Comparison of transverse versus longitudinal skin incisions for femoral endarterectomy and patchplasty.

INTRODUCTION: Access to the femoral artery for a femoral endarterectomy and patchplasty (CFE) can be undertaken either through transverse (TI) or longitudinal incision (LI). LIs have been shown in previous studies to have higher groin complications though these were undertaken in multiple types of vascular procedures. We looked at wound complications for patients undergoing elective CFE procedures only with or without angioplasty via TI or LI. METHODS: All patients who had undergone CFE were retrospectively analysed from a prospective database. Length of stay, wound complications and readmission rates were recorded. Factors for wound complication were looked at using logistic regression with backward elimination. RESULTS: 122 CFE procedures were performed (30 TI) over the study period. 92 (76.7%) of patients had a prosthetic patch used, whilst 57 (46.7%) patients underwent an adjunctive endovascular procedure, namely, iliac angioplasty and stenting. Median length of stay was 3 days for both groups. The wound complication rate was 6.7% in the TI group and 22.6% in the LI group. 85.6% of the wound complications were identified after discharge. 6/122 (4.9%) were readmitted for intravenous antibiotics, whilst others were managed in the outpatient setting. TI (aOR = 0.15; 95% 0.03-0.75) and combined open FE with endovascular revascularisation (aOR = 0.33; 95% 0.11-0.95) had protective effects on wound complications. Type of the patch used was not associated with any wound complications (p = 0.07). CONCLUSION: Compared to traditional LI, TI for CFE and OTA have lower risk of wound complications and reduced readmission rates in our series. We advocate adopting TI as the standard for femoral artery procedures rather than LI.

A prospective, randomized study comparing ultrasound versus fluoroscopic guided femoral arterial access in noncardiac vascular patients.

OBJECTIVE: The aim of our prospective, single-center, randomized study was to compare the procedural outcomes and complication rates of ultrasound (US)-guided common femoral artery (CFA) access to fluoroscopic guidance in noncardiac procedures. METHODS: A total of 635 patients undergoing femoral access for noncardiac diagnostic or interventional procedures were randomized 1:1 to receive either fluoroscopic or US-guided access. The primary end point of the study was successful CFA cannulation. Secondary end points included the first-pass success rate, time to sheath insertion, and accidental venipunctures rate. Both short (24 hours) and midterm (30-90 days postprocedure) access complications were assessed by practitioners blinded to patient randomization. RESULTS: Successful CFA cannulation occurred in 93% of US-guided procedures compared with 86% of fluoroscopy-guided access (P = .002). US guidance was associated with increased rates of first-attempt success (74% vs 42%; P < .001), fewer inadvertent venipunctures (2% vs 10 %; P < .001), and decreased median time to cannulation (80 vs 100 seconds; P < .001) compared with fluoroscopy. Rates of complications did not differ at 24 hours (1% vs 1%; P = .99) or 30 to 90 days (2% vs 4%; P = .15) in fluoroscopy vs US-guided access. When access was performed by vascular surgery trainees (residents and fellows), US guidance retained superior rates of successful CFA cannulation compared to fluoroscopy guided access (n = 298; 96% vs 89%; P = .03). Trainees' time to achieve CFA cannulation was similar to attendings' when using US guidance (median, 85 vs 77 seconds; P = .14); however, with fluoroscopy, trainees' times were significantly longer than those of attendings (137 vs 86 seconds; P = .001). CONCLUSIONS: In comparison to fluoroscopy, US-guided CFA cannulation had a higher rate of success, faster cannulation, and fewer venipunctures in the absence of increased complications.

Use of a balloon-expandable sheath for transfemoral complex endovascular aortic repair.

