Diagnostic and Therapeutic Cardiovascular Procedures
Femoral Arterial Access and Closure
Sripal Bangalore, MD, MHA; Deepak L. Bhatt, MD, MPH, FAHA
F emoral arterial access is the most common method of
vascular access for coronary angiography and percutane-
ous coronary intervention in the United States.1 It is an often
underestimated but important aspect of the procedure, and is
the single most frequent cause of complications during
coronary angiography and intervention.2 Hyperlinked to this
article is a video that shows a PVI procedure performed at VA
Boston Healthcare System, West Roxbury Campus. Most
vascular complications are preventable by following good
access technique, starting with a thorough history and phys-
ical examination. In addition to a routine review of systems,
the history should specifically focus on the presence of
symptoms suggestive of peripheral arterial disease (PAD)
(intermittent claudication/rest pain/foot ulcers), prior inter-
ventions for PAD, including arterial bypass grafts or stenting,
recent femoral access, closure device used (if any), any groin
complications from prior procedures (pseudoaneurysms, ar-
teriovenous fistulae, retroperitoneal bleeding, ischemic vas-
cular problems, femoral arterial dissections), presence of
active groin infection, prior surgery or radiation therapy to the
groin, and presence of iliac or aortoiliac aneurysms (size and
location) (Table 1). The history should also focus on whether
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the patient can lie supine for prolonged periods of time (eg,
chronic lower back pain, congestive heart failure, chronic
obstructive pulmonary disease) because this can modulate the
choice for access (femoral versus radial) and closure (manual
compression versus closure device). In addition to routine
examination of the main systems, physical examination
should focus on inspection of the groin for any signs of
infection (especially in morbidly obese patients with signifi-
cant skin folds), palpation and auscultation (for bruits) of the
femoral pulse, and palpation of the distal arterial pulses,
including bilateral dorsalis pedis, posterior tibial, and popli-
teal arteries. In patients with nonpalpable pulses, Doppler
ultrasonography should be used. Pertinent findings should be
documented in the patient’s chart to serve as a baseline record
of the patient’s peripheral pulses. The presence of any of the
aforementioned conditions should prompt strong consideration
for an alternative approach, such as radial (preferred) or brachial
artery, although most of the aforementioned conditions are not
an absolute contraindication for a femoral artery approach, and
the procedure can be done relatively safely with the use of
smaller sheaths (4F or 5F).
From the New York University School of Medicine, New York, NY (S.B.); and Veterans Affairs Boston Healthcare System, Brigham and Women’s
Hospital, and Harvard Medical School, Boston, MA (D.L.B.).
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/124/5/e147/DC1.
Correspondence to Deepak L. Bhatt, MD, MPH, FAHA, Department of Cardiology, Veterans Affairs Boston Healthcare System, 1400 VFW Parkway,
Boston, MA 02132. E-mail dlbhattmd@post.harvard.edu
(Circulation. 2011;124:e147-e156.)
© 2011 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
e147
Anatomic Considerations
Compelling evidence suggests that femoral arterial access
complications are related to the site of femoral arterial
puncture. Knowledge of the normal course of the common
femoral artery (CFA) is therefore vital. The CFA is a
continuation of the external iliac artery and crosses the pelvic
brim at the level of the inguinal ligament, which extends from
the spine of the anterior superior iliac crest to the pubic
tubercle (Figure 1). The CFA then passes through the femoral
sheath and branches into the superficial femoral artery and
the profunda femoris artery. The femoral sheath has 3
compartments. The lateral compartment contains the femoral
artery, the intermediate compartment contains the femoral
vein, and the medial and smallest compartment is called the
femoral canal. The femoral canal contains efferent lymphatic
vessels and a lymph node embedded in a small amount of
areolar tissue. Lateral to the femoral artery and outside the
femoral sheath is the femoral nerve.
Ideal Femoral Arterial Puncture Site
The CFA represents an ideal site for arterial access and sheath
insertion because it is relatively large, is less involved with
atherosclerosis, and is readily compressible against the un-
derlying head of the femur. Caudal punctures usually result in
greater propensity for cannulation below the bifurcation into
the superficial femoral artery or the profunda, where the lack
of underlying bony structure and lack of scaffolding by
femoral sheath result in an increased association with bleed-
ing, hematoma, and pseudoaneurysms.3,4 When a double wall
puncture or bleeding (due to inadequate compression) occurs
in the CFA, the femoral sheath limits the spread of hematoma
and thereby tamponades the arteriotomy site, preventing
pseudoaneurysm formation.3 The smaller caliber of the arter-
ies below the bifurcation also makes them more prone to
catheter-related arterial occlusions.4 In addition, the tributar-
ies of the femoral vein course above the superficial femoral
artery, increasing the risk of arteriovenous fistula.
