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Arterial Closure Device Insertion Technique

  • Author: Venkat Rajaram, MD, MS; Chief Editor: Karlheinz Peter, MD, PhD  more...
 
Updated: Jul 10, 2013
 

Approach Considerations

6F Angioseal can be used for sheath sizes of 6F and smaller, and 8F Angioseal can be used for 8F or smaller sheaths. Perclose can be used for sheath sizes 5-8F.

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Femoral Angiography Prior to Closure

Prior to using any closure, always confirm the position of the arteriotomy site with femoral angiography in the right anterior oblique view after securing the sheath. Pull the sheath medially during femoral angiography to clearly demonstrate the entry point of the sheath into the artery.

This routine step is used to assess the feasibility of using a closure device and, more importantly, as risk stratification for complications.[3, 5] . Look for the following:

  • Arteriotomy site below inguinal ligament and above the bifurcation of common femoral artery
  • Presence of calcium
  • Presence of disease such as stenosis or dissection
  • Posterior wall stick/continuing bleeding
  • Abnormalities such as arteriovenous fistula or pseudoaneurysms

It is prudent to clean the sheath and the skin around with a chlorhexidine preparation kit and change to a new pair of sterile gloves.

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Angioseal

See the list below:

  1. Open the contents under strict sterile conditions. Use the contents within one hour of opening the seal.
  2. Prepare the contents before proceeding with access closure. Insert the arteriotomy locator into the Angioseal sheath oriented in the correct direction. This can be ensured by pointing the green arrow on the hub of the sheath toward the green arrow on the arteriotomy locator. After ensuring proper orientation, snap the arteriotomy locator into the sheath. Open the packet that contains the Angioseal device and keep it available for use. Keep the J-tip guidewire that comes in the packet available for use.
  3. Remove the femoral sheath that was used for the procedure over the Angioseal guidewire while maintaining pressure above the access site to ensure continued hemostasis. The Angioseal guidewire will maintain access to the arteriotomy once the sheath is removed.
  4. Insert the sheath/arteriotomy locator assembly over the Angioseal wire with the side with markers and the green arrows facing up. If necessary, thread the wire back into the assembly until the wire is seen about an inch through the distal end. This will help secure the wire so that it is not threaded into the artery and lost.
  5. When the tip of the insertion sheath is about 1.5 cm into the artery, blood will begin to flow from the drip hole in the locator.
  6. Withdraw the arteriotomy locator/insertion sheath assembly until blood slows or stops flowing from the drip hole. This indicates that the distal locator holes of the insertion sheath have exited the artery.
  7. Reinsert the assembly again (no more than 2 cm) until the blood flows through the drip hole again. (The word Angioseal is printed on the sheath, and each letter is separated by about a centimeter. This can be used as a guide to measure the depth of insertion and confirm the position of the sheath.) Deeper reinsertion may interfere with the anchor’s performance.
  8. Holding the insertion sheath steady, the arteriotomy locator and guidewire are removed. The arteriotomy locater can be removed by twisting it down while holding the hub of the insertion sheath steady.
  9. Verify the position of the Angioseal sheath again. If the position has changed, repeat steps 4 through 9.
  10. Holding the hub of the sheath in position with the left hand, grasp the Angioseal device at the bypass tube with the other hand closer to the distal tip. Advance the device into the hole in the sheath hub with the reference indicator (green arrows) on the device and the hub of the sheath on the same side facing each other. In this position, the device will snap into the sheath when advanced. If carrier tube advancement is met with resistance when insertion is almost complete, the anchor may be impinging on the posterior wall of the artery. Stop advancing. Reposition the sheath by reducing the angle of the sheath to the skin surface or by pulling the sheath back by 1-2 mm and redeploy.
  11. After snapping the Angioseal device in position, hold the hub of the sheath with one hand and pull the cap of the device away from the hub. Continue until resistance is felt, which results from the anchor catching the distal tip of the sheath. If deployed correctly, the edge of the device cap will fall within the colored bands on the device sleeve. After the anchor position is confirmed, pull the device cap into the full rear locked position.
  12. Pull the device sheath assembly in the direction of the track. This allows the anchor to position against the vessel wall.
  13. Continue to pull and maintain the tension on the device sheath assembly to expose the tamper, which should be advanced into the track to compact the collagen. Failure to maintain tension on the device sheath assembly may lead to advancement of collagen into the arterial lumen. This should be avoided.
  14. Continue the tension on the assembly while simultaneously advancing the tamper until the clear stop is revealed distal to the sheath and the black compaction marker is revealed above the tamper. Once hemostasis is achieved and resistance is felt, stop advancing the tamper.
  15. Cut the suture below the clear stop and remove the tamper tube. Cut the suture below the skin line by holding tension on the thread with the index finger and thumb of the left hand while pushing the skin and soft tissue with the other fingers. Alternatively, a hemostat can be used to push the skin and lock the thread while holding the thread with the other hand. The suture is then cut. This ensures cutting the suture below the level of the skin and below the black compaction marker.

