Large Bore Femoral and Axillary Closure with Dr. Amir Kaki

August 13, 2019

Vascular Closure Techniques and Devices

Amir Kaki, MD, FACC, FSCAI discusses large bore femoral and axillary closure techniques as well as vascular closure devices currently on the market and in the pipeline. Dr. Kaki is an associate professor of medicine at Wayne State University and also director of MCS and complex coronary intervention and associated director of interventional cardiology at Ascension St John Hospital in Detroit, Michigan.

“It’s hard to have a reliable, safe closure if you don’t have a really good access,” Dr. Kaki emphasizes, before presenting a safe and effective protocol that has been used to explant large bore access sheaths in almost 1500 large bore cases at his institution. The protocol he describes entails:

  • Contralateral access
  • Exchange for a 7 Fr crossover sheath after wiring to ipsilateral SFA
  • Advance 8-10x40mm balloon (1:1 matching size of ipsilateral EIA)
  • Inflate balloon until waveform dampens
  • Explant large bore access sheath
  • Tie down pre-deployed Perclose sutures
  • Deflate balloon and observe whether achieving hemostasis
  • If hemostasis not achieved, advance balloon to arteriotomy site

Dr. Kaki explains that the desired closure for a large bore sheath should be fully percutaneous, easy to use, safe, secure, reliable, and fully bioabsorbable. He discusses several closure devices, some of which are currently available in the US and others that are still in the product pipeline:

  • InSeal® VCD, a self-expandable nitinol frame covered with a biodegradable membrane that is currently undergoing CE mark in Europe
  • PerQseal®, a patch-based fully absorbable implant in the pipeline that seals large arteriotomies (at least 7 mm) from the inside
  • Prostar® XL percutaneous vascular surgical (PVS) system, a suture based VCD that is currently available and primarily used for EVAR and TEVAR patients
  • MANTA™, a biomechanical VCD that recently received FDA-approval and CE mark

Dr. Kaki also discusses axillary dry closure and covered stent placement. He describes a case with major perforation of the axillary artery, where holding manual pressure while the covered stent was being prepared was effective and feasible. He emphasizes the importance of precisely placing the stent between meaningful axillary branches, noting again that good access dictates good closure.

In Dr. Kaki’s opinion, axillary access is the best available alternative access technique. He emphasizes that axillary access allows patients to sit up, walk short distances, bridge to recovery, and bridge to definitive therapy. He also notes the faster insertion time than other alternative access, which can expedite door-to-unload, as well as lower rates of infection compared to femoral access.

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