Authors' Note: On April 30, 2019, Terumo Medical Corporation issued a voluntary product recall for and discontinued manufacturing of the SoloPath Balloon Expandable Sheath System, the device used for the procedures outlined in this article. Data collection, data analysis, and manuscript submission occurred prior to notice of this recall. The authors of this article were unaware of adverse events associated with this device and the 15 procedures reviewed for this series were free of events related to the reason for this device recall. Management of iliac artery disease remains a challenging problem in the setting of complex endovascular aortic procedures. In spite of the nonavailability of the device outlined in this article, the authors feel that the value of innovative solutions to this clinical problem (including the use of a balloon expandable sheath) merits public review of this technique and its results. Vascular access complications contribute to the morbidity of fenestrated endovascular aneurysm repair (FEVAR). As the ability to perform these procedures progresses, new techniques emerge to overcome difficult peripheral vascular anatomy and to minimize these complications. We describe our use of a balloon-expandable sheath to accommodate the multiple accesses needed for bridging stent placement during FEVAR in patients with highly calcified, tortuous, or small-diameter access vessels. We used this sheath for successful completion of FEVAR in 15 patients with challenging iliofemoral disease. There was one iliofemoral complication and no limb loss. Given the significant source of morbidity that vascular access complications contribute to endovascular procedures, we believe that a balloon-expandable sheath is a useful adjunct in FEVAR with complex iliac anatomy.

A reality check in transradial access: a single-centre comparison of transradial and transfemoral access for abdominal and peripheral intervention.

OBJECTIVES: The purpose of this study was to describe a single institution's experience with transradial access (TRA) for angiographic interventions, and to compare technical success, complication rate and radiation dose of procedures performed with TRA to those performed with transfemoral access (TFA). METHODS: A retrospective cohort study of patients undergoing peripheral interventions via TRA or TFA from 2015 to 2017 was performed. The cohort comprised 33 patients undergoing 44 procedures via TRA and 37 patients undergoing 44 procedures via TFA. Outcome measures were technical success, access-related complications, fluoroscopy time and radiation exposure. Differences at p < 0.05 were considered to be statistically significant. RESULTS: Baseline characteristics were similar between patients who had procedures via TRA versus those who had procedures via TFA, including age, sex and body mass index. Technical success was achieved in 41/44 (93.2%) of procedures performed via TRA, compared to 44/44 (100%) of procedures performed via TFA (p = 0.241). There were three access-related complications (6.8%) when TRA was performed, compared to none when TFA was performed (p = 0.241). Fluoroscopy time was longer in procedures performed with TRA compared to those performed with TFA (27.3 vs 20.4, p = 0.033). Dose area product (DAP) did not differ with access site choice (p = 0.186). CONCLUSIONS: TRA is a safe and feasible alternative to TFA for a range of peripheral interventions. However, TRA must be performed with prudence as it is not without complications and is technically challenging, leading to longer fluoroscopy time. KEY POINTS: • Transradial access (TRA) is feasible in a variety of peripheral interventions, achieving success in 93.2% of cases. • Access-related complications are comparable between transfemoral access (TFA) and TRA (p = 0.241), but prudence must be taken during TRA as it could be technically challenging. • Procedures performed with TRA tend to have longer fluoroscopy time compared to those performed with TFA (p = 0.033), but the DAPs are comparable (p = 0.186).

Safety and efficacy of clip-based vs. suture mediated vascular closure for femoral access hemostasis: A prospective randomized single center study comparing the StarClose and the ProGlide device.

OBJECTIVES: This study is the first head-to-head analysis of StarClose vs. ProGlide in patients undergoing 5F or 6F percutaneous coronary catheterization or peripheral artery interventions. BACKGROUND: The clip based StarClose and the suture mediated ProGlide vascular closure device are well established for femoral hemostasis in endovascular therapy. However, until now no prospective randomized study compared the safety and efficacy of the two devices. METHODS: This prospective, randomized, single-center study enrolled 505 patients (69.6 ± 11.2 years) resulting in 538 procedures due to more than one intervention in several patients: We analyzed 422 cardiac catheterization and 116 peripheral artery interventions via a common femoral artery access. Patients were randomized to StarClose or ProGlide (1:1). In-hospital complications (major bleeding, hematoma, pseudoaneurysm, vessel occlusion, and arteriovenous fistula) and device failure were recorded. The puncture site was assessed by ultrasound in all patients prior to discharge. RESULTS: Overall complication rate was 3.9%. There were more complications after utilization of StarClose compared to ProGlide (5.6 vs. 2.2%, P = 0.064), which was significant in adjusted logistic regression analysis with a 2.9-fold increased risk of complications for StarClose (P < 0.05). In the subgroup of coronary catheterizations there were significantly more complications for StarClose compared to ProGlide (1.4 vs. 5.2%, P < 0.05) with a 4.7-fold increased risk. Device failure rate was not significantly different between the two devices. CONCLUSION: In this first randomized trial comparing the two closure systems complication rate was higher for StarClose with equal efficacy compared to ProGlide. © 2017 Wiley Periodicals, Inc.

Hemostatic Wound Dressing for Postinterventional Hemostasis in Large Femoral Artery Access Sites: An Initial Efficacy and Safety Study.

PURPOSE: To present the results of a prospective single-center study that evaluated the safety and efficacy of a hemostatic dressing following femoral artery access. METHODS: Within a 9-month period, 80 patients (mean age 68±14 years; 55 men) were treated with a hemostatic dressing patch (Hematrix Active Patch) containing aminocaproic acid, calcium chloride, and thrombin after endovascular procedures via a 6- to 8-F femoral artery access. After removing the sheath, the wound dressing was placed on the puncture site followed by constant manual compression adapted to the sheath size (specified pressure times: 8 minutes for 6-F, 9 minutes for 7-F, and 10 minutes for 8-F). Patients were treated with an additional pressure bandage for 24 hours. Hemostasis was checked clinically and with duplex ultrasound after patch removal and at 24 hours. Patient characteristics [platelets, systolic blood pressure, international normalized ratio (INR), and partial thromboplastin time (PTT)], sheath sizes, and approach direction were compared among patients with successful hemostasis (within specified pressure times) vs those with prolonged compression. RESULTS: A total of 39 6-F, 19 7-F, and 22 8-F sheaths were employed. In 73 (91.2%) of 80 patients, hemostasis was reached within the prespecified pressure times (mean 8.8±0.8 minutes). In 7 patients (4 6-F, 1 7-F, 2 8-F) a longer compression time was necessary (mean 34±30 minutes). No serious major complication occurred. Twelve (15.0%) minor and 5 (6.3%) moderate subcutaneous hematomas were observed. Two (2.5%) false aneurysms were treated successfully. Ambulation and discharge was possible within 24 hours in 79 (98.7%) cases. Patients with initial hemostasis and those with prolonged compression did not differ substantially (p>0.05) according to sheath size, approach direction, INR (1.09±0.3 vs 1.11±0.3), platelets (234±47×10(3)/µL vs 249±93×10(3)/µL), systolic blood pressure (150±26 vs 152±17 mm Hg), or PTT (31±7.9 vs 34.8±10.0 seconds). CONCLUSION: The evaluated wound dressing seems to be safe and effective in reducing time to hemostasis in large arterial access sites. However, a randomized trial with a larger population and an active control group is necessary to confirm these preliminary data. Moreover, additional focus on shortening the time to ambulation is required in future studies.

Comparison of Transradial vs Transfemoral Access for Aortoiliac and Femoropopliteal Interventions: A Single-Center Experience.

PURPOSE: To compare the procedure and safety outcomes of the transradial approach (TRA) with the femoral approach (FA) for treating aortoiliac and femoropopliteal stenoses and occlusions. METHODS: A single-center retrospective study was conducted involving 188 patients (mean age 66.4±10.8 years; 116 men) with lower limb claudication or critical limb ischemia who underwent aortoiliac (131, 62.4%) or femoropopliteal (79, 37.6%) interventions on 210 lesions over a 3-year period. Operator discretion determined TRA suitability; exclusions included Raynaud's disease, upper limb occlusive disease, previous TRA difficulties, or planned hemodialysis. Lesion characteristics, clinical endpoints, and access site complications were compared. RESULTS: FA was used primarily in 123 patients and the TRA (12 left and 53 right radial arteries) in 65 procedures. Eleven (16.9%) TRAs failed vs 9 (7.3%) FAs (p=0.42). Crossover to FA was due to occlusive lesions requiring alternative equipment in 9 cases and to tortuosity of the aortic arch vessels in 2 patients. The 134 FA interventions (balloon angioplasty, stents) were retrograde (112, 83.6%) or antegrade (22, 16.4%). There were significantly more TASC C/D lesions in the FA group (p=0.02). Sheath sizes (5-F to 8-F) did not differ between groups, and no significant differences were found between FA vs TRA in terms of procedure time (50.0±28.9 vs 46.8±25.1 minutes, p=0.50) or length of stay (2.2±0.6 vs 2.1±0.3 days, p=0.24). While there were no strokes, access site complications occurred in 6.0% of the FA patients vs 3.7% of the TRA patients (p=0.12). CONCLUSION: The transradial approach for aortoiliac and femoropopliteal interventions is safe and efficacious compared with the transfemoral approach for a range of lesion subtypes. Nevertheless, there remains a need for improvements in peripheral device and catheter technology to decrease transradial failure rates.

Safety and effectiveness of a novel vascular closure device: a prospective study of the ExoSeal compared to the Angio-Seal and ProGlide.

PURPOSE: To prospectively assess the safety and efficacy of a novel absorbable vascular closure device (ExoSeal) in patients undergoing cardiac catheterization with femoral access compared to the established collagen-based (Angio-Seal) and suture-mediated (ProGlide) closure devices. METHODS: This prospective, observational, dual-center, non-randomized, non-blinded study enrolled 1013 patients (65.1 ± 11.8 years) undergoing cardiac catheterization via a common femoral artery access in which hemostasis was achieved using a vascular closure device (255 Angio-Seal, 258 ProGlide, and 500 ExoSeal). In hospital complications (bleeding, hematoma, pseudoaneurysm, vessel occlusion, dissection, and arteriovenous fistula) of the puncture site and device failures (persistent bleeding) were recorded and compared for ExoSeal vs. the established devices (Angio-Seal + ProGlide). RESULTS: There were more complications after utilization of ExoSeal compared to established devices (3.6% vs. 1.2%, p=0.012). No significant difference was observed in the device success rate between the established vascular closure devices (96.3%) and the novel device (94.8%, p=0.28). Considering each closure system, Angio-Seal had the lowest complication rate (0.4%) and the highest efficacy (99.2%); the latter differed significantly from ExoSeal (94.8%, p=0.001). Logistic regression analysis revealed a >3-fold odds of complications when using ExoSeal, which remained unchanged in multivariate analysis. CONCLUSION: Utilization of the novel vascular closure device is associated with a higher complication rate and a similar device failure rate compared to collagen-based and suture-mediated devices, with Angio-Seal having the lowest complication and device failure rates.

Ultrasound guided arterial access for combat medics: A blinded proof-of-concept study using echogenic needles.

BACKGROUND: Obtaining percutaneous vascular access in hemodynamically unstable patients with constricted vessels can be challenging. Training combat medics in this procedure is necessary for administration of fluid and blood products and introducing endovascular bleeding control tools in pre-hospital settings. Echogenic coated needles might provide better ultrasound visibility in invasive procedures and hereby lower complications. The primary aim was to evaluate the efficacy of a microteaching program for obtaining ultrasound-guided femoral artery access for ultrasound inexperienced combat medics. The secondary aim was to assess the additional value of innovative echogenic coated needles in ultrasound-guided vascular access. METHODS: Combat medics participated in a four-step microteaching program. The program consisted of a theoretical and step-by-step practical part with three different models including live and dead tissue & a REBOA Access Task Trainer. During the final test, all participants had to obtain femoral artery access on a pressurized post-mortem human specimen model with both echogenic coated and conventional needles. Self-perceived and observed performance as well as procedure times were scored. RESULTS: All nine participants succeeded in blood vessel visualization and obtaining vascular access in the two models within 3 minutes and were significantly faster during the second attempt on the pressurized post-mortem human specimen model. Scoring comparison and usability preference by ultrasound inexperienced personnel showed a significant difference in favor of the echogenic coated needles. CONCLUSION: Microteaching may be an effective approach to train combat medics in obtaining ultrasound-guided percutaneous femoral artery access. The use of echogenic coatings on needles could be a valuable adjunct and provide advantage in obtaining vascular access. Future research should focus on realistic simulation of austere situations and further evaluation of the use of echogenic coated instruments for vascular access in these pre-hospital settings.

