2%), and 9 Fr (13%). Transbrachial access was used for delivering stent grafts to the femoral artery in 13% of the patients, inflation of an occlusive balloon within the iliac artery in 10%, and treatment of iatrogenic femoral artery stenosis in 2%. Successful valve replacement was achieved in all cases. Brachial sheaths were removed by manual compression following administration of protamine sulfate. There were no major access site complications or VARC-3 type ≥2 bleeding related to the brachial vascular access. Brachial artery occlusion occurred in two patients (4%) who underwent surgical vascular repair. Two (2) additional patients developed mild arm ischaemia, which was treated conservatively. Periprocedural mortality was 0% and early mortality was 8%.

CONCLUSIONS

Transbrachial secondary access in TAVR procedures was feasible and enabled percutaneous vascular repair in cases of femoral artery injury.

Complication rates of percutaneous brachial artery puncture: effect of live ultrasound guidance

Purpose

The current literature on the use of brachial artery access is controversial. Some studies found increased puncture site complications. Others found no higher complication rates than in patients with femoral or radial access. The purpose of this study was to determine the impact of ultrasound (US)-guidance on access site complications.

Materials and methods

This is a single-center retrospective study of all consecutive patients with brachial arterial access for interventional procedures. Complications were classified into minor complications (conservative treatment only) and major complications (requiring surgical intervention). The brachial artery was cannulated in the antecubital fossa under US-guidance. After the intervention, manual compression or closure devices, both followed by a compression bandage for 3 h, either achieved hemostasis.

Results

Seventy-five procedures in seventy-one patients were performed in the study period using brachial access. Access was successful in all cases (100%). Procedures in different vascular territories were performed: neurovascular (10/13.5%), upper extremity (32/43.2%), visceral (20/27.0%), and lower extremity (12/16.3%). Sheath size ranged from 3.2F to 8F (mean: 5F). Closure devices were used in 17 cases (22.7%). In total, six complications were observed (8.0%), four minor complications (5.3%, mostly puncture site hematomas), and two major complications, that needed surgical treatment (2.7%). No brachial artery thrombosis or upper extremity ischemia occurred.

Conclusion

Exclusive use of US-guidance resulted in a low risk of brachial artery access site complications in our study compared to the literature. US-guidance has been proven to reduce the risk of access site complications in several studies in femoral access. In addition, brachial artery access yields a high technical success rate and requires no additional injection of spasmolytic medication. Sheath size was the single significant predictor for complications.

Venous Thrombus Following Trans-Brachial Access Puncture After Iliac-Arterial Stent Implantation

A rare complication-basilic vein thrombus of brachial access was reported by duplex ultrasound in this case 2 days after stenting implantation surgery on the left iliac artery via brachial access. More attention should be paid on the procedure of artery access puncture in operation to avoid the unexpected complications.

A Retrospective Study Comparing the Effectiveness and Safety of EXOSEAL Vascular Closure Device to Manual Compression in Patients Undergoing Percutaneous Transbrachial Procedures

BACKGROUND

This study aimed to assess the safety and efficacy of EXOSEAL vascular closure device (EVCD) insertion by comparing its performance with manual compression (MC) in achieving hemostasis at the brachial artery puncture site.

METHODS

A retrospective study of brachial artery access by using either MC or EVCD for achieving hemostasis from March 2016 to October 2017 was conducted. Patients with Stanford type B aortic dissection (TBAD) undergoing percutaneous transbrachial procedures were included. Time to hemostasis (TTH) was the primary efficacy end point. Seven-day incidence of major access site-related complications was the primary safety end point. TTH and major and minor complications associated with treatment of these 2 groups were also evaluated.

RESULTS

A total of 157 patients with TBAD undergoing percutaneous transbrachial procedures entered the analysis. Of these, 107 patients underwent EVCD insertion and 50 patients underwent MC. The baseline characteristics of the 2 groups were similar. TTH was significantly shorter for EVCD over MC (P < 0.05). The TTH ≥10 min in the MC group was 100.0% (n = 50), but in the EVCD group, it was ≤2 min, 87.9% (n = 107); 2-5 min, 7.5% (n = 107); and ≥10 min, 4.7% (n = 107). The EVCD group had several major complications, while the MC group had none. Two patients (1.9%, n = 107) required vascular repair, one patient (0.6%, n = 107) required blood transfusion, and 1 patient (0.6%, n = 107) developed upper limb numbness and weakness after EVCD deployment. Minor complication such as the occurrence of hematoma (≤5 cm) in the MC group was 4 (8.0%) but was also 4 (3.7%) in the EVCD group, showing statistically significant difference (P = 0.030). The incidence of ecchymosis was 8 (7.5%) in the EVCD group when compared with 13 (26.0%) in the MC group, which showed statistically significant difference (P = 0.001). Other major and minor complications showed no significant differences between these 2 groups.

