Preventing Access Site Complications and Limiting Vascular Injury

Hello and welcome to the August 2021 edition of Vascular Disease Management. This month there are multiple articles of great interest. I have chosen to comment on Dr. Ramesh Adiraju and colleagues’ article “Controlled Step-Down Access Closure for Large Bore Access.”

In this article, the authors describe a step-by-step technique utilized at their community-based hospital to decrease bleeding complications and limit vascular injury when large bore devices are utilized. Dr. Adiraju and colleagues explain the rationale of first preclosing with a Perclose device then placing a smaller sheath over a 0.35" guidewire and applying tension to the long end of the suture device to tighten, but not cinch, a knot in the device while allowing vascular recoil to take place around the smaller sheath. If there is no bleeding around the smaller sheath during the observational period, the smaller sheath is removed and the suture-mediated device achieves vascular control with a 0.35" wire in place by again applying tension to the long end of the suture. If hemostasis is achieved with the wire in place, then the knot is tied. If bleeding is not controlled while the wire is in place, additional devices can be introduced over the 0.35" wire to achieve subsequent successful closure. The authors cite the advantages of this technique, including the need for fewer additional Perclose devices, less blood loss, and less potential for arterial injury. Dr. Adiraju and colleagues report high rates of success and low complication rates. The authors appropriately note the limitations of this study, including that it is only a single-center experience with few operators, it has a relatively small sample size, and women are under-represented.

I have chosen to comment on this article because large bore percutaneous access is being utilized far more frequently as interventionists are appropriately utilizing large bore devices for hemodynamic support, percutaneous valve replacement, and treatment of aneurysms. Vascular access management in these cases is crucial. Lessons that can be learned from the ability to close large bore access may also potentially be applied to help interventionists achieve greater success in access site management in all interventions regardless of the access size that has been chosen.

Every percutaneous procedure begins with access and ends with management of the access site. Failure to achieve ideal closure of the access site can result not only in local complications such as blood loss, pain, hematoma, pseudoaneurysms, and vascular occlusion but in some cases result in subsequent failure of an initially successful intervention secondary to hypotension from blood loss, the need to reverse anticoagulation, the potential requirement of covered stents, and in some cases the potential for death.

Access site complications usually occur immediately following an intervention but can be delayed, occurring days following discharge. Newer trends with percutaneous procedures, including more indications for interventional therapy resulting in increased number of cases, greater utilization of large bore devices, and a shift to performing procedures on an outpatient basis or in office-based labs where bleeding complications are potentially far more dangerous, necessitate that we continue to improve our abilities to ideally manage access sites following intervention.

Although many new devices have been approved to improve access site management, complications remain a source of increased cost, risk, pain, and litigation. Many clinicians are still utilizing manual compression only to manage access sites as several studies have shown relative equipoise with many of the closure devices.

Complications arising from failure to achieve ideal access are difficult to manage, time-consuming, and potentially fatal. Limiting these problems can save costs, lessen pain, improve patient satisfaction, and dramatically improve ultimate interventional outcomes. Solving the problem of access-related complications remains a goal that all interventionists hope to achieve. We must devote more attention to solving this problem.