The use of large-bore sheaths has risen exponentially in the last decade partly due to the growth of structural heart interventions and various mechanical circulatory support options. from Journal of Invasive Cardiology. Bleeding ipsilateral external iliac artery large-bore sheath

Vascular access is a crucial step, which every interventional cardiologist needs to be skilled with to consistently achieve excellent periprocedural outcomes. Some operators argue that it is the most important aspect of the entire intervention. Hence, careful planning of vascular access in an individualized fashion – based on the patient’s clinical status, anatomy, and technical requirements of the intervention – is the first step in securing optimal procedural safety and successful results. We briefly review multiple aspects of vascular access and management including site selection, ultrasound guidance, micro-puncture techniques, sheathless techniques, limb perfusion, clinical monitoring, large bore closure, and management of complications. Approaching every vascular access in a systematic way, even in emergent situations, allows operators to minimize the risk of complications, especially in an often severely ill patient population.

An occlusive large bore sheath is a frequently encountered situation in cases of cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Resultant acute limb ischemia could be a catastrophic complication which significantly affects the prognosis of an already sick patient population. A novel, yet simple, technique using the radial artery, instead of the ipsilateral or contralateral common femoral artery (CFA), as a donor vessel of an external bypass which provides antegrade perfusion to a limb with an occlusive large bore sheath is hereby described. Radial access (RA) has been shown to improve mortality in acute coronary syndrome; however, it is sometimes avoided by some operators in CS cases due to the possible appropriate need for MCS. This technique offers a substitution of a second CFA access for a RA in order to provide adequate ipsilateral limb perfusion. Hence, one can start a CS case with a default RA and perform peripheral angiography after diagnostic cardiac catheterization. If the peripheral vasculature is inappropriate for MCS, the patient would have already benefited from the mortality advantage of RA. If obstructive PAD is absent, then an occlusive Impella sheath can be placed in a CFA after antegrade ipsilateral superficial femoral artery (SFA) access is obtained for an external radial to femoral bypass, while the PCI is performed through the Impella sheath according to the single access PCI technique. Finally, the advantages and disadvantages of this new approach are described and compared with each of the traditionally known external and internal femoral bypass techniques.

Vascular access closure is essential in large-bore arteriotomy procedures, such as transcatheter aortic valve replacement. ​Suture-based devices are frequently used for vascular access closure. MANTA (Teleflex) is a collagen plug–based device used to achieve hemostasis with evolving efficacy and safety data. This study aimed to evaluate plug-based versus suture-based closure devices following large-bore arteriotomy procedures. We conducted a systematic review searching PubMed, Cochrane Library, and ClinicalTrials.gov (inception through November 2021) for studies evaluating plug-based versus suture-based closure devices following large-bore arteriotomy procedures. We performed a meta-analysis comparing the length of stay, device failure, mortality, bleeding, and vascular complications between these 2 types of devices. Eleven studies (2 randomized controlled trials and 9 observational studies) with a total of 3123 patients were included in this analysis. Compared with suture-based devices, plug-based devices were associated with a significant decrease in the length of stay (standardized mean difference: −0.14; 95% CI, −0.25 to −0.03) and vascular closure device failure (odds ratio, 0.63; