Residency · Residency · Interventional Radiology

Closure Devices and Hemostasis

Manual Compression

Technique

Manual compression involves applying direct pressure over the arteriotomy site -- not the skin puncture, which may be more caudal due to the needle angle. Compression is typically held for 15 to 20 minutes for diagnostic cases (4-5 Fr) and 20 to 30 minutes for interventional cases (6-8 Fr). The distal pulse should be maintained during compression to avoid thrombosis. Post-compression bed rest ranges from 2 to 6 hours depending on sheath size and anticoagulation status.

Advantages

Manual compression has no device cost, carries no risk of device-related complications, and is applicable to all patients regardless of anatomy.

Disadvantages

The approach requires prolonged compression time and bed rest, is staff-intensive, causes patient discomfort, and in some studies has higher hematoma rates compared with closure devices.

Vascular Closure Devices (VCDs)

Collagen Plug-Based: Angio-Seal

Mechanism

The Angio-Seal works through a sandwich mechanism. An intravascular anchor made of bioabsorbable polymer is deployed inside the artery, while a collagen plug seals the arteriotomy from outside. A suture connects the two components. All components resorb within 60 to 90 days.

Technique

The operator inserts the locator over the wire and confirms arterial blood flow through the side port. The device is then advanced, the anchor is deployed, and the operator pulls back to the arterial wall before deploying the collagen plug. The suture is cut flush with the skin.

Sizes

The Angio-Seal is available in 6 Fr and 8 Fr platforms.

Contraindications

Contraindications include a CFA diameter less than 5 mm, significant anterior wall calcification at the puncture site, puncture into the SFA, PFA, or bifurcation, a prior closure device at the same site within 90 days, active infection at the access site, and severe peripheral arterial disease at the access site.

Suture-Mediated: Perclose ProGlide

Mechanism

The Perclose ProGlide deploys sutures percutaneously to close the arteriotomy with a knot. It can also be used in a "preclose" technique for large-bore access, such as TAVR or EVAR.

Technique

The device is deployed at a 45-degree angle to the skin, and blood flow is confirmed in the marker lumen. The needles are deployed, the suture is captured, and the device is withdrawn. The knot is then tied down to close the arteriotomy. For the preclose technique, two Perclose devices are deployed at 10 and 2 o'clock orientations before upsizing. The sutures are tied after sheath removal at the end of the procedure.

Sizes

The Perclose accommodates access sizes from 5 to 21 Fr (with the preclose technique for large-bore access).

Extravascular Plug: Mynx

Mechanism

The Mynx deploys a polyethylene glycol (PEG) sealant in the tissue tract outside the artery. The PEG expands upon contact with moisture, creating a plug. There is no intravascular component.

Advantages

The Mynx can be used in scarred groins and near the bifurcation, and it leaves no intravascular foreign body.

Disadvantages

It requires adequate tissue tract depth and is less effective in anticoagulated patients.

Other Devices

The MANTA is a large-bore closure device (10-25 Fr) using a collagen plug with intravascular toggle, increasingly used for TAVR and large-bore endovascular procedures. The StarClose deploys a nitinol clip on the adventitia and is less commonly used. The FemoSeal uses an absorbable anchor and plug system.

Closure Device Comparison

Evidence and Controversies

Time to Ambulation

Multiple randomized controlled trials demonstrate reduced time to ambulation with VCDs compared to manual compression (1-2 hours versus 4-6 hours). Early ambulation improves patient satisfaction and reduces hospital length of stay.

Complication Rates

Meta-analyses show mixed results regarding complication rates. Some studies show reduced complication rates with VCDs while others show equivalent rates to manual compression. VCDs may shift the type of complication -- resulting in less hematoma but introducing the potential for device-related complications like arterial occlusion, distal embolization, or infection. The ISAR-CLOSURE trial found no significant difference in vascular complications between VCDs and manual compression.

Controversial Areas

Several areas remain controversial: the use of VCDs in patients on therapeutic anticoagulation (with increasing evidence supporting safety), closure devices in antegrade punctures (off-label for most devices), the reliability of the preclose technique for large-bore access versus surgical cutdown, repeat closure at the same site (most devices require a minimum 90-day interval), and use in SFA or non-CFA puncture sites (generally contraindicated).

Special Scenarios

Anticoagulated Patients

VCDs can be used with caution in anticoagulated patients, and protamine reversal of heparin may not be necessary. Device selection based on mechanism may be important, as suture-mediated devices may be more effective than collagen-based ones in anticoagulated patients.

Obese Patients

In obese patients, operators should ensure adequate tract length for plug-based devices and use ultrasound to confirm CFA puncture location before deploying a VCD.

Calcified Arteries

Anterior wall calcification may prevent proper anchor deployment (Angio-Seal) or suture deployment (Perclose). Manual compression or Mynx may be safer options in these cases.

Failed Closure Device

If a VCD fails, manual compression should be applied immediately. If active bleeding persists, options include a covered stent, ultrasound-guided thrombin injection, or surgical repair. A second closure device should not be attempted at the same site in the same session.

<image>Step-by-step illustration of Angio-Seal vascular closure device deployment. Four sequential panels: (1) Locator inserted with arterial blood return from the side port; (2) Intravascular anchor deployed and pulled back against the inner arterial wall; (3) Collagen plug advanced to the outer arterial wall; (4) Completed seal showing the anchor inside the artery, collagen plug outside, and connecting suture, with the arteriotomy sandwiched between the two components.</image>

<image>Illustration of the Perclose ProGlide preclose technique for large-bore access. Four panels: (1) Two ProGlide devices deployed at 10 and 2 o'clock positions with sutures left loose; (2) Wire maintained and access upsized to large-bore sheath; (3) After procedure completion, large sheath removed over a wire; (4) Previously placed sutures tied down sequentially to close the arteriotomy, with final result showing a sealed access site.</image>

<image>Cross-sectional anatomical illustration comparing three closure device mechanisms at the common femoral artery: (A) Angio-Seal with intravascular anchor and extravascular collagen plug; (B) Perclose suture-mediated closure with sutures tied at the arterial wall; (C) Mynx extravascular PEG sealant plug in the tissue tract with no intravascular component. Each shows the relationship to the arterial wall, subcutaneous tissue, and skin.</image>

Clinical Pearls

VCD deployment requires proper CFA puncture confirmed by fluoroscopy -- the puncture must be over the femoral head. Closure devices should never be deployed in the SFA, PFA, or external iliac artery. Before deploying any VCD, the operator should check for contraindications including vessel size, calcification, puncture location, and prior device history.

The preclose technique with Perclose ProGlide is the standard approach for large-bore access, such as TAVR and EVAR with sheaths larger than 12 Fr. If a VCD fails, manual compression should be applied immediately with a low threshold for ultrasound evaluation. All operators should maintain familiarity with manual compression, as it remains the fallback for all access site hemostasis. Documenting the closure device used, lot number, and any complications is important for follow-up and future access planning.

References

• Defined Practice Standards: SIR Clinical Practice Guidelines on Arterial Access Site Management, JVIR, 2020
• ISAR-CLOSURE Trial (JACC Cardiovasc Interv 2010): VCD vs. manual compression complications
• Defined by meta-analyses by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Defined by Robertson et al., J Vasc Surg 2016 -- VCD safety and efficacy
• Defined by Defined by Defined by MANTA device pivotal trial data (EuroIntervention 2020)
• Defined by Defined by Manufacturer IFU for Angio-Seal, Perclose ProGlide, and Mynx for device-specific contraindications

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