Although low femoral arterial cannulation results in com-
plications, cannulation of the femoral artery above the ingui-
nal ligament (in the external iliac artery) is associated with an
increased risk of retroperitoneal hemorrhage due to lack of an
underlying bony structure preventing effective compression
and tamponade.5 The inferior epigastric artery courses toward
DOI: 10.1161/CIRCULATIONAHA.111.032235
 e148 Circulation August 2, 2011

Table 1. Important Considerations in Difficult Femoral

Arterial Access
Conditions
Absent/weak femoral pulse
Iliofemoral bypass grafts
Prior femoral arterial access and
closure device used
No restriction if a suture-based (Perclose)
Prior femoral arterial access site
complications (dissection,
pseudoaneurysm, ischemic limb)
Active groin infection
Prior groin surgery (excessive
scarring)/radiation therapy
Tortuous iliofemoral arterial system
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Recommendations
Consider radial artery approach
Doppler needle (SmartNeedle)
Micropuncture needle
Consider radial artery approach
Micropuncture needle and smaller
sheaths (4F or 5F)
If collagen plug–based (Angio-Seal)
closure device used, wait 3 mo
before reaccess (although reaccess
1 cm proximal to prior access site
has been shown to be safe)
or a nitinol clip–based (Starclose)
closure device used
Use contralateral femoral arterial
site
Use contralateral femoral arterial Figure 1. Normal anatomy of the femoral artery as depicted on
site a right anterior oblique view of a femoral angiography. CFA indi-
cates common femoral artery; PFA, profunda femoris artery; and
Consider radial arterial access SFA, superficial femoral artery.
Use contralateral femoral arterial
site rule).7 The optimal location for an ideal femoral arterial puncture
Consider radial arterial access is best assessed from prior femoral angiograms, if available. In
Consider radial arterial access patients without prior femoral angiograms, various external
Consider use of a longer sheath landmarks have been used to access the femoral artery, as

once arterial access is obtained follows8:

Calcified common femoral artery Consider contralateral femoral
artery (if less calcified) 1. Skin/inguinal crease: The skin crease has been used as
Consider radial arterial approach a marker for the underlying inguinal ligament, and an
arterial puncture 2 to 3 cm below the mid point of the
Known aneurysms of the iliofemoral Consider radial arterial approach
skin crease has been used. However, the skin crease is
or aortoiliac system Consider use of exchange length not a reliable marker for the inguinal ligament, espe-
wires for all catheter exchanges cially in obese patients, in whom it tends to be lower
Severe back pain, inability to lie flat Consider radial arterial approach than the inguinal ligament.
for prolonged periods of time Consider closure device use 2. Bony landmarks: A point 2 to 3 cm below the mid
Morbidly obese Consider radial arterial approach
inguinal point, which is the mid point between the
anterior superior iliac spine and pubic tubercle, has been
Consider micropuncture or
used by some operators as a site for femoral arterial
Smart Needle use
cannulation. However, although bony landmarks are
better than the skin crease, they seldom correspond to
the exact location of the inguinal ligament.7
the inguinal ligament before turning upward. The lowest
3. Maximal pulse: Although arterial cannulation at the site
point of the inferior epigastric artery thus corresponds to the of maximal pulse may aid in easy cannulation of the
inguinal ligament. Any arterial puncture above the level of femoral artery, relying on the amplitude of the pulse
the lowest point of inferior epigastric artery (on femoral alone could result in high or low puncture. This could
angiography) is associated with a significant increase in the be particularly important in obese patients in whom the
risk of retroperitoneal hemorrhage.6 However, it should be only place where the femoral artery is palpable corre-
noted that infrainguinal puncture and bleeding can also cause sponds to a region with a smaller amount of soft tissue
retroperitoneal hemorrhage by tracking of the blood upward and might not correspond to the ideal site.
underneath the ligament and into the retroperitoneal space, as 4. Fluoroscopic landmark: Although fluoroscopic guid-
was shown elegantly by Rupp et al.7 Similarly, cannulation of ance was originally proposed for “femoral puncture
when the arterial pulse was diminished or obscured, for
the femoral artery right underneath the inguinal ligament
training purposes, and for analysis and correction of
could be problematic because the taut inguinal ligament must missed punctures,”9 it is being used increasingly and is
be compressed to effectively compress the femoral artery. now a commonly recommended technique for femoral
The ideal site of femoral arterial puncture (not skin puncture) artery puncture. Routine use of fluoroscopic guidance
is a point ⬇1 cm lateral to the most medial aspect of the femoral reduces the risk of vascular complications,10 although
head, midway between its superior and inferior borders (Rupp’s not every study supports that contention.11,12 The tech-
 Bangalore and Bhatt
nique uses visualization of the femoral head under
fluoroscopy in a posterior-anterior projection. A metal
clamp is used as a marker to identify the most ideal
location of femoral artery cannulation, as described
above. This is achieved by a skin puncture done at the
lower border of the femoral head, with the needle
entering the skin at a 30° to 45° angle (with a steeper
angle in more obese patients). The broad upper and
lower limits of an ideal puncture are below the inguinal
ligament, but well above the femoral artery bifurcation.
Dotter et al9 found that the femoral artery bifurcation
was 2 to 66 mm below the femoral head, whereas Rupp
et al7 found that the inguinal ligament was 15 mm
superior to the mid femoral head, giving a window of 3
to 5 cm where an ideal puncture could be made.
However, in the majority of cases (⬇77%), the bifur-
cation is below the level of the femoral head. Hence, a
target zone from the lower border of the head of femur
to the mid portion of the head is ideal, whereas the
safety spot (even in the 23% of cases with high femoral
artery bifurcation) is at the mid portion of the head of
femur.13
Steps for Successful Femoral
Arterial Cannulation
Conscious Sedation and Local Anesthesia
Femoral artery cannulation is the most uncomfortable part for
the patient, and most likely to be remembered by one
undergoing uncomplicated coronary angiography. Adequate
conscious sedation (for example, 1 mg of midazolam and 25
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␮g IV of fentanyl; the dose is reduced in the elderly) is key
to ensure patient relaxation and cooperation. After the
planned site of skin entry by the needle (lower border of
femoral head on fluoroscopy) is confirmed, femoral arterial
pulsation should be felt with the tips of the middle and index
fingers, parallel to the course of the artery. Adequate local
anesthetic should then be given, starting with a dermal bleb
with a 25-guage needle to anesthetize the skin. A 22-gauge
needle is then used to anesthetize deeper tissue planes,
starting with the deepest point and working backward toward
the skin. It is best practice to pull back on the plunger of the
syringe before injecting to ensure that the needle is not in a
blood vessel. Intravascular injection of the local anesthetic
agent could result in serious arrhythmias. Approximately 10
to 20 mL of local anesthetic agent should be injected around
the femoral artery site, ensuring adequate local anesthesia
from the skin to the level of the artery. Giving too much local
anesthesia may obscure femoral arterial pulsation and make
access a challenge. Similarly, giving too little may make the
patient less able to tolerate the procedure. While local
anesthesia is administered, the patient should be monitored
for any vasovagal reaction.
Nick and Tunnel Approach
Some operators follow the nick and tunnel approach, in which
a 2- to 3-mm nick is made parallel to the skin crease at the site
of the local anesthesia with a scalpel blade. The nick is then
enlarged and deepened with the use of the tip of a small
curved forceps (clamp). The nick and tunnel approach en-
sures less resistance while the arterial sheath is advanced
Vascular Access and Closure e149
(especially for larger sheaths) and increases the likelihood
that vascular bleeding will manifest as an ooze rather than a
hidden hematoma. The disadvantages of this technique are
that, in instances in which femoral artery cannulation cannot
be obtained at the site of a skin nick, an additional skin nick
may have to be performed, with occasional tract oozing after
the sheath is removed. To avoid this, many operators com-
pletely avoid the nick and tunnel approach, especially when
using a smaller sheath (4F to 5F). As an alternate approach,
a small nick can be made after femoral artery access with the
needle in place and the guidewire through it.
Femoral Arterial Cannulation
With adequate local anesthesia, femoral arterial access is
obtained with the use of an 18-gauge needle, employing the
modified Seldinger’s technique with an anterior wall stick.
With palpation of the femoral artery with the index and
middle fingers of 1 hand, the needle is held with the index
finger and thumb with the needle tip bevel facing upward.
The skin is entered at a 30° to 45° angle to ensure that the
artery will be cannulated 2 cm superior to the skin entry site.
A more vertical entry may make advancing the sheath and
guide catheters difficult and also promote kinking. As the
needle approaches the femoral artery, pulsations can be felt
through the needle. Some operators examine the groin fluo-
roscopically at this stage to ensure that the needle is at the
level of the mid femoral head. Once the femoral artery is
cannulated, good pulsatile blood flow should be ensured
before any guidewire advancement. A 0.035-inch J-tip guide-
wire is then advanced through the needle into the femoral
artery, iliac artery, and descending aorta. If any resistance is
encountered during wire advancement, it should be done
under fluoroscopy. If resistance is encountered as the guide-
wire leaves the needle tip, the guidewire should be removed
and the needle adjusted to ensure brisk flow. In obese
patients, lowering the hub of the needle before guidewire
insertion can help to overcome this issue. Similarly, when the
needle is up against the wall, slight repositioning either
laterally or medially will aid in smooth guidewire advance-
ment. In cases in which the guidewire encounters resistance
in the external or common iliac artery, attempts should be
made to advance the guidewire under fluoroscopy, taking
extra precautions not to use force. If this does not work,
especially in patients with tortuous iliac arteries, the J-tipped
guidewire should be exchanged for a steerable 0.035-inch
wire, such as a Wholey wire (Covidien, Mansfield, MA).
With sufficient length of wire in the artery, a small skin nick
is made, and the cannulation needle is then exchanged for a
femoral arterial sheath with the dilator inside it. The J-tip
guidewire and dilator are removed, and the side port is
flushed with heparinized saline.
Femoral Angiography
Unless the glomerular filtration rate is markedly reduced, all
patients should have a femoral angiogram regardless of
planned closure device used and preferably before coronary
angiography. Before angiography, the side port of the sheath
must be connected to the pressure transducer, and a record of
the common femoral arterial pressure should be made (any
 e150 Circulation August 2, 2011
dampening of pressure waveform in relation to the cuff
pressure should raise the possibility of PAD or of the sheath
in a dissection plane). Femoral angiography is then performed
with an ipsilateral anterior oblique view at 30o to 45o
angulation. This angulation is ideal to visualize the bifurca-
tion of the CFA. However, it should be noted that this view
should not be used to interpret a high femoral artery cannu-
lation. If there is any concern for a high femoral arterial
cannulation, repeat femoral angiography should be performed
in the posterior-anterior projection. Care must be taken to
avoid irradiating the operator’s hands during angiography and
also to prevent accidentally pulling out the sheath during
injection. Femoral angiography performed before a procedure
aids in assessing the location of the puncture, the presence of
any complications (perforation, dissection), the size of fem-
oral/iliac arteries, and presence of PAD (which may guide the
choice of guidewire). Deferring a coronary intervention
should be considered if the femoral artery cannulation is
deemed to be too high because the risk of retroperitoneal
hemorrhage may increase substantially.
