The Peri-Close Technique: A Novel Method for the Closure of Large-Bore Arterial Access

Click here for the accompanying video of the peri-close technique.

Abstract

Objectives: To introduce a novel technique for the closure of large-bore arterial access. Background: The closure of large-bore arterial access is an increasingly prevalent issue. Here, we present a novel technique for the closure of large-bore arterial access. Methods: A suture-mediated closure (SMC) device is used in a typical “pre-close” manner. After the procedure, the sheath is removed with the wire in place. The knot is pushed down onto the wire. A second SMC device is then deployed over the wire to close the newly modified arteriotomy. Conclusion: The “peri-close” technique is a simple method for the closure of large-bore arterial access.

Background

With the rise in procedures such as transcatheter aortic valve replacement and extracorporeal membrane oxygenation (ECMO), the closure of large-bore arteriotomies via percutaneous methods is increasingly frequent. The previously described “pre-close” technique uses two suture-mediated closure (SMC) devices deployed prior to sheath insertion. The devices are deployed, orthogonally, at ten and two o’clock.^1,2 This is not ideal, as SMC devices are designed to be deployed parallel to the long axis of the artery. Off-axis orientation risks failure of the device if the needles do not puncture both edges of the arteriotomy or if the foot plates do not capture the suture.  A hybrid technique, using an SMC device in a pre-close manner, followed by reinsertion of a 6 French (Fr) sheath and then deployment of a collagen plug-mediated device, has also been described.³ Although this hybrid technique allows the initial SMC device to be deployed at the correct orientation, reinserting an additional sheath wastes equipment. Plug-based devices have the disadvantage of losing wire position before the device is deployed and prohibit immediate re-access at the same location.³

Here, we describe a novel “peri-close” technique that uses two SMC devices deployed sequentially; the first in a typical pre-close fashion and the other in the normal manner after removal of the sheath.

Methods

Initial arteriotomy is achieved with ultrasound and micro-puncture techniques using a 5 Fr sheath, and then dilated to 8 Fr. A stab incision is made onto the dilator. Forceps are used to enlarge the tract. The SMC device is fed over the wire and deployed in the typical pre-close fashion, but with the foot plates oriented parallel to the long axis of the artery, i.e., twelve o’clock. A stiff wire is inserted into the closure device, exchanging it for a large-bore sheath, and the procedure is performed. When ready to close, a soft wire is inserted into the sheath with the dilator, then the sheath and dilator are removed with the wire in place. Using the pushing tool, the knot is pushed down on to the wire, locked and cut (Figure 1, Panel A). At this point, the wire maintains access to the newly modified arteriotomy. The second SMC device is advanced over the wire (Figure 1, Panel B). The device is deployed in the normal fashion with the feet of the device parallel to the long axis of the artery and the device oriented to twelve o’clock. The sutures are harvested and, using the pushing tool, the knot is advanced down onto the modified arteriotomy, closing the hole (Figure 1, Panel C). The knot is locked and cut, and pressure is applied at the site if complete hemostasis has not already been achieved.

Discussion

The peri-close technique for percutaneous closure of large-bore access is the primary closure technique for structural heart and peripheral ECMO cases at our institution. This technique is simple, and utilizes a device that is both well known to the interventionalist and more salvageable than other devices. It is easier to perform with a single operator than the double pre-close technique and does not require extra equipment like hybrid techniques. Both devices are deployed in the standard fashion, simplifying the procedure and eliminating confusion regarding the orientation of the devices. The peri-close technique delivers the sutures side by side, giving a reliable closure. The pre-close technique deploys sutures in a crossover pattern that risks incomplete closure (Figure 1, Panel D). In our experience using this novel technique, there appear to be fewer bleeding complications and less incidence of device failure, but formal studies should be completed. We find the peri-close technique to be the method of choice for large-bore access. 

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

The authors can be contacted via David Luke, MD, at: davidluke1988@gmail.com

1. Lata K, Kaki A, Grines C, et al. Pre-close technique of percutaneous closure for delayed hemostasis of large-bore femoral sheaths. J Interv Cardiol. 2018 Aug; 31(4): 504-510. doi: 10.1111/joic.12490.
2. Dato I, Burzotta F, Trani C, et al. Percutaneous management of vascular access in transfemoral transcatheter aortic valve implantation. World J Cardiol. 2014; 6(8): 836-846. doi:10.4330/wjc.v6.i8.836
3. Amponsah MK, Tayal R, Khakwani Z, et al. Safety and efficacy of a novel “hybrid closure”; technique in large-bore arteriotomies. Int J Angiol. 2017; 26(2): 116-120. doi:10.1055/s-0037-1598252.