Access Device and Closure Device: Suggested Techniques

For years, cath labs have been closing catheterization access sites with closure devices or with the use of manual pressure. Over the years, I have found that using closure devices as well as holding manual pressure have both been beneficial in cardiac or peripheral catheterizations. Not all sites can be closed with a closure device, for such reasons as low or high stick, plaque or calcium, size of track, disease, etc.

Very recently, I tried using a different kind of access device on some of our femoral access cases, the Axera 2 (Arstasis, Inc.). This device creates a unique and shallow angle path into the femoral artery. In some patients, I have found it to be a favorable option. In particular, patients with diseased arteries are at risk for closure device failure. Holding manual pressure on certain patients is more difficult than others, such as patients with more tissue. If the patient probably will not be a candidate for a closure device, then I will use the Axera 2. The majority of patients in whom we use this device are those with peripheral vascular disease.

The concept behind the device involves an overlapping of tissue within the shallower, and longer arteriotomy tract of the femoral artery.  This tissue-on-tissue bond is stronger that the standard, short 45 degree arteriotomy and effectively seals the access track. It makes holding manual pressure easier, which, in turn, makes closing the artery more comfortable for the patient. The company states, “Once the procedure is complete, short and gentle manual compression is applied, resulting in a secure closure with no foreign body left behind — thus eliminating the risk of infections and other complications related to vascular implants.” While I currently use closure devices on most of our patients, the Axera 2 is a good choice to minimize complications in patients with peripheral vascular disease and may also be a good choice for additional patient subsets as we get more experience with the device.

Ultimately, deciding which closure device to use depends on the patient. Ninety percent of the time I use Perclose (Abbott Vascular). If patient is overweight, with extremely long tracks, Angio-Seal (St. Jude Medical) might be a better choice. 

When closing an intra-aortic balloon pump (IABP) access site, I prefer to close using Angio-Seal. I am not sure how prevalent it is to close IABP access sites, but I started doing it about 10 years ago with great success. Some cardiologists I have worked with do prefer that the IABP sites be closed, if possible. It requires taking a femoral injection shot before inserting the IABP to confirm the vessel can be sealed using the Angio-Seal. Once the IABP is ready to be removed per the cardiologist, it must be done using sterile technique, just like any other closure. Most of the time, removing the sheath and the IABP is done at the same time, since most balloons will not fit through the sheath once inserted. A .025” wire must be used, since a .035” will not fit into the balloon. Once the wire is advanced into the body, remove the IABP and sheath simultaneously, leaving the wire in place. (This is easier with two people assisting). Once the IABP balloon is removed, then the technique is the same as using the 8 French Angio-Seal, utilizing a long wire. It seals the puncture site as if using an Angio-Seal for a normal closure. With this technique of sealing the IABP site, we have seen that the patient is more comfortable and is able to sit up more quickly, with less chance of bleeding. 

Some cardiologists never like to use closure devices and prefer manual pressure on all procedures, which is fine, but closure devices can make the recovery time for the patient more comfortable. In the end, manual pressure is always the solution for any failed closure device. 

Questions? If you have a subject you would like covered or an area of interest, please contact Phillip Mumford, RCIS, at p_mumford@aol.com.  Follow Phillip on Twitter: @phillip_mumford.