Novel Approach in Percutaneous Large-Bore Arteriotomy Closure: Manta With Angiographic Guidance

We present two cases of percutaneous closure of an Impella CP (Abiomed) and venoarterial extracorporeal membrane oxygenation (VA-ECMO), respectively, with the use of a Manta vascular closure device (VCD) (Teleflex) and angiogram-guided measurement of skin-to-arteriotomy distance, which is shown to be simple, safe, effective, and time- and manpower-saving.

History of Presentation, Investigation, and Management

This article describes two cases of acute myocardial infarction with cardiogenic shock. The first patient required Impella CP support, while the second patient required a combination of VA-ECMO and Impella CP. The cardiac function of both patients recovered after a staged percutaneous coronary intervention (PCI) was completed several days after the first procedure. Thus, weaning of the Impella CP in the first patient and VA-ECMO in the second patient was planned.

Procedure #1 – Removal of Impella CP Using a 14 French Manta

Measurement

1. A vascular access used for PCI was already in place, contralateral to that used for the Impella. This vascular access serves as: (A) a portal for contrast injection and angiographic measurement; (B) a portal for post-closure evaluation by digital subtraction angiogram (DSA); and (C) an emergency access for salvage in case of closure device failure. Alternatively, access can be obtained on the same as the Impella device by puncturing the superficial femoral artery (SFA) distal to the arteriotomy, with the sheath inserted retrograde.

2. The skin entry of the Impella was marked with a metal pointer.

3. A ruler with a sterile cover was placed parallel to the Impella driveline in the coronal plane under fluoroscopy (Figures 1-2).

4. Without changing the alignment of the ruler, an angiogram at a left anterior oblique 90-degree (true lateral) angle was performed, with contrast injected via a cross-over internal mammary (IM) catheter. Apart from measuring the skin-arteriotomy distance, this angiogram also confirmed the position of the arteriotomy, which was well above the femoral bifurcation.

5. Calibration of the length was done, and the distance between the skin (marked with the metal pointer) to the Impella arteriotomy was measured (Figure 3).

Regain vascular access

6. Access was regained by delivering the .035-inch J-wire to the aorta through the reaccess port. The Impella was then removed, while the wire was kept (if an earlier version of the Impella is used where no reaccess port is available, vascular access can be regained by puncturing the Impella driveline and bringing the wire into the aorta, a procedure outlined by Bhalla et al¹).

7. A 14 French (Fr) Manta was deployed in the usual fashion (Figure 4).

Closure

8. A DSA was performed to ensure satisfactory hemostasis (Video 1).

Video 1. Digital subtraction angiogram showing satisfactory hemostasis after Impella arteriotomy was closed with a 14 French Manta (Teleflex).

9. Skin and track oozing was stopped by manual compression before the Manta was cut loose.

10. The PCI sheath was removed and the arteriotomy was closed by a 6 Fr collagen-based VCD (Angio-Seal [Terumo]).

The patient completed rehabilitation and was discharged home 5 weeks after admission.

Procedure #2 — VA-ECMO Decannulation Using a 14 Fr Manta

Using the same steps above, the 17 Fr return cannula of the VA-ECMO system was removed and the arteriotomy closed with a 14 Fr Manta. On angiography, it was noted that the return cannula entry was at the profunda femoris artery instead of the superficial femoral artery (SFA). However, it did not affect the closure procedure (Video 2).

Video 2. Digital subtraction angiogram showing satisfactory hemostasis after the return extracorporeal membrane oxygenation (ECMO) cannula arteriotomy was closed with a 14 French Manta.

The VA-ECMO access cannula was closed with a figure-of-8 knot and manual compression, while the reperfusion catheter arteriotomies were closed with the combination of a collagen-based VCD and suture-based VCD (Perclose ProGlide [Abbott Vascular]).

The patient was later discharged after completing rehabilitation.

Discussion

Various percutaneous closure techniques for large-bore arteriotomy have been described, such as computed tomography (CT) or ultrasound- guided Manta closure^2,3, pre or post closure with two suture-based VCDs, or a combination of one suture-based VCD and one collagen-based VCD.^4,5 However, we find transporting a patient to CT disruptive, and time- and manpower-consuming, while ultrasound-guided closure is operator dependent, and is subjected to erroneous measurement, usually a result of undue pressure exerted on the skin through the ultrasound probe. Pre closure poses an infection risk, as the sutures are exposed for days, and post closure with a suture-based VCD, especially for VA-ECMO, risks the sutures being deployed improperly owing to the large size of the arteriotomy,⁵ although this can be mitigated using diligent ultrasound guidance.

The technique described herein of Manta closure with angiogram-guided measurement offers several advantages. First, it is less technically demanding and therefore, offers reproducible results. Second, hemostasis can be checked using DSA. Third, if complications occur, an already-in-place vascular access allows for rapid remedial action. This technique is especially well-suited when the patient is already on mechanical circulatory support, requires a staged procedure such as PCI to be done in the catheterization laboratory, and is expected to be decannulated in the same setting, since vascular access for the closure procedure is already in place.

Conclusion

Angiogram-guided percutaneous closure with a Manta closure device for the large-bore arteriotomy required by use of VA-ECMO and Impella is simple, safe, effective, and time- and manpower-saving. 

Acknowledgements. We would like to thank all members of the cardiology team of Tuen Mun Hospital, Hong Kong, for their professional assistance on different aspects in the field of cardiology, from clerical to clinical work.

Disclosures: The authors report no conflicts of interest regarding the content herein.

Darren Jat-Lon Wong, MBBS, Resident Specialist (Cardiology), Department of Medicine and Geriatrics, Tuen Mun Hospital, 23, Tsing Chung Koon Road, Tuen Mun, New Territories, Hong Kong, can be contacted at darrenwongjl@gmail.com

References

1. Bhalla V, Marycz D, Wilson RE, et al. A novel technique for Impella removal from non-preclosed arteries using Perclose ProGlide closure device. Cath Lab Digest. 2018 Apr; 26(4):1,18. Accessed May 10, 2022. Available at https://www.hmpgloballearningnetwork.com/site/cathlab/article/Novel-Technique-Impella-Removal-Non-Preclosed-Arteries-Using-Perclose-ProGlide-Closure.

2. Hassan MF, Lawrence M, Lee D, et al. Simplified percutaneous VA ECMO decannulation using the MANTA vascular closure device: initial US experience. J Card Surg. 2020; 35: 217-221. doi: 10.1111/jocs.14308

3. Au SY, Fong KM, Ng WG, et al. Real-time ultrasound-guided bedside closure of arteriotomy wound using MANTA closure device during venoarterial extracorporeal membrane oxygenation decannulation. Perfusion. 2021; 36: 118-121. doi: 10.1177/0267659120932429

4. Martin-Tuffreau AS, Bagate F, Boukantar M, et al. Complete percutaneous angio-guided approach using preclosing for venoarterial extracorporeal membrane oxygenation implantation and explantation in patients with refractory cardiogenic shock or cardiac arrest. Crit Care. 2021 Mar 7; 25(1): 93. doi: 10.1186/s13054-021-03522-8

5. Au SY, Chan KS, Fong KM, et al. Bedside decannulation of peripheral VA-ECMO using percutaneous Perclose ProGlide post-close technique. J Emerg Crit Care Med 4:4. doi: 10.21037/jeccm.2019.09.08