Catheterization and Cardiovascular Interventions 83:226–227 (2014)
Editorial Comment Vascular Access Closure—Size Still Matters Sa’ar Minha, MD, and Lowell F. Satler,* MD Division of Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
Cardiogenic shock complicating an acute myocardial infarction is still associated with high rates of morbidity and mortality despite advances in revascularization and critical care therapy [1]. Intuitively, due to pump failure, “supporting” the heart with an auxiliary pump should translate into improved outcome but all major clinical trials have failed to establish these merits [2, 3]. Nevertheless, operators frequently feel that lack of hard end point evidence should not prevent them from performing certain procedures on an individual basis. In this issue of CCI, Kim et al. report the case of a 44-year-old gentleman who presented with ST-elevation myocardial infarction later complicated by refractory cardiogenic shock despite successful revascularization [4]. After an initial support with Impella 2.5L, which was later replaced to a TandemHeart system, the patient survived to discharge. The authors focus on a clever technique to extract the Impella system after the original 13 F introducer sheath was peeled away. By utilizing a “mother and child” telescopic technique, a short 14 F sheath was mounted over a long 9 F sheath allowing a smooth transition for the motor to be extracted through the 14 F sheath, which was left for further vascular access and monitoring. This allowed the avoidance of a potential adverse event of bleeding complicating the removal of the Impella device under full anticoagulation. But then what? A 14 F hole still exists. External prolonged compression is possible but hemostasis is unpredictable. Although many closure devices are under development, there is still no immediate, approved practical solution at this point. However, the experience of large bore vascular access site closure, developed in part by teams involved in transcatheter aortic valve replacement (TAVR) and endovascular aneurysm repair, may offer a different option: using pre-closure techniques R XL or with a suture mediated closure device (ProstarV Perclose Proglide; Abbott vascular, Abbott Park, IL) may be the answer [5]. At our institute, all TAVRs are pre-closed with 2 Proglide devices that allow apposition C 2014 Wiley Periodicals, Inc. V
Fig. 1. Access site pre- and post-TAVR closure algorithm.
of the large hole in the vessel. If after sheath removal and knot tying, blood oozing is still noted, a collagenbased vascular closure device (Angio-SealTM; St. Jude Medical, St. Paul, MN) is deployed to complete the hemostasis (Fig. 1). With the use of the pre-closure method, we believe that our complication rate and need for surgical open closure and repair has dramatically diminished. Although one would be challenged to advocate pre-closure for all medium vascular access sites (10–14 F), it does create an opportunity to carefully assess proposed solutions to manage this important increasing clinical problem. The possibility of pre-closing the access site and then the complete closure of the site several days later 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: [email protected] 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)
Vascular Access Closure
may cause other problems regarding sterility and potential infections. Until clinical data become available embracing this option, this alternative needs to be cautiously explored. Future potential technical advances should lead to the deployment of a closure device without the need for pre-closure. REFERENCES 1. Anderson ML, Peterson ED, Peng SA, Wang TY, Ohman EM, Bhatt DL, Saucedo JF, Roe MT. Differences in the profile, treatment, and prognosis of patients with cardiogenic shock by myocardial infarction classification: A report from NCDR. Circ Cardiovasc Qual Outcomes 2013;6:708–715. 2. Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, de Waha A, Richardt G, Hennersdorf M, Empen K,
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et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): Final 12 month results of a randomised, open-label trial. Lancet 2013;382:1638–1645. 3. Seyfarth M, Sibbing D, Bauer I, Frohlich G, Bott-Flugel L, Byrne R, Dirschinger J, Kastrati A, Schomig A. A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction. J Am Coll Cardiol 2008;52:1584–1588. R 2.5 4. Kim MS, Clegg S, Messenger JC. Removal of ImpellaV while maintaining vascular access: A solution to a vascular quandary. Catheter Cardiovasc Interv 2014;83:223–225. 5. Toggweiler S, Leipsic J, Binder RK, Freeman M, Barbanti M, Heijmen RH, Wood DA, Webb JG. Management of vascular access in transcatheter aortic valve replacement. I. Basic anatomy, imaging, sheaths, wires, and access routes. JACC Cardiovasc Interv 2013;6:643–653.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Editorial Comment Vascular Access Closure—Size Still Matters Sa’ar Minha, MD, and Lowell F. Satler,* MD Division of Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia
