Sunday, December 6, 2015

Vascular Access / Arteriotomy Closure Devices

Any arterial case, whether for a diagnostic 4-vessel angiogram, coronary catheterization, or transarterial chemoembolization, will require access into an artery, most commonly the right common femoral artery. After the case ends, the artery needs to be closed to achieve hemostasis and prevent further bleeding. The most basic closure "device" is manual pressure for 15 minutes. While this is effective, the downsides include no true closure of the wound in the vessel wall, operator dependence, and limited reliability in patients with large body habitus.

Closure devices have been developed to both mitigate the risks of bleeding as well as reduce the suite time required for such cases. Below are step by step instructions (and links to videos) for several common devices:


This device functions by placing a metallic clip around the arteriotomy. While effective, the drawback is that a permanent device is left within the patient, potentially limiting future access. 

  1. Prep groin, kit by flushing introducer stylet into hub
  2. Exchange 5/6Fr sheath over wire for introducer
  3. Remove wire and stylet together, leaving stylet. Fix left hand against patient.
  4. Attach StarClose to introducer [#1] and switch left hand to device.
  5. With R hand, push [#2] to break the seal and deploy footplate.
  6. GENTLY RETRACT DEVICE UNTIL TENSION FELT - footplate now against inner wall.
  7. With R#2 above, #3+4 on handle, use R thumb to depress [#3] to fully break seal
  8. Tilt handle straight up, then push [#4] to deploy clip.
  9. Hold manual pressure for 2 minutes.


This device is suture mediated. The suture is absorbable, and multiple PerClose's can be used to close larger arteriotomies. 

  1. Prep groin; prep kit with saline into sideport where blood will come, wet introducer part
  2. Exchange 5/6Fr sheath over wire for introducer
  3. Once white triangle reached, remove wire
  4. Advance until *pulsatile* blood return seen - Retract [#1] to deploy footplates
  5. Retract device until blood return disappears
  6. Deploy [#2] to advance suture through wall
  7. Deploy [#3] to loop suture through arteriotomy. Pull out stylet and cut suture
  8. Depress [#4] to close footplate
  9. Pull back device to free both sutures, then pull through. Remove device.
  10. Put knot pusher on LONG thread and push down with LEFT thumb on top of device
  11. Synch down on suture with short thread.
  12. Take knot pusher off long thread and place on both. Repeat motion, but now cut knot.


This device functions by placing an absorbable polyethylene glycol plug in the tissue tract above the arrteriotomy.  

  1. Prep groin; prep kit with saline into sideport where blood will come, wet introducer part
  2. Draw 3 cc NS into syringe
  3. Introduce wire/balloon through existing sheath until white marker.
  4. Inflate balloon until inverse Oreo (white-black-white) seen at back of device. Close stopcock
  5. Grasp black handle and pull back two stops (balloon to sheath tip; balloon-sheath to vessel wall)
  6. Open sheath sidearm to confirm temporary hemostasis
  7. Advance shuttle to definitive stop, then withdraw sheath back to starting position
  8. Grasp the white tube at skin level and advance until green marker fully expose to tamp PEG grip tip onto vessel wall
  9. Hold in place for 30 seconds, then lay down for 90 seconds
  10. WIthdraw syringe to full negative, open stopcock, and withdraw through pusher device.
  11. Withdraw pusher device while holding pressure on vessel up to 60 seconds

To learn more about these closure devices and IR procedures in general, check out the Handbook of Interventional Radiologic Procedures: