Venous access closure using a purse‐string suture without heparin antagonism or additional compression after MitraClip implantation

Abstract

ObjectivesThis observational study was designed to analyze the safety and feasibility of percutaneous skin closure using a purse‐string suture (PSS) after MitraClip procedures.MethodsForty‐one consecutive patients with severe mitral regurgitation who underwent MitraClip implantation from February 2018 to January 2019 at our institution received a PSS after percutaneous mitral valve repair before withdrawal of the 24‐French (Fr) sheath. Protamine was not administered after venous closure at procedure end. No compression therapy (e.g., compression bandage or pneumatic compression device) was used. Patients were on bed rest for 6 hrs prior to suture removal, which was accomplished 18–24 hrs after MitraClip implantation. We analyzed the occurrence of any vascular or thromboembolic complications during the hospital stay and until the 3‐month follow‐up.ResultsThe primary endpoint—any access‐related major complication—did not occur in any patients. None of the patients revealed a pseudoaneurysm or an arteriovenous fistula, a thromboembolic complication, or local stenosis related to the PSS closure. The secondary endpoint— minor access‐site vascular complications (hematoma)— was documented in six (14.6%) patients.ConclusionsVenous access‐site closure with a PSS without the need for protamine administration or compression therapy appears to be safe and feasible in patients undergoing MitraClip implantation with access via a 24‐Fr sheath.

New approaches to achieving hemostasis after venous access in cardiovascular patients

“…No difference was found regarding hematomas <5 cm (13.6% vs. 11.5%, P = 0.39) or >5 cm (8.7% vs. 7.8%; P = 0.69), arterio-venous fistulas (3.9% vs. 2.2%; P = 0.22), or pseudoaneurysm (0.87% vs. 7.8%; P = 0.69) [33]. Another study by Akkaya et al [23] reported that venous access site closure with a purse-string suture without the use of protamine or compression appears to be safe and feasible in patients undergoing mitral valve repair with MitraClip (Abbott Vascular, Santa Clara, CA, US) implantation using a 24 F caliber venous sheath. Similarly, Kypta et al [22] favored the safety of subcutaneous double purse-string sutures in patients on anticoagulation undergoing leadless pacemaker implantation using sheaths with 18-23 F internal diameter, and 27 F outer diameter.…”

“…Multiple studies have established the efficacy and safety of the suture techniques, particularly FO8, even after procedures involving multiple femoral venous accesses with up to 24 F caliber sheaths. Suture techniques offer immediate hemostasis with comparable venous access complication rate to manual compression [5,8,16,22,23,25,32,33].…”

“…The running stitch circles the sheath in such a way that when the ends are pulled, subcutaneous tissue is compressed to pressure on the puncture site (Figure 1B). The purse-string has been applied in a few studies using sheaths up to 24 F. It shows significant advantages compared to manual compression with a magnitude of difference similar to that of the FO8 [22,23,33,40]. The randomized GITAR study involving ablations for AF using 8.5-15 F venous sheaths in presence of anticoagulant reported that the average time required to achieve hemostasis was significantly reduced (0.45 ± 2.0 minutes vs. 10.44 ± 2.2 minutes; P <0.001) in the purse-string group than manual compression group, respectively.…”

“…The trend towards large-caliber sheaths and the use of uninterrupted anticoagulation often prolong the manual compression process and undermine its effectiveness even further [6][7][8][9][10][11]. Alternative approaches to achieving an immediate and safe venous access site hemostasis are becoming increasingly important and include subcutaneous suture techniques and vascular closure devices [5][6][7][8][22][23][24][25][26].…”

The “Woggle” Technique for Venous Access Site Management: An Old Technique for a New Need

“…Achieving hemostasis in venous access is similar to arterial district and can be achieved by different approaches (e.g., manual compression, mechanical external compression, and dedicated devices). However, only in the case of venous access, some studies reported purse-string suture as a valid alternative even in large bore [ 2 ]. Although very effective, the suture can be difficult to remove if the knot becomes buried in tissues narrowing the puncture sites, which may be puckered.…”