Special Considerations
Ultrasound-Guided Femoral Arterial Cannulation
Ultrasound guidance is increasingly used for venous cannu-
lation for central line placement. However, the data on
ultrasound-guided arterial cannulation are limited. The tech-
nique involves ultrasonography of the femoral artery with the
use of a 7-MHz transducer draped in a sterile sleeve. With the
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use of landmarks described previously (anatomic/fluoro-
scopic), the ultrasound probe is held over the proposed site of
arterial cannulation. The probe is then moved caudally to
visualize the bifurcation and cranially to visualize the com-
mon femoral artery. The femoral artery can be differentiated
from the femoral vein in that it is less compressible, as well
as by the direction of blood flow by color Doppler ultra-
sonography and by a triphasic signal versus a more mono-
phasic signal (femoral vein) on pulse Doppler ultrasonogra-
phy. Some operators even advocate administration of local
anesthesia under ultrasound guidance, which ensures that the
soft tissues around the artery are infiltrated for effective local
anesthesia. Once the CFA is located and a disease-free
segment is visualized, a real-time ultrasound-guided arterial
cannulation can then be performed. Carefully scoring the
needle with a scalpel or hemostat may make it more visible on
ultrasound. With the probe held in 1 hand or by a second
operator, the Seldinger needle is then advanced under ultra-
sound guidance. The position of the needle is shifted as
needed on the basis of its position on the ultrasonogram. The
advantage of ultrasound guidance is that it avoids accidental
venous puncture in anatomic variants in which the femoral
vein or its branches lie directly above the artery. It can also
potentially avoid cannulation into more diseased segments of
the artery as well as avoid cannulation into a branch vessel
because of anatomic variation (high femoral arterial bifurca-
tion). The disadvantage is the extra time needed to set up the
equipment and time taken for the additional step in obtaining
femoral access.
The data to support the routine use of ultrasound guidance
during angiography are limited. Wacker et al14 assessed the
utility of color duplex ultrasonography in aiding vascular
access in patients with an absent palpable pulse or after 3
unsuccessful palpation-guided cannulation attempts and
found a 100% success rate with the technique with fewer
passes required. Similarly, in 30 consecutive patients under-
going peripheral vascular procedures, Yeow et al15 showed a
high success rate (96%) for the establishment of antegrade
CFA or superficial femoral artery access. Dudeck et al16
randomized 112 patients undergoing coronary angiography to
ultrasound-guided puncture versus traditional palpation-
guided puncture of the femoral artery. They found that only in
patients with a weak arterial pulse and in those with a leg
circumference of ⱖ60 cm did ultrasound guidance signifi-
cantly decrease the number of attempts needed as well as the
time for successful arterial puncture. In contrast, time for
vessel cannulation was increased in patients with strong
arterial pulse in the ultrasound guidance group, and there was
no difference in the rate of femoral arterial complications
with the use of this technique. However, in this study, patients
on anticoagulation were excluded, and only 4F or 5F sheaths
were used, which could have potentially reduced the compli-
cation rate and hence any benefit of the ultrasound-guided
technique. Nevertheless, ultrasound-guided femoral arterial
cannulation is an acceptable option, especially in obese
patients or in those with a weak pulse.
Femoral Arterial Cannulation With a
Micropuncture Needle
In instances in which the vessel may be small, calcified, or
tortuous, or when the patient in on anticoagulation, a smaller
access needle may be desirable to reduce the risk of compli-
cations. Use of a 21-gauge micropuncture needle decreases
the size of the hole by 56% over a standard 18-gauge needle
and decreases flow through the hole nearly 6-fold, resulting in
decreased risk of complications from errant sticks or inad-
vertent back wall punctures.17 However, at present there is no
clear evidence to suggest that routine use of micropuncture
will reduce the risk of femoral access site complications.
A micropuncture kit includes a 21-gauge needle, an 0.018-
inch stainless steel guidewire with soft flexible tapered tip,
and a 4F micropuncture sheath with dilator for initial access.
The femoral artery is entered with the use of the 21-gauge
needle. After blood flow from the hub is ensured, a floppy-
tipped 0.018-inch guidewire is then threaded, followed by
removal of the needle. Of note, the backflow of blood from
the hub might not be as pulsatile as that seen with an
18-gauge needle because the resistance to flow is inversely
proportional to the fourth power of the radius (Poiseuille’s
law). Some operators verify the position of the tip of the
needle under fluoroscopy at this stage. If the tip appears to be
too high or low, the needle could be removed at this stage,
with manual compression held for 5 minutes and a repeat
attempt at femoral arterial access done after the position is
adjusted. Once the needle is in an acceptable position, a
floppy-tipped 0.018-inch guidewire is then threaded (usually
under fluoroscopic guidance), followed by removal of the
needle. A 4F short catheter with 3F inner dilator is placed
 Bangalore and Bhatt
over the existing wire, followed by removal of the dilator and
wire. Then, an appropriately sized wire (0.035 inch) can be
placed through the 4F catheter with subsequent upsizing to a
desired sheath size.