Ambulation

The patient can ambulate normally within 2 hours following Angioseal placement. However, factors such as use of anticoagulants, access issues, and overall patient status, both general and cardiac, need to be considered while deciding and the length of bedrest before ambulation.

Angioseal technique
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Perclose (Proglide Suture-Mediated Closure)

See the list below:

  1. Open the contents of the packet under sterile conditions and flush the Proglide device. Keep wet gauze handy to hold the hydrophilic Proglide tube.
  2. Remove the arterial sheath over a short 0.038-inch J-tip wire while holding pressure over the groin to obtain hemostasis. The authors prefer to use the long J-tip wire (145 cm) for additional margin of safety in preserving access.
  3. Backload the Proglide SMC device over the wire. With the wire acting as a rail, advance the SMC device into the arteriotomy until the wire exit port on the device is at the level of the skin. The wire then is removed gently holding the device body to prevent the device from being dislodged inadvertently.
  4. Advance the device further with a to-and-fro toque, holding the body until backflow of blood is seen through the marker lumen.
  5. With the device at a 45° angle, deploy the foot pedal by lifting the lever on top of the handle (marked as #1).
  6. Position the foot pedal against the wall of the artery by pulling the device. At this point, backflow of blood through the marker lumen will cease. If there is continued blood flow through the marker, the foot pedal needs to be repositioned.
  7. At this point, deploy the needle by pushing the plunger (in the direction marked #2) until the collar of the plunger comes in contact with the body.
  8. Pull the plunger back (in the direction marked #3) to disengage the needle. Completely remove the plunger with the needles from the body of the device. Notice that the suture is attached to the anterior needle and the posterior needle is free. Pull the plunger until the suture is taut and cut the suture from the anterior needle distal to the link with the optional Quickcut suture trimmer located on the handle.
  9. Relax the tension on the device and return the foot pedal to the original position by turning the lever to the original position (marked #4).
  10. Gradually withdraw the SMC device until the guidewire port is visible. Through this port, pull both ends of the suture from the proximal metallic part of the device.
  11. Notice that one suture limb is white (nonrail end), and the other limb is blue (rail end through which the knot is railed distally).
  12. If the SMC device is deployed at the beginning, a guidewire could be inserted after pulling back the device and exposing the guidewire port before pushing the knot. The suture could be set aside and intervention could be pursued.
  13. In the event of failure to deploy the suture, or other forms of device failure, access to the arteriotomy can be gained by advancing a guidewire.
  14. The authors do not routinely insert a guidewire before proceeding further.
  15. The rail limb (blue) is wrapped around the left index finger, and the knot is advanced by applying tension to this wire while quickly removing the Perclose device.
  16. Ensure hemostasis by inspecting and asking the patient to cough or raise his or her leg. If the guidewire had been reinserted, it can be removed at this point and the knot advanced by applying gentle tension to the rail limb. Do not use the knot pusher or suture trimmer to push the knot until the guidewire is removed if one has been reintroduced.
    Perclose technique

Knot advancement

The authors prefer using the suture trimmer for knot advancement, as it gives good support and allows passage into the track easily.

17. Wrap the rail (blue) limb in the left forefinger. Place the nonrail (white) limb securely between the left thumb and forefinger. Retract the black knob in the suture remover and place both the sutures into the window at the distal end of the suture trimmer. Ensure smooth play of the suture trimmer over the sutures. With the rail limb wrapped in the left forefinger, drop the nonrail (white) limb and hold the suture trimmer with the tip of the left thumb. Advance the knot with the suture trimmer using a single hand technique, pushing the suture trimmer into the tissue track with the left thumb while holding tension on the rail (blue) limb with the left forefinger. Gently tug the nonrail (white) limb to secure the knot. Check again for hemostasis, as described above. The above steps may be repeated to achieve hemostasis again.