Comparison of Distal Transradial and Femoral Access in Endovascular Treatment of Non-coronary Arterial Disease.

This study compared the efficacy and safety of distal transradial access (dTRA) and common femoral artery access (CFA) for endovascular treatment of non-coronary arterial disease. 102 interventions were divided into dTRA (n = 51) and CFA (n = 51) groups; the puncture success rate was 100% in both groups. The mean number of punctures and puncture time were greater in the dTRA than CFA group (1.86 vs 1.04 and 3.96 vs ≤1.00 min, p < .001 for both), whereas the access-related complication rate was comparable. The surgical success rate was higher in the CFA than dTRA group (98.0 vs 84.3, p = .036), and the operative time was longer in the dTRA than CFA group (99.09 vs 84.10 min, p = .017). The postoperative adverse event rate was not different between the dTRA and CFA groups. dTRA is a safe and feasible access for non-coronary arterial disease and is comparable to CFA in terms of puncture success, access-related complications, and major adverse events. The dTRA is inferior to CFA in the treatment of lower extremity arterial disease. Due to the increase in the operation time and the contrast medium volume in the dTRA, it is necessary to be vigilant about contrast nephropathy and late radiological random side effects.

Surgical External Iliac Artery Access for Transcatheter Aortic Valve Replacement Is a Safe, Suitable Alternative to Common Femoral Artery Access.

Background Many patients undergoing transcatheter aortic valve replacement (TAVR) have peripheral artery disease necessitating surgical access. This study reviews the preoperative risk factors, procedural characteristics, and outcomes in patients undergoing surgical common femoral artery (CFA) and external iliac artery (EIA) access through a retro-inguinal groin incision for TAVR. Methods A single-center TAVR database was retrospectively analyzed for patients undergoing surgical cutdown (January 1, 2016 - December 31, 2020). Access sites were evaluated on preoperative imaging. Data on demographics, imaging, procedural characteristics, and outcomes were collected. The vascular surgeon selected the cutdown site. Results A hundred and thirty TAVR patients had surgical cutdown. The choice of access site was either the common femoral artery (82 patients, 63%) or the iliac artery (48 patients, 37%). There was no difference in age, BMI, or medical risk factors. There was no difference in iliac diameter or circumferential iliac calcium. In the iliac group, there was a smaller mean CFA size and a higher incidence of circumferential CFA calcium. In the femoral group, there was: a lower mean sheath-to-CFA ratio, a trend toward increased unplanned endarterectomy, and a higher incidence of 30-day readmission. There was no difference in adjunct procedure use. Conclusion EIA surgical access had similar complication rates and length of stay with a reduced tendency for unplanned endarterectomy when compared to CFA access. The EIA is a suitable access site for TAVR in select patients.

A Comparative Analysis of the Early and Late Complication Rates and the Effect of Calcification on the Efficacy of MANTA and ProGlide Vascular Closure Devices.