Femoral Arterial Cannulation With a SmartNeedle
The SmartNeedle (Vascular Solutions, Minneapolis, MN) is a
flow needle attached to a Doppler probe, which can be used
in patients with pulses that are difficult to palpate (eg, altered
anatomy, scarring due to multiple procedures, obese patients,
severe aortic stenosis with pulsus parvus, patients in cardio-
genic shock, or patients with PAD). The needle is connected
to a hand-held monitor wrapped in a sterile sleeve. The needle
is advanced through the skin while the operator listens to the
Doppler signal. When the needle approaches the artery, the
Doppler signal becomes louder, assisting in femoral arterial
cannulation. The pulsatile sound from the artery as it is
approached is distinct from the vein. Once the needle enters
the artery, pulsatile blood flow should be ensured, and the rest
of the procedure is as described previously. The efficacy and
safety of using the SmartNeedle for venous cannulation have
been established.18 However, the data for femoral arterial
access are limited. Blank et al,19 in a study of 114 patients
undergoing coronary angiography, found that compared with
a standard needle, the SmartNeedle resulted in successful
femoral arterial cannulation on the first attempt in 100% of
cases, whereas ⬎1 attempt was needed in 72% of cases when
the standard needle was used. SmartNeedle use was also
associated with a reduction in the risk of any hematoma (25%
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versus 46%) or hematomas ⬎5 cm (14% versus 28%)
compared with the standard needle.
Femoral Arterial Cannulation in Patients With
Iliofemoral Bypass Grafts
In patients with PAD and iliofemoral bypass grafts, access via
the nongrafted side (if the graft is unilateral) or radial side (if
bilateral) is desirable. In cases in which femoral access is
desirable, a micropuncture needle is preferred, and the needle
should be directed to the hub of the graft. After backflow of
blood is ensured, the micropuncture guidewire should be
advanced under fluoroscopy. In cases in which the guidewire
enters the native artery and fails to advance beyond a stenosis,
the needle should be exchanged for the 4F micropuncture
sheath, and a femoral angiogram should be performed to
roadmap the native and the bypass graft course. Depending
on the angiogram, the wire can be directed into the graft, or
if the arteriotomy site is cranial, the sheath can be removed
and the area manually compressed and reaccessed at the
desired position. In most cases of graft access, it is recom-
mended to achieve vascular closure via manual compression,
and vascular closure devices should usually be avoided.
Vascular Closure
Manual Compression
Worldwide, manual compression is the most commonly used
technique to achieve hemostasis after removal of a femoral
arterial sheath. The femoral arterial sheath should be left in
for the least amount of time after angiography because the
risk of thrombotic vascular complications as well as bleeding
Vascular Access and Closure e151
increases with the duration the sheath is left in place. As such,
the sheath should be removed immediately after diagnostic
procedures (if no anticoagulation is used). When anticoagu-
lants are used for the procedure, the sheath should be
removed when the activated clotting time is ⬍150 to 160
seconds or the partial thromboplastin time is ⬍45 seconds
(when heparin is used), 2 hours after bivalirudin is stopped, 6
to 8 hours after the last enoxaparin dose, or when the
fibrinogen level is ⬎150 mg/dL when fibrinolytics are used.
If the patient is on warfarin and the international normalized
ratio is ⬎2.0, consideration must be given to using a closure
device or using fresh frozen plasma before sheath removal
(although with a radial artery approach, the situation may
have been avoided). Before the arterial sheath is removed, the
following checklist must be reviewed to ensure comfort both
for the patient and for the operator doing manual compres-
sion. The patient should be moved closer to the side edge of
the bed next to the operator removing the sheath (to prevent
the operator having to reach over and strain the back), the bed
should be lowered to levels that would be comfortable for the
operator, the patient should be connected to a monitor to
assess heart rate (continuously) and blood pressure (initially
every 2 minutes), the blood pressure should be treated if too
high, and the nurse monitoring the patient should be informed
of the procedure and ready with medications in case of a
vasovagal reaction.
Under sterile precautions, the sutures holding the sheath in
place are removed, and the sheath is allowed to bleed back
briefly to expel any thrombus. The artery is then palpated
from the skin nick cranially with the use of 3 fingers
(preferably fingertips). With gentle pressure over the artery
with the fingertips of 1 hand, the sheath is removed with the
other, allowing for back bleeding at the skin incision site to
flush out any remaining thrombus. Manual compression is
then applied with the fingertips with the 3-finger approach
from the skin nick proximally along the length of the artery
while the distal pulse is preserved (checked every few
minutes). Alternately, a rolled gauge can be placed along the
length of the artery and pressure applied to it with the palm of
the hand, with the operator leaning forward and using his/her
upper body weight to transmit force. The duration of com-
pression varies with the French size of the catheter (a rough
rule is for each 1F to hold for 5 minutes). The pressure should
be reduced during the last 5 minutes of compression to 25%
of initial pressure. Once hemostasis is achieved, the distal
pulse is palpated to ensure adequate limb perfusion. If the
patient has both an arterial and a venous sheath, the arterial
sheath should be removed first and the venous sheath re-
moved 5 minutes later. This technique avoids the risk of
arteriovenous fistula formation and also preserves a venous
access for medication administration in case of a vasovagal
reaction. After the sheaths are removed, the site is cleaned
with an antiseptic solution and covered with a small trans-
parent dressing. Opaque dressings and large dressings should
be avoided because they might mask bleeding and hematoma
formation. Historically, advice on bed rest has depended on
the size of the sheath, with the corresponding leg straight for
a minimum of 1 hour for each French size of the arterial
sheath (eg, 10F⫽10 hours). However, the adequate duration
 e152 Circulation August 2, 2011
Table 2. Vascular Closure Device Classification
Active Approximators Passive Approximators
Angio-Seal (St Jude Medical, Inc, Boomerang (Cardiva Medical,
St Paul, MN) Mountain View, CA)
AngioLink (Medtronic CardioVascular, Duett (Vascular Solutions, Inc,
Santa Rosa, CA) Minneapolis, MN)
FISH (Morris Innovative Research, Mynx (AccessClosure,
Bloomington, IN) Mountain View, CA)
Perclose (Abbott Vascular, Santa VasoSeal (Datascope Corp,
Clara, CA) Montvale, NJ)
Starclose (Abbott Vascular, Santa
Clara, CA)
SuperStitch (Sutura, Inc, Fountain
Valley, CA)
Only Food and Drug Administration–approved devices are listed.