18. Once hemostasis has been achieved, advance the suture trimmer into the tissue track with both limbs of the suture still in place in the suture trimmer. Hold tension over both limbs and cut the sutures deep in the track close to the arteriotomy by advancing the trimmer into the track and by pulling back the red lever on the handle of the suture remover with the right thumb. Keep the red trimming lever pulled back while withdrawing the suture trimmer and the cut sutures from the track to avoid any damage to tissue. The procedure may be repeated if only one limb of the suture is cut.

Suture breakage

Excess tension to the suture limbs can lead to breakage and should be avoided. If this happens at any stage while access to arteriotomy is still available through a guidewire, the broken suture can be discarded and the closure repeated with another Perclose SMC device. If the suture breaks after the device and guidewire are removed, hemostasis has to be ensured with manual compression.

Ambulation

The patient can ambulate normally in 2 hours following Perclose device placement. However, factors such as use of anticoagulants, access issues, and overall patient status, both general and cardiac, need to be considered while deciding and the length of bedrest before ambulation.

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Contributor Information and Disclosures
Author

Venkat Rajaram, MD, MS Interventional Fellow, Department of Cardiology, Temple University Medical Center

Venkat Rajaram, MD, MS is a member of the following medical societies: American College of Cardiology, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Coauthor(s)

Neeraj Tandon, MBBS Chief, Cardiology Section, Associate Professor of Medicine, Medical Service, Overton Brooks Veterans Affairs Medical Center

Neeraj Tandon, MBBS is a member of the following medical societies: American College of Cardiology, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Karlheinz Peter, MD, PhD Professor of Medicine, Monash University; Head of Centre of Thrombosis and Myocardial Infarction, Head of Division of Atherothrombosis and Vascular Biology, Associate Director, Baker Heart Research Institute; Interventional Cardiologist, The Alfred Hospital, Australia

Karlheinz Peter, MD, PhD is a member of the following medical societies: American Heart Association, German Cardiac Society, Cardiac Society of Australia and New Zealand

Disclosure: Nothing to disclose.

References
  1. Patel MR, Jneid H, Derdeyn CP, Klein LW, Levine GN, Lookstein RA, et al. Arteriotomy closure devices for cardiovascular procedures: a scientific statement from the American Heart Association. Circulation. 2010 Nov 2. 122(18):1882-93. [Medline].

  2. Meyerson SL, Feldman T, Desai TR, Leef J, Schwartz LB, McKinsey JF. Angiographic access site complications in the era of arterial closure devices. Vasc Endovascular Surg. 2002 Mar-Apr. 36(2):137-44. [Medline].

  3. Sherev DA, Shaw RE, Brent BN. Angiographic predictors of femoral access site complications: implication for planned percutaneous coronary intervention. Catheter Cardiovasc Interv. 2005 Jun. 65(2):196-202. [Medline].

  4. Tavris DR, Gallauresi BA, Lin B, et al. Risk of local adverse events following cardiac catheterization by hemostasis device use and gender. J Invasive Cardiol 2004;16:459–64.

  5. Turi ZG. Optimizing vascular access: routine femoral angiography keeps the vascular complication away. Catheter Cardiovasc Interv. 2005 Jun. 65(2):203-4. [Medline].

  6. Applegate RJ, Rankin KM, Little WC, Kahl FR, Kutcher MA. Restick following initial Angioseal use. Catheter Cardiovasc Interv. 2003 Feb. 58(2):181-4. [Medline].

 
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Angioseal Equipment
Angioseal technique
Perclose equipment
Perclose technique
Table 1. Device-Specific Precautions
Clinical Condition Angioseal Proglide
Concurrent warfarin therapy Use caution Data not available
Allergy to beef/collagen Use caution Data not available
Pregnancy/lactation Use caution Data not available
Thrombolysis Use caution Data not available
Vascular graft Use caution Data not available
Inflammatory/autoimmune Use caution Data not available
Uncontrolled hypertension (systolic >180) Use caution Data not available
Bleeding diathesis Use caution Data not available
Peripheral vascular disease Use caution Use caution
Calcified iliac artery Use caution Use caution
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