CONCLUSIONS

After invasive procedures by 6F percutaneous access via the brachial artery in preprocedurally fully anticoagulated patients, TTH was significantly reduced in patients who underwent EVCD when compared with patients who underwent MC. MC is a safer and more convenient way to achieve hemostasis but has higher incidence of minor complications.

A Stopped Pilot Study of the ProGlide Closure Device After Transbrachial Endovascular Interventions

Purpose: To evaluate the feasibility and safety of the suture-mediated ProGlide device in closure of the brachial artery after endovascular interventions. Materials and Methods: From 2016 to 2017, a pilot study was performed using the ProGlide to achieve hemostasis after percutaneous access of distal brachial arteries >4 mm in diameter. In an interim analysis, the results were compared to a matched control group taken from a 60-patient historical cohort who underwent brachial artery access and manual compression to achieve hemostasis between 2014 and 2017. The primary outcome was access-related reintervention and the secondary outcome was the incidence of access-site complications. Results: Seven patients (mean age 67.9 years; 6 men) were enrolled in the study before it was stopped in 2017. Four patients experienced 6 access-site complications (neuropathy, hematoma, occlusion, and pseudoaneurysm). These resulted in 3 access-related reinterventions: surgical evacuation of a hematoma, thrombectomy of the occluded brachial artery, and surgical repair of the pseudoaneurysm. In the interim comparison to the 19 matched patients (mean age 61.9 years; 6 men), the ProGlide group had proportionally more patients experiencing access-related complications (57% vs 16% for manual compression, p=0.035) and resultant reinterventions (43% vs 11%, p=0.064). Based on this data the trial was stopped. Conclusion: Considering this experience, it is not advisable to use the ProGlide in transbrachial endovascular interventions due to the high incidence of complications and access-related reinterventions.

Hemostasis After Brachial Artery Access With the MynxGrip Device: A Case Report

Purpose

Brachial access is occasionally used for endovascular procedures when other more established or safer ones (eg, femoral or radial) are contraindicated. Although manual compression is the standard of care after brachial arteriotomy, suboptimal compression may lead to bleeding or thrombosis. Arteriotomy closure devices have thus been proposed as an alternative means to achieve hemostasis after brachial arteriotomy. Yet, there is a paucity of evidence and a limited spectrum of devices suitable for brachial arteriotomy closure. We present the use of the MynxGrip closure device after brachial arteriotomy.

Case

A 70-year-old gentleman underwent brachial arteriotomy followed by iliac artery stenting with a 7F compatible device. Hemostasis was then achieved with the MynxGrip device, uneventfully.

Conclusions

This clinical vignette highlights the feasibility and safety of brachial use of the MynxGrip device in experienced hands, suggesting that it can represent a useful adjunct to the armamentarium of the endovascular specialist.

Efficacy and Safety of Transbrachial Access for Iliac Endovascular Interventions

Purpose: To evaluate the use of a brachial artery access for endovascular treatment of iliac artery disease. Methods: A retrospective review was conducted of 201 patients (mean age 73 years; 147 men) treated via a brachial artery access for iliac artery stenosis. The majority (n=141, 70%) presented with lifestyle-limiting claudication (Rutherford category 3), whereas the incidence of critical limb ischemia (Rutherford categories 4–6) was 30% (n=70). Diagnostic angiography revealed a TransAtlantic Inter-Society Consensus II (TASC) C/D lesion in 114 (57%) patients. The primary outcome was technical success achieved exclusively with a brachial artery access. Secondary outcomes were secondary technical success (adjunctive transfemoral access), access site complications, and stroke/transient ischemic attack (TIA). Results: In 17 (8%) patients, lesion crossing was unsuccessful, while an adjunctive transfemoral approach was necessary to restore iliac vessel patency in 23 (11%) cases. Thus, the primary and secondary technical success rates were 81% and 92%, respectively. Local hematomas (9, 4%) dominated the access site complications, followed by pseudoaneurysms (8, 4%), late brachial artery bleeding (4, 2%), brachial artery occlusion (2, 1%), and puncture site infection (2, 1%). No transient or permanent median nerve dysfunction was observed. The stroke/TIA rate was 2% (n=4). A single patient died due to acute coronary syndrome (0.5% mortality). TASC II class (p=0.58), sex (p=0.66), and target vessel (p>0.3 for all locations) had no effect on technical success. Female gender unfavorably influenced the incidence of access site complications (hazard ratio 6.7, 95% confidence interval 2.7 to 15, p<0.001), but sheath size did not (p=0.22). Conclusion: Brachial artery access enables endovascular treatment of iliac artery disease in the majority of patients, although an adjunctive transfemoral access may be required. However, the high incidences of access site complications and cerebral events remain a significant limitation of the transbrachial approach.

Successful Use of the MYNXGRIP Closure Device during Repeated Transbrachial Percutaneous Peripheral Intervention

The use of closure devices after transbrachial arterial puncture is still controversial. Here we report on a case where the MYNXGRIP (AccessClosure Inc., Santa Clara, CA, USA) could be used successfully in a patient, who underwent percutaneous peripheral arterial intervention twice via transbrachial access.