Vascular closure devices

Editor in Chief: Michael S. Fenster, MD [mailto:msf@3giinc.com]

Background
At the very heart of any successful endovascular procedure is successful arterial entry and exit. The first successful cardiac catheterization, according to Andre Cournand, was performed on an equine patient in 1844 utilizing a retrograde approach through both the jugular vein and carotid artery1. Human retrograde left heart catheterization was first reported by Zimmerman2  and Limon-Lason3. in 1950. Shortly thereafter in 1953, Seldinger developed the percutaneous technique and this technique was quickly adapted to left heart cardiac catheterizations. With the growth of Interventional Cardiology in the years following Grüntzig’s introduction of coronary angioplasty in 19774, the percutaneous approach became, and today remains, by far the most common method of performing catheterization, angiography and endovascular intervention. Within the realm of percutaneous approaches, the majority of the procedures are performed from the femoral approach, with a minority being done from a radial approach. Brachial and axillary are also used in a minority of procedures5. Reasons for the continued preference of the femoral route for access includes the vessel size, operator training and equipment, radiation exposure (operator), and the advent of vascular closure devices. Studies have suggested that between 8-10% of all patients selected for a transradial approach will convert to a transfemoral route6,7,8.

Current Limitations of Vascular Closure Devices

 * Require long learning curve
 * Small vessel size (<4.0–5.0mm); a contraindication to use
 * Non-common femoral artery ‘sticks’; a contraindication to use
 * Peripheral vascular disease; a contraindication to use (very common problem)
 * Significant endoluminal device components (prone to thrombosis)
 * High costs
 * Require bed rest post closure
 * Impaired or delayed common femoral artery re-entry (re-access concerns)
 * Non-inert, very reactive, permanent and absorbable device components (therefore may be prone to infection and common femoral artery scarring)
 * Catastrophic complications (1–2%, but may be underreported)
 * Poorly compatible with anticoagulated patients (increased bleeding)