of bed rest after sheath removal appears to be decreasing, and,
in certain settings, ambulation as early as 1 hour after removal of
a 5F sheath20,21 or 1.5 hours after removal of a 6F sheath22,23 has
been shown to be safe.
The advantages of manual compression are that it is
associated with the lowest vascular complication rate, as
shown in numerous studies. The disadvantages are discomfort
associated with sheath removal; inability to tolerate pro-
longed supine position due to a variety of comorbid condi-
tions (eg, spinal stenosis, chronic low back pain, congestion
heart failure, severe chronic obstructive pulmonary disease,
severe valvular disease); longer duration of time to ambula-
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tion; and potentially increased time to hospital discharge.
Vascular Closure Device
Vascular closure devices (VCD) have emerged as an effective
alternative to traditional mechanical compression after an-
giography since their introduction. The data on efficacy and
safety of these devices are controversial. A number of
meta-analyses and randomized and nonrandomized studies
have shown variable results. Some studies have shown
efficacy equivalent to that of manual compression,24,25 and a
few have shown superiority of these devices to manual
compression.26 –29 However, other studies have expressed
concern about an increased risk of complications with these
devices.30 –36 Concerns also exist regarding excess vascular
inflammation and scarring associated with VCDs. Neverthe-
less, these devices have the potential to reduce the time to
hemostasis, facilitate early patient mobilization, decrease
hospital length of stay (if same-day discharge is adopted for
percutaneous coronary interventions), and improve patient
satisfaction.28,37– 42
The commonly available VCDs are listed in Table 2. VCDs
are classified as follows17: (1) active approximators, in which
the device actively approximates the arteriotomy site such as
use of anchor and collagen plug (Angio-Seal), suture (Per-
close), or a nitinol clip (Starclose), versus passive approxi-
mators, in which the arteriotomy is sealed passively by using
either a sealant (gel foam) or thrombin, which facilitates clot
formation; (2) foreign body versus none, based on whether a
foreign body (suture, clip, sealant, anchor, plug) is left behind
in the body; (3) extraluminal, in which there is no foreign
body left inside the artery, versus intraluminal, in which a
foreign body is left inside the artery; and (4) temporary, in
which the foreign body gets absorbed over a period of time,
versus permanent, in which it stays permanently.
A variety of assisted compression devices are available that
can help to achieve hemostasis noninvasively or are used as
an adjunct to manual compression. These include mechanical
compression devices such as the FemoStop and the RadiStop
(Radi Medical System, Uppsala, Sweden) and various topical
hemostasis pads and patches such as the Chito-Seal (Abbott
Vascular, Santa Clara, CA), V⫹Pad (Angiotech Interven-
tional, Chicago, IL), Syvek Patch (Marine Polymer Technol-
ogies, Danvers, MA), SafeSeal (Medrad Interventional/Pos-
sis, Pittsburgh, PA), and D-Stat (Vascular Solutions, Inc,
Osseo, MN).
We will discuss the 3 commonly used VCDs: the collagen
plug– based (Angio-Seal), the suture-based (Perclose), and
the nitinol clip– based (Starclose) devices.
Contraindications/Caution for Using a Vascular
Closure Device
Although there is no absolute contraindication for the use of
VCD (except perhaps allergic reaction to any of its compo-
nents), the following conditions should warrant consideration
for an alternate strategy. These include low punctures at the
bifurcation or in the superficial femoral or the profunda
femoris artery (increased risk of ischemic complications);
high puncture above the level of the inferior epigastric artery
(2.8 times the risk of retroperitoneal hemorrhage)17; patients
with moderate to severe PAD at the site of sheath entry
(increased risk of ischemic complications); patients with
small (⬍4 to 5 mm) femoral artery caliber (increased risk of
ischemic complications); patients with diabetes mellitus and
other immunodeficiency (increased risk of infection); and
patients who have known allergies to beef products, collagen,
collagen products, or polyglycolic or polylactic acid polymers
(for the Angio-Seal device).
Angio-Seal Insertion Technique
Angio-Seal (St Jude Medical, St Paul, MN) is an anchor/
collagen plug– based active approximator and is the most
commonly used VCD in the United States. It involves a short
learning curve and has the highest success rate of all the
VCDs. It achieves hemostasis by active approximation with
the use of an intravascular anchor and a collagen plug
sandwich. The intravascular anchor usually resorbs in 3
months. The disadvantage of this device is the presence of the
intravascular anchor, which can cause ischemic complica-
tions in small femoral arteries or in rare cases of anchor
embolization. The intravascular anchor, the collagen plug,
and the suture that holds the 2 together extend into the tissue
tract, serving as nidus for infection. It can be used only for
sheath size ⱕ8F.