Cardiogenic shock complicating an acute myocardial infarction is still associated with high rates of morbidity and mortality despite advances in revascularization and critical care therapy [1]. Intuitively, due to pump failure, “supporting” the heart with an auxiliary pump should translate into improved outcome but all major clinical trials have failed to establish these merits [2, 3]. Nevertheless, operators frequently feel that lack of hard end point evidence should not prevent them from performing certain procedures on an individual basis. In this issue of CCI, Kim et al. report the case of a 44-year-old gentleman who presented with ST-elevation myocardial infarction later complicated by refractory cardiogenic shock despite successful revascularization [4]. After an initial support with Impella 2.5L, which was later replaced to a TandemHeart system, the patient survived to discharge. The authors focus on a clever technique to extract the Impella system after the original 13 F introducer sheath was peeled away. By utilizing a “mother and child” telescopic technique, a short 14 F sheath was mounted over a long 9 F sheath allowing a smooth transition for the motor to be extracted through the 14 F sheath, which was left for further vascular access and monitoring. This allowed the avoidance of a potential adverse event of bleeding complicating the removal of the Impella device under full anticoagulation. But then what? A 14 F hole still exists. External prolonged compression is possible but hemostasis is unpredictable. Although many closure devices are under development, there is still no immediate, approved practical solution at this point. However, the experience of large bore vascular access site closure, developed in part by teams involved in transcatheter aortic valve replacement (TAVR) and endovascular aneurysm repair, may offer a different option: using pre-closure techniques R XL or with a suture mediated closure device (ProstarV Perclose Proglide; Abbott vascular, Abbott Park, IL) may be the answer [5]. At our institute, all TAVRs are pre-closed with 2 Proglide devices that allow apposition C 2014 Wiley Periodicals, Inc. V
Fig. 1. Access site pre- and post-TAVR closure algorithm.
of the large hole in the vessel. If after sheath removal and knot tying, blood oozing is still noted, a collagenbased vascular closure device (Angio-SealTM; St. Jude Medical, St. Paul, MN) is deployed to complete the hemostasis (Fig. 1). With the use of the pre-closure method, we believe that our complication rate and need for surgical open closure and repair has dramatically diminished. Although one would be challenged to advocate pre-closure for all medium vascular access sites (10–14 F), it does create an opportunity to carefully assess proposed solutions to manage this important increasing clinical problem. The possibility of pre-closing the access site and then the complete closure of the site several days later 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: [email protected] 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)
Vascular Access Closure
may cause other problems regarding sterility and potential infections. Until clinical data become available embracing this option, this alternative needs to be cautiously explored. Future potential technical advances should lead to the deployment of a closure device without the need for pre-closure. REFERENCES 1. Anderson ML, Peterson ED, Peng SA, Wang TY, Ohman EM, Bhatt DL, Saucedo JF, Roe MT. Differences in the profile, treatment, and prognosis of patients with cardiogenic shock by myocardial infarction classification: A report from NCDR. Circ Cardiovasc Qual Outcomes 2013;6:708–715. 2. Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, de Waha A, Richardt G, Hennersdorf M, Empen K,
227
et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): Final 12 month results of a randomised, open-label trial. Lancet 2013;382:1638–1645. 3. Seyfarth M, Sibbing D, Bauer I, Frohlich G, Bott-Flugel L, Byrne R, Dirschinger J, Kastrati A, Schomig A. A randomized clinical trial to evaluate the safety and efficacy of a percutaneous left ventricular assist device versus intra-aortic balloon pumping for treatment of cardiogenic shock caused by myocardial infarction. J Am Coll Cardiol 2008;52:1584–1588. R 2.5 4. Kim MS, Clegg S, Messenger JC. Removal of ImpellaV while maintaining vascular access: A solution to a vascular quandary. Catheter Cardiovasc Interv 2014;83:223–225. 5. Toggweiler S, Leipsic J, Binder RK, Freeman M, Barbanti M, Heijmen RH, Wood DA, Webb JG. Management of vascular access in transcatheter aortic valve replacement. I. Basic anatomy, imaging, sheaths, wires, and access routes. JACC Cardiovasc Interv 2013;6:643–653.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
