Benefits and Drawbacks of Vascular Closure Devices

In the November issue of Vascular Disease Management, we present a debate on the use of vascular closure devices between Drs. Abela, Diep, and Ahsan as protagonists and Dr. Armstrong as the antagonist. Each makes great points about the use of these devices. 

Complications of vascular access are not benign. Complications may arise from vessel thrombosis, dissection, or bleeding. These complications usually are associated with pain and some initial limitation of mobility. Severe complications may result in the need for transfusion, direct vascular repair, and death in rare cases. Long-term outcomes are adversely affected by access-site complications, particularly when there is need for transfusion. Access-site complications are commonly cited as being causal in cases of malpractice litigation. It is the goal of all who perform diagnostic and interventional procedures to eliminate these complications. 

The development of devices that close the site of vessel entry (vascular closure devices) have facilitated earlier ambulation and have allowed some procedures that previously required open surgery to be performed percutaneously. These devices can reduce serious bleeding complications and may obviate the need for prolonged compression, which may have deleterious effects of vascular thrombosis related to decreased flow and pain associated with compression at the access site. Vascular closure devices may be intravascular plugs, clip or suture mediated, extravascular plugs, or tunneling devices (through the vessel wall), each of which has its own positive attributes as well as liabilities. All of these devices unfortunately have limitations. 

As with any device, there are cases in which there may be failure to adequately deploy a device as intended, therefore the operator may have to resort to manual compression in a patient who may be fully anticoagulated. Vascular closure devices only close the anterior wall puncture. Posterior wall punctures, (particularly large bore punctures) are not closed with these devices but can be controlled by manual compression. Manual compression may not be performed when closure devices are used if the operator falsely concludes there has been adequate deployment with no continued bleeding, leading to substantial blood loss. There is also potential for catastrophic closure complications such as vascular occlusion, infection, and embolization. There are individual cases where certain types of vascular closure devices should not be utilized. Intravascular plugs should not be placed in severely obstructed access vessels as they may result in total vascular occlusion. Suture-mediated devices and external plugs can fail to seal in densely calcified and diseased vessels. Occasionally suture-mediated devices may engage the back wall of the vessel.

Obviously greater vigilance preprocedure, intraprocedure, and postprocedure is needed to avoid access-site complications. It is imperative that sheaths not be occlusive, that there is proper anticoagulation, and that there is appropriate use of medications to avoid vascular spasm. Routine utilization of micropuncture technique coupled with ultrasound guidance may avoid posterior wall injury, identify obstructive stenoses to be avoided with puncture, and ensure that puncture occurs at a proper level (below the inguinal ligament, above the femoral bifurcation, and in a nondiseased portion of vessel). This could also help with identification of patients who are good candidates for closure and those who are not. It could also influence operators in some cases to seek an alternate access site. 

Perhaps imaging following placement of a vascular closure device could be equally important, because this could identify cases where closure is not achieved, leading to earlier conversion to manual compression, and cases where there may be vascular obstruction from the device that can be addressed promptly. Patients should be counseled about activity post procedure and their blood pressure should be controlled. Successful access without complication is of paramount importance and deserves as much attention as the intervention.