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Review
. 2024 Sep;17(9):e014156.
doi: 10.1161/CIRCINTERVENTIONS.124.014156. Epub 2024 Aug 21.

Femoral Large Bore Sheath Management: How to Prevent Vascular Complications From Vessel Puncture to Sheath Removal

Lazzaro Paraggio  1 , Francesco Bianchini  2 , Cristina Aurigemma  1 , Enrico Romagnoli  1 , Emiliano Bianchini  2 , Andrea Zito  2 , Mattia Lunardi  1 , Carlo Trani  1   2 , Francesco Burzotta  1   2
Affiliations
Review

Femoral Large Bore Sheath Management: How to Prevent Vascular Complications From Vessel Puncture to Sheath Removal

Lazzaro Paraggio et al. Circ Cardiovasc Interv. 2024 Sep.

Abstract

Transfemoral access is nowadays required for an increasing number of percutaneous procedures, such as structural heart interventions, mechanical circulatory support, and interventional electrophysiology/pacing. Despite technological advancements and improved techniques, these devices necessitate large-bore (≥12 French) arterial/venous sheaths, posing a significant risk of bleeding and vascular complications, whose occurrence has been related to an increase in morbidity and mortality. Therefore, optimizing large-bore vascular access management is crucial in endovascular interventions. Technical options, including optimized preprocedural planning and proper selection and utilization of vascular closure devices, have been developed to increase safety. This review explores the comprehensive management of large-bore accesses, from optimal vascular puncture to sheath removal. It also discusses strategies for managing closure device failure, with the goal of minimizing vascular complications.

Keywords: femoral artery; heart assist device; peripheral artery disease; transcatheter aortic valve replacement; vascular access devices.

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Conflict of interest statement

Drs Burzotta and Trani received speaker fees from Abbott Vascular, Abiomed, Medtronic, and Terumo. Dr Paraggio received speaker fees from Abiomed and Terumo. Dr Aurigemma received speaker fees from Abbott Vascular, Abiomed, Medtronic, Terumo, and Daiichi Sankyo. Dr Romagnoli received speaker fees from Abiomed, Abbott Vascular, and Terumo. Dr Bianchini received a research grant from Abbott Vascular. The other authors report no conflicts of interest to declare.

Figures

Figure 1.
Figure 1.
Overview of common techniques for femoral artery puncture. CFA indicates common femoral artery; and US, ultrasound. Created with BioRender.com.
Figure 2.
Figure 2.
The angio-guided-ultrasound (AGU) guidance. CFA indicates common femoral artery; and US, ultrasound. Created with BioRender.com.
Figure 3.
Figure 3.
Standard suture technique vs parallel suture technique. Two Perclose ProGlide sutures are inserted into the vessel wall using the standard suture technique (A and B) or the parallel technique (E and F). After tightening the knots, crosswise (C and D) or parallel (G and H) orientation of the sutures from the intravascular view is shown. Created with BioRender.com.
Figure 4.
Figure 4.
MANTA-related vascular complications. Correct placement of the MANTA device (A). Toggle dislodgement, often caused by severe artery calcification, can result in stenosis or acute occlusion (B). Inadequate placement of the toggle, which may occur due to a high puncture site and interference with inguinal ligament, can lead to minor/major bleedings (C). Improper apposition of the plug, often due to insufficient movement down the tampered tube, can cause pseudoaneurysm and potential late rupture (D). CFA indicates common femoral artery; PFA, profunda femoral artery; and SFA, superficial femoral artery. Created with BioRender.com.
Figure 5.
Figure 5.
Overview of hemostasis techniques in the absence of elective preclosure. CFA indicates common femoral artery; PAD, peripheral artery disease; and VCD, vascular closure device. Created with BioRender.com.
Figure 6.
Figure 6.
Overview of most common vascular complications and endovascular bail-out management. Created with BioRender.com.
Figure 7.
Figure 7.
Pledget-assisted hemostasis technique. This technique implicates placing a nonabsorbable polytetrafluoroethylene pledget (6.5 mm×4 mm×1.5 mm; A) over the 2 ProGlide sutures (B). The pledget is then pressed down using the ProGlide knot-pusher and secured with a manually tied sliding knot (C through E). This method ensures stable alignment with the vessel wall for optimal hemostasis (F). Created with BioRender.com.
Figure 8.
Figure 8.
Subcutaneous sutures techniques for large-bore transvenous transcatheter procedures. Figure-of-eight suture (A); purse-string suture (B). Created with BioRender.com
See this image and copyright information in PMC

References

    1. Burzotta F, Shoeib O, Aurigemma C, Trani C. Angio-Guidewire-Ultrasound (AGU) guidance for femoral access in procedures requiring large sheaths. J Invasive Cardiol. 2019;31:E37–E39. - PubMed
    1. Chieffo A, Burzotta F, Pappalardo F, Briguori C, Garbo R, Masiero G, Nicolini E, Ribichini F, Trani C, Álvarez BC, et al. . Clinical expert consensus document on the use of percutaneous left ventricular assist support devices during complex high-risk indicated PCI: Italian Society of Interventional Cardiology Working Group Endorsed by Spanish and Portuguese Interventional Cardiology Societies. Int J Cardiol. 2019;293:84–90. doi: 10.1016/j.ijcard.2019.05.065 - PubMed
    1. Avvedimento M, Real C, Nuche J, Farjat-Pasos J, Galhardo A, Trinh K-H, Robichaud M, Delarochellière R, Paradis J-M, Poulin A, et al. . Incidence, predictors, and prognostic impact of bleeding events after TAVR according to VARC-3 criteria. JACC Cardiovasc Interv. 2023;16:2262–2274. doi: 10.1016/j.jcin.2023.07.005 - PubMed
    1. Lunardi M, Pighi M, Banning A, Reimers B, Castriota F, Tomai F, Venturi G, Pesarini G, Scarsini R, Kotronias R, et al. . Vascular complications after transcatheter aortic valve implantation: treatment modalities and long-term clinical impact. Eur J Cardiothorac Surg. 2022;61:934–941. doi: 10.1093/ejcts/ezab499 - PubMed
    1. Généreux P, Piazza N, Alu MC, Nazif T, Hahn RT, Pibarot P, Bax JJ, Leipsic JA, Blanke P, Blackstone EH, et al. ; VARC-3 WRITING COMMITTEE. Valve academic research consortium 3: updated endpoint definitions for aortic valve clinical research. J Am Coll Cardiol. 2021;77:2717–2746. doi: 10.1016/j.jacc.2021.02.038 - PubMed

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