The Angio-Seal device consists of (1) a delivery device
composed of a biodegradable anchor and a collagen plug; (2)
an insertion sheath and arteriotomy locator, which is a
modified dilator; and (3) a 0.035- or 0.038-inch 70-cm J-tip
guidewire. A femoral angiogram should be obtained before
the procedure to ensure that there are no contraindications (as
 Bangalore and Bhatt
Figure 2. Angio-Seal deployment technique. A, Locate the arteriotomy site; B, set the anchor at the arteriotomy site; and C, seal the
site with the collagen plug. (Angio-Seal is a trademark of St Jude Medical. Reprinted with permission from St. Jude Medical, © 2009;
all rights reserved.)
discussed above). Routine regloving of and reprepping of the
area before VCD insertion may potentially reduce the risk of
infection. Before the sheath is removed, it should be flushed
and free of thrombus. The Angio-Seal device comes in 2
sizes, 6F or 8F, depending on the size of the femoral arterial
sheath used. The arteriotomy locator is inserted into the
insertion sheath until the 2 pieces snap securely together
Downloaded from http://ahajournals.org by on July 24, 2020
(Figure 2). The J-tip guidewire is inserted through the femoral
arterial sheath, and the sheath is removed over the guidewire,
ensuring adequate guidewire length inside the artery. The
insertion sheath with arteriotomy locator is then loaded onto
the guidewire and advanced until pulsatile flow is observed
from the arteriotomy locator (Figure 2A). Some operators
then withdraw the assembly until blood slows or stops from
the drip hole and then readvance until pulsatile flow is again
noticed, at which point the distal tip is just distal to the
arteriotomy site. The insertion sheath is then stabilized with
one hand while the arteriotomy locator and guidewire are
removed with the other by flexing it upward. The insertion
sheath is then held steady, and the delivery device is inserted
into it by holding the bypass tube, ensuring that the reference
indicators of the insertion sheath and the delivery device are
facing upward. The delivery device is advanced until it snaps
into the insertion device. The insertion sheath is then held
steady while the device cap is pulled back until it assumes a
fully rear-locked position. This deploys the anchor. The
assembly is withdrawn until the anchor is up against the
arterial wall, at which time the collagen plug is also deployed,
and a tamper tube now becomes visible (Figure 2B). The
assembly back is held, and the tamper tube is pushed down
while the operator pulls back on the assembly at the same
time (Figure 2C). A clear stop is exposed on the suture, and
in most cases a black compaction marker is seen beyond it.
The suture is then cut below the clear stop, and the tamper
tube is removed. The remainder of the suture is then cut,
going in below the skin level as close to the knot as possible.
A sterile dressing is applied to the site. Reaccess at the site of
Vascular Access and Closure e153
Angio-Seal deployment should be done ⬎90 days after the
procedure (to allow the anchor and the suture to be absorbed).
However, reaccess within 90 days can be performed safely 1
cm proximal to the prior arteriotomy site.43
Perclose Deployment Technique
The Perclose device (Abbott Vascular, Santa Clara, CA) is a
suture-based active approximator that mimics a surgical
suture. It involves a higher learning curve, has been shown to
have a higher failure rate,44,45 and results in a longer time to
achieve hemostasis than the collagen plug– based (Angio-
Seal) device.45 The device leaves behind a suture and hence
could be a nidus for infection. The reported infection rate
(⬇0.3%)46 is comparable to that with Angio-Seal device.
The device consists of the (1) delivery device consisting of
a biodegradable pretied suture; (2) snared knot pusher; and
(3) suture trimmer. After a femoral angiogram to ensure that
a closable arteriotomy site is obtained, a 0.035-inch J-tipped
guidewire is inserted through the femoral artery sheath. The
sheath is then removed over the guidewire. The Perclose
device is then inserted over the guidewire until the guidewire
exit port is at the skin level. The guidewire is then removed,
and the device is advanced until pulsatile blood flow is seen
from the marker lumen (Figure 3A). The device is then
deployed in 4 steps (Figure 3A) as follows. In step 1, the lever
is lifted up to deploy the foot plate inside the artery, and the
device is pulled back slowly until resistance is felt when the
foot is up against the arterial wall. The pulsatile flow through
the marker slows and ceases. In step 2, with the device held
steady with 1 hand, the plunger is depressed, which deploys
the needles. In step 3, with the device held steady with 1
hand, the plunger is retracted to retrieve the suture and is
pulled back until the suture is taut. At this stage, the plunger
is freed by cutting the suture with the use of the quick cut or
a sterile scissor. In step 4, the back tension on the device is
reduced, and the foot lever is returned to the nondeployed
position. The device is now withdrawn until the guidewire
 e154 Circulation August 2, 2011
Figure 3. Perclose deployment technique. A, Position the
device at the arteriotomy site; B, use the snared knot pusher for
deployment of the suture. (Perclose is a trademark of Abbott
Vascular. Reprinted with permission from Abbott Vascular,
© 2009; all rights reserved.)
Downloaded from http://ahajournals.org by on July 24, 2020
exit port is at a slight distance from the skin level. At this
point, there should be minimal bleeding around the device,
unless the arteriotomy is in fact larger than the diameter of the
device, which does not bode well for successful hemostasis.
