Editorial Comment

Vascular Access Closure—SizeStill Matters

Sa’ar Minha, MD, and Lowell F. Satler,* MD

Division of Cardiology, MedStar Washington HospitalCenter, Washington, District of Columbia

Cardiogenic shock complicating an acute myocardialinfarction is still associated with high rates of morbid-ity and mortality despite advances in revascularizationand critical care therapy [1]. Intuitively, due to pumpfailure, “supporting” the heart with an auxiliary pumpshould translate into improved outcome but allmajor clinical trials have failed to establish these mer-its [2, 3]. Nevertheless, operators frequently feel thatlack of hard end point evidence should not preventthem from performing certain procedures on an indi-vidual basis. In this issue of CCI, Kim et al. report thecase of a 44-year-old gentleman who presented withST-elevation myocardial infarction later complicatedby refractory cardiogenic shock despite successful re-vascularization [4]. After an initial support withImpella 2.5L, which was later replaced to a Tandem-Heart system, the patient survived to discharge. Theauthors focus on a clever technique to extract theImpella system after the original 13 F introducer sheathwas peeled away. By utilizing a “mother and child”telescopic technique, a short 14 F sheath was mountedover a long 9 F sheath allowing a smooth transition forthe motor to be extracted through the 14 F sheath,which was left for further vascular access and monitor-ing. This allowed the avoidance of a potential adverseevent of bleeding complicating the removal of theImpella device under full anticoagulation.

But then what? A 14 F hole still exists. External pro-longed compression is possible but hemostasis is unpre-dictable. Although many closure devices are underdevelopment, there is still no immediate, approved prac-tical solution at this point. However, the experience oflarge bore vascular access site closure, developed in partby teams involved in transcatheter aortic valve replace-ment (TAVR) and endovascular aneurysm repair, mayoffer a different option: using pre-closure techniqueswith a suture mediated closure device (ProstarVR XL orPerclose Proglide; Abbott vascular, Abbott Park, IL)may be the answer [5]. At our institute, all TAVRs arepre-closed with 2 Proglide devices that allow apposition

of the large hole in the vessel. If after sheath removaland knot tying, blood oozing is still noted, a collagen-based vascular closure device (Angio-SealTM; St. JudeMedical, St. Paul, MN) is deployed to complete thehemostasis (Fig. 1).

With the use of the pre-closure method, we believethat our complication rate and need for surgical openclosure and repair has dramatically diminished. Althoughone would be challenged to advocate pre-closure for allmedium vascular access sites (10–14 F), it does createan opportunity to carefully assess proposed solutions tomanage this important increasing clinical problem.

The possibility of pre-closing the access site andthen the complete closure of the site several days later

Fig. 1. Access site pre- and post-TAVR closure algorithm.

Conflict of interest: Nothing to report.

*Correspondence to: Lowell F. Satler, MD, MedStar Washington

Hospital Center, 110 Irving Street, NW, Suite 4B-1, Washington,

DC 20010. E-mail: satlerlowell@gmail.com

Received 26 November 2013; Revision accepted 27 November 2013

DOI: 10.1002/ccd.25313

Published online 17 January 2014 in Wiley Online Library

(wileyonlinelibrary.com)

VC 2014 Wiley Periodicals, Inc.

Catheterization and Cardiovascular Interventions 83:226–227 (2014)

may cause other problems regarding sterility andpotential infections. Until clinical data become avail-able embracing this option, this alternative needs to becautiously explored. Future potential technical advan-ces should lead to the deployment of a closure devicewithout the need for pre-closure.

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Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).