Introduction The Perclose ProGlide and, more recently, MANTA Large-Bore Closure Device are commonly used vascular closure devices (VCDs) for managing large-bore vascular access haemostasis. The extent of calcification in the common femoral artery (CFA) plays a crucial role in choosing between these devices. ProGlide may face challenges with anterior calcification, while MANTA may have issues with posterior calcification. Our study compared their effectiveness, adjunct usage, calcification impact and early/late complications. Methods A retrospective analysis of procedures involving large-bore CFA access from 2017 to 2022 was conducted. Closure was grouped according to VCD as Group A (ProGlide) and Group B (MANTA). Calcification was designated as anterior and posterior and combined on pre-operative computed tomography angiography along 10 mm segments with 0.625 mm slice thickness. The success of haemostasis was graded as Grade 1 (haemostasis without adjuncts), Grade 2 (haemostasis with adjuncts) and Grade 3 (failed haemostasis needing rescue); Grades 1 and 2 were pooled as successful haemostasis. Statistical analysis was undertaken in Minitab 21 for Windows, particularly analysing calcification and its impact on the success of haemostasis. Results We evaluated 370 large-bore CFA accesses, distributed across two groups: Group A(64.9%, n=243) and Group B (35.1%, n=127), for a total of 205 endovascular procedures (93.1% (191) EVAR and 5.3% (11) TEVAR). The mean age was 74.9±8 years, predominantly males (88.2%, n=181). The average body mass index (BMI) was 28±5.8, with 20.9% (43) individuals having diabetes and 18.5% (37) current smokers. The mean sheath size OD was 16±2.5, with 4.5% (11) re-do groins in Group A and 6.2% (8) in Group B. Successful haemostasis was achieved in 91.8% (n=223) in Group A (44.8%, n=109 Grade 2) and 90.5% (n=115) in Group B (21%, n=27 Grade 2). Rescue operations were needed in 8.2% (20) in Group A and 9.1% (12) in Group B. Pseudoaneurysms developed more commonly in Grade 2 haemostasis with 9.9% (11) in Group A and 1.6% (2) in Group B (p=0.3). Anterior calcification was observed in 14.8% (36) in Group A and 18.8% (24) in Group B. In comparison, posterior calcification was present in 62.5% (152) in Group A and 66.9% (85) in Group B. Notably, calcification did not significantly impact haemostasis (p=0.79). Additional VCD deployment was necessary due to device failure in 4.5% (11) cases in Group A and 1.5% (2) cases in Group B. Conclusion The overall success rate was comparable between the two groups. However, Group A required more adjuncts to achieve successful haemostasis. The site of calcification did not impact the efficacy of closure devices. Pseudoaneurysm formation was more frequent when adjuncts were needed.

Transradial versus Transfemoral Approaches in Diagnostic and Therapeutic Neuroendovascular Interventions: A Meta-Analysis of Current Literature.

BACKGROUND: The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures. METHODS: A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures. RESULTS: Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P < 0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P < 0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P < 0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P < 0.01). CONCLUSIONS: Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.

An Alternative Technique to Achieve Haemostasis During PEVAR Using Perclose ProGlide.

INTRODUCTION: Percutaneous endovascular abdominal aortic aneurysm repair (PEVAR) using the Perclose ProGlide suture mediated closure device is currently performed on a global scale. A safe, effective, and cheap technique for achieving haemostasis during PEVAR is described that allows the reversible downsizing of the arteriotomy, without using any other devices. TECHNIQUE: The procedure consists of pulling the blue thread of the pre-implanted ProGlide, advancing the knot close to the arterial wall by pushing it with the dilator of a small introducer sheath, and maintaining the system under tension by grasping the end of the blue thread with a haemostat until bleeding control is achieved. DISCUSSION: Seventeen PEVAR femoral access downsizing procedures have been performed between February and June 2018 and no complications were observed. The technique could be useful in everyday practice and has now become the author's standard practice.

Common Femoral Artery Access on YouTube: What Practices are Being Shown and Who is Delivering the Message?