If hemostasis is critical, the guidewire can be readvanced
through the device at this stage; if the device fails, another
sheath can be placed. Next, the 2 suture ends are removed
from the device, and the blue rail suture limb is loaded onto
the snare knot pusher. The blue rail limb is then wrapped
on the forefinger of the left hand, with gentle traction applied.
The Perclose device can now be removed from the body.
Back tension is maintained on the blue rail limb, and the knot
pusher is advanced into the skin tract parallel to the suture
limb. If the wire was left in place, it should be removed before
the knot is cinched. The knot pusher is then pushed forward
while back tension on the rail limb is maintained, until the
knot pusher stops against the anterior wall of the artery
(Figure 3B). The white nonrail suture limb is then tightened.
Wetting the sutures with saline can help the knot to go down
the tract with ease. The knot trimmer is then loaded onto both
suture limbs while the operator keeps tension on the limbs. It
is then advanced all the way down to the knot, and the knot
is trimmed by pulling back on the red trimming lever. The cut
sutures are removed, and the site is inspected for hemostasis.
The artery is palpated for an arterial pulse distal to the suture
site. A small transparent sterile dressing is applied to the site.
There is no reaccess restriction after the use of this device.
For larger devices, such as stent grafts or percutaneous
valves, the technique of “preclosure” before sheath placement
can be very useful.47
Figure 4. Starclose deployment technique. A, Insert the clip
applier flex guide into the sheath hub and advance until a click
is heard; B, sheath splitting. (Starclose is a trademark of Abbott
Vascular. Reprinted with permission from Abbott Vascular,
© 2009; all rights reserved.)
Starclose Deployment Technique
The Starclose device (Abbott Vascular, Santa Clara, CA) is a
nitinol clip– based active approximator that is extraluminal.
The advantage of this device is the shorter learning curve
compared with Perclose and the extraluminal nature of the clip,
which potentially decreases ischemic vascular complications.
The Starclose device consists of the (1) clip applicator; (2)
delivery sheath; (3) dilator; and (4) 0.035-inch J-tip guide-
wire. After obtaining a femoral angiogram to ensure a
“closable” arteriotomy site, the skin tract is enlarged with a
curved tip forceps adequate to allow delivery of the bulky
shaft of the Starclose device. The dilator is inserted into the
Starclose delivery sheath (Figure 4A). The 0.035-inch J-tip
guidewire is inserted through the femoral artery sheath, which
is exchanged for a Starclose delivery sheath. The guidewire
and the dilator are removed. The clip applier is then loaded
into the sheath until a click is heard at the hub of the sheath
(Figure 4A). The assembly is then retracted by 3 to 4 cm, and
the plunger is depressed to deploy the locator wings. The
sheath is then split partially, and the device is lowered into the
tract to ensure deliverability of the device. The device is then
stabilized with the left hand and is retracted until a resistance
is felt when the locator wings are up against the arterial wall.
With the device at a 45° angle, the sheath is split all the way
down to the artery until a click is heard (Figure 4B). The clip
applier is stabilized with the left hand and is raised to a 60°
to 75° angle. The assembly is then gently pressed down until
 Bangalore and Bhatt
arterial pulsations are felt. With gentle downward pressure,
the clip is deployed, maintaining downward pressure for 2 to
3 seconds. The tissue around the clip applier is depressed with
the left hand, the clip applier is removed, and pressure is held
for several seconds. A sterile dressing is applied to the site.
Similar to the Perclose device, there is no reaccess restriction
after use of this device, although this has not been well tested.
Venous Closure
The Perclose and Starclose devices can also be used as
closure devices for veins (not approved by the Food and Drug
Administration). The technique is similar to arterial closure
except that care should be taken not to apply too much back
tension, which can tear the thin venous wall. Routine use of
closure devices for the femoral vein is not recommended but
may be considered in certain cases, such as after fibrinolytic
therapy.
Conclusions
Vascular complications are the most common complication
during either diagnostic or interventional procedures. Preven-
tion of vascular complications starts with good “access
hygiene,” which involves review of prior femoral angiograms
(when available), routine use of fluoroscopy to aid access, use
of smaller catheters (4F to 5F for diagnostic catheterization),
and prompt removal of sheaths whenever possible. VCDs are
now increasingly utilized for arterial closure and have been
shown to considerably reduce the time to hemostasis and time
to ambulation, improve patient satisfaction, and reduce length
Downloaded from http://ahajournals.org by on July 24, 2020
of stay (if same-day discharge is implemented). However, the
vascular complication rate is still high, and strategies like
radial access show promise for reducing this risk (up to 73%
reduction in major bleeding).1,48,49 Recent randomized trials
such as the Radial Versus Femoral Artery Access Site Study
(RIVAL) will help to determine whether routine radial
artery cannulation is superior to femoral arterial access.50
Regardless, femoral access will remain an important skill
for physicians performing cardiovascular diagnostic and
therapeutic procedures.
Acknowledgments
We would like to thank the nurses in the Veterans Affairs Boston
Catheterization Laboratory who helped with the filming of the
cases: Diane Lapsley, RN, Scott Sandstrum RN, and Kimberly
Shattuck, RN.
Disclosures
Dr Bangalore has no relevant disclosures. Dr Bhatt discloses the
following: research grants from AstraZeneca, Bristol-Myers Squibb,
Eisai, Sanofi Aventis, and The Medicines Company.
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KEY WORDS: angiography 䡲 intervention 䡲 percutaneous coronary
intervention 䡲 percutaneous procedures