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1、Peripheral vessel: mechanical or chemical closure,Cardiovascular Interventional laboratoratory, San Donato Milanese Hospital, Milano Director Prof. Luigi Inglese Nadia Mollichelli,June 14th MEET 2007. Multidisciplinary European Endovascular therapy,Manual compression: the gold standard,Seldinger tec
2、hnique, introduced in 1951, obtained the hemostasis at the end of the procedure by manual pressure for 10-15 minutes, followed by 6-8 hours of bed rest, in patients with normal coagulation parameters. Seldinger SI. Catheter placement of needles in percutaneous arteriography; a new technique. Acta Ra
3、diol 1953; 39: 368-76.,Later on the introduction of mechanical methods as Femostop, Compressar or Clamp easy facilitated the problem of manual compression but didnt reduce the time of patient bed rest and the rate of hematoma formation.,Mechanical compression,Vascular closure device,The new interven
4、tional tecniques have increased the use of new devices that require large sheaths, periprocedural anticoagulation and most important double antiplatelet therapy with a consequent increase in the access site related complication of up to 17%. Waksman et Al. Predictors of groin complication after ball
5、oon and new device coronary intervention. Am J Cardiol 1995; 75: 886-889.,Ideal closure device,Easy device application High successful rate with short time to hemostasis Low rates of complications Possibility of repeated vascular access,Available closure devices and their mechanisms of action,Major
6、complications of VCD,Hematoma requiring trasfusion or surgery Pseudoaneurysm Arteriovenous fistula Retroperitoneal hematoma Femoral artery thrombosis Access site infection Device embolization Failure,Predictors of vascular complications,Age and Gender Severe PVD Diabetes Sheath size Final ACT level
7、Peri PCI pharmacotherapy (thrombolitics, GP IIb/IIIa inhibitors) Multiple arterial puncture attempts Operator learning curve,AngioSeal,The AngioSeal device was introduced in Europe 1994. It consists of an anchor, a collagen plug, and a suture. The biodegradable collagen plug induces platelet activat
8、ion and aggregation, and releases coagulation factors. AngioSeal produces a sandwich closure of the arteriotomy site between the anchor and collagen plug,Co-polymer Anchor,Collagen Sponge,Suture,AngioSeal: hemostasis mechanisms,PRIMARY MECHANISM MECHANICAL: Anchor-Collagen Arteriotomy Sandwich,SECON
9、DARY MECHANISM BIOCHEMICAL: Coagulation-inducing Properties of Collagen,Internal components of AngioSeal,Anchor: inside the artery, smooth, tapered dome shape, blend of lactide and glycolide polymers. Non thrombogenic. Breakdown via hydrolisis in less than 90 days.,Collagen: bovine collagen, which i
10、s pressed on the outer surface of the artery. Break down through leukocytosis in less than 90 days,Suture: polyglicolic acid. Break down via hydrolisis, significant absorption at 30 days, complete in 60-90 days,AngioSeal deployment: step 1,Thread the arteriotomy locator/insertion sheath assembly ove
11、r the guidewire When blood begins to flow from the proximal drip hole the insertion sheath is in the artery The dilatator/sheath combination is withdrawn until flow ceases and then reinserted 1-2 cm.,The locator system is removed and the AngioSeal carrier tube is introduced through the hemostatic va
12、lve Gently pullback on AngioSeal device cap until resistance felt,which deploys the anchor,AngioSeal deployment:step 2,Once the Device Cap is locked into rear position, fully withdraw device sheath assembly until resistance is felt, which indicates that the anchor is against the inner arterial wall.
13、 Grip Tamper Tube and slide it down to advance knot and collagen to the artery, while maintaining upward tension on suture. A marker on the suture indicates adequate depth,AngioSeal deployment: step 3,Angiography of the femoral artery access site,The routine use of a femoral angiogram through the or
14、iginal procedure sheath prior to puncture closure with a closure device can prevent complications associated with sub-optimal vascular access, unrecognized peripheral vascular disease, small diameter vessels and other anatomical variants,Femoral puncture close to the biforcation Collagen in arterial
15、 lumen, high risk of thrombosis,High FA biforcation,Artery diameter,AngioSeal is controindicated if the artery diameter is less than 4mm because the anchor cannot deploy.,Femoral puncture close to a plaque No perfect anchor adherence, collagen in arterial lumen, high risk of thrombosis,Disadvantages
16、 of the collagen plug,Potential risk of local infection in delayed closure Repeat puncture of the artery within 3 months is not recommended because of the theoretical possibility of disrupting or disloging the hemostatic plug. Applegate showed that restick of the artery in which Angioseal device has been deployed 90 days can be performed safely 1 cm above or below the original stick. Cathet Cardiovasc Intervent 2003; 58: 181-84.,Studies investigating AngioSeal vascular closure devices,