OBJECTIVES: Novice learners are increasingly turning to YouTube as a learning resource for surgical procedures. One example of such a procedure is common femoral artery puncture and sheath placement. Practitioners in several specialties perform this procedure to access the arterial system for angiography and intervention. We set forth to compare the techniques demonstrated on YouTube by the various specialists, as well as compare each specialty׳s prevalence on this website. METHODS: YouTube (www.youtube.com) was accessed in December 2015 at multiple time points with a cleared-cache web browser for the keyword search categories: "femoral artery access," "femoral access," and "angiography access." The top 500 videos from each of these keyword searches were analyzed. Videos were categorized by practitioner specialty, technique, duration of video, age of video, and total views. Videos with clear demonstration of femoral artery access were included in the analysis. All industry videos were excluded from the analysis. Categorical variables were compared using Fisher׳s exact test, and continuous variables were compared with the Student׳s t-test. RESULTS: A total of 2460, 4680 and 1800 videos were found for each keyword search, respectively. Of these, 33 videos clearly demonstrated femoral artery access technique. Vascular specialists, compared to interventional cardiology and radiology, had fewer videos (n = 4 vs. 14) and older videos (3.5 ± 2.1y vs. 2.25 ± 0.5y, p < 0.05). The vascular specialists demonstrated ultrasound-guided access, while interventional cardiology predominantly demonstrated landmark-guided access (p < 0.05). CONCLUSIONS: Although YouTube and other online resources are being used by novice learners, vascular specialists are underrepresented for femoral artery access, a foundational vascular procedure. Other practitioners demonstrate videos with landmark-guided access and rarely demonstrate ultrasound use. As recognized vascular experts, vascular surgeons should improve their visibility in online learning resources.

Death Due to an Unusual Angio-Seal-Related Complication: Case Report and Literature Review.

Angio-SealTM is a vascular closure device (VCD) that can be applied to the femoral artery following cardiac catheterization to achieve hemostasis. Although it has been demonstrated to be superior to conventional manual pressure and to reduce time to hemostasis and patient ambulation, the use of this VCD is not without its complications. In this report, we describe the case of a 55-year-old man who died due to an extremely rare event that occurred several hours after the deployment of an Angio-SealTM VCD: acute complete transverse laceration of the femoral artery that occurred because of the particular fragility of the vessel due to an unrecognized and asymptomatic arteriosclerotic disease. Few data are available in the literature about the incidence of such events, and much more remains to be done to determine how to prevent and manage its occurrence.

A single center multioperator initial experience of 4,195 patients at a primary radial intervention program in a tertiary level center.

BACKGROUND: There has been an increase the acceptability and the number of the procedures via the radial approach. We present our experience pertaining to the clinical characteristics, procedural details and post procedural outcome of patients undergoing radial artery access, coronary angiographies over a period of 4 years at a primary care tertiary level center. MATERIALS AND METHODS: A retrospective analysis of all the coronary artery procedures during the last 4 years was done and the various parameters related to these procedures noted. RESULTS: In 4195 procedures performed, success in radial artery procedures was achieved in 3975 (94.8%) procedures. The average puncture time and total procedure time was 9.5 + 3 min (min) and 15 + 2.5 min in the initial 500 patients, whereas the times taken in the final 695 patients were just 1.5 + 0.5 min and 3.0 + 1.5 min respectively. The total fluoroscopy time was not significantly different among the groups, when performed by an operator with training in the femoral route for angiography. Cardiology fellows needed more fluoroscopy time when mastering the radial route. Crossover of access sites was seen in 220 patients (5.2%). CONCLUSIONS: After 100 procedures, radial access coronary angiographies take less than 4.5 min, with first attempt radial artery access and negligible complication rates. Prior experience of coronary angiography helps in the reduction of fluoroscopy time during the learning curve.

Retroperitoneal hemorrhage as a complication of percutaneous intervention: report of 2 cases and review of the literature.

Retroperitoneal hemorrhage (RPH) is an infrequent but serious complication of transfemoral percutaneous procedures. We present 2 cases and review the literature regarding the incidence, risk factors, clinical features and complications of RPH. We propose a management strategy for this problem emphasizing an anatomical based interventional approach if the patient does not stabilize with volume resuscitation.