A Stitch in Time Saves Nine

In this issue of the Journal of Invasive Cardiology, Mehta and colleagues provide an interesting report describing their initial clinical experience with a device, the X-Press system, for percutaneous closure of a femoral arterial access site. The device uses the placement of sutures to directly close the puncture site. There are several important points to note. The first is that the X-Press device was simple to use and appeared to be easier to use than other currently available systems, with a mean deployment time of about 5.5 minutes.1 The low failure rate with the X-Press device (about 6%) included the first cases done with the new device, and as such represent some of the “learning curve”. As experience with the device increases, this rate of non-closure will likely diminish further. Second, it is important to note that there were no major complications of distal limb ischemia or pseudo-aneurysm formation at the puncture site. The complications reported were related to those cases where the device failed to close the puncture site, and in those cases the authors reverted to the standard method of manual compression to the site, and bleeding was controlled. See Mehta et al. on pages 9–12 The X-Press device uses a suture for closure of the puncture site, and as such has a certain appeal compared to the various collagen plug devices, such as the AngioSeal device, which has been shown in randomized clinical trials to be efficacious compared to manual compression.2 Vasoseal is another collagen plug device that has been shown to be effective.3 However, there are still some rare, but potential, problems with these devices, such as collagen material intruding into the lumen of the artery, distal embolization or thrombosis, allergic reactions to the collagen protein, and possible foreign body reaction or infection. In this era of innovation in minimally invasive coronary interventions, necessitating the use of chimeric antibody to platelet glycoprotein IIb/IIIa integrin, any improvement in hemostasis of the access site is an important advance for patient care.4 Hemostasis allows early ambulation of the patient, increases patient comfort, and allows earlier discharge from hospital. These improvements help to minimize hospital costs and lessen bleeding complications. Currently, the technology of these devices limits their use to punctures made by catheters of 6 French size or smaller. We hope that continuing improvements in this technology will allow us to one day use similar devices for closure of larger punctures. In that case, these devices could achieve hemostasis in those patients with an intra-aortic balloon pump, or those undergoing endovascular stenting procedures, where we currently need to use larger diameter catheters. This would extend the benefits of hemostasis and earlier ambulation to these other groups of patients.

1. Duffin MC, Muhlestein JB, Alisson SB, et al. Femoral arterial puncture management after percutaneous coronary procedures: A comparison of clinical outcomes and patient satisfaction between manual compression and two different vascular closure devices. J Invas Cardiol 2001;13:354–362. 2. Kussmaul WG, Buchbinder M, Whitlow PL, et al. Femoral artery hemostasis using an implantable device (AngioSeal) after coronary angioplasty. Cathet Cardiovasc Diagn 1996;37:362–365. 3. Foran JP, Patel D, Brookes J, Wainwright RJ. Early mobilisation after percutaneous cardiac catheterization using collagen plug (Vasoseal) haemostasis. Br Heart J 1993;69:424–429. 4. Aguirre FV, Topol FJ, Ferguson JJ, et al. Bleeding complications with the chimeric antibody to platelet glycoprotein IIb/IIIa integrin in patients undergoing percutaneous coronary intervention. The EPIC Investigators. Circulation 1995;91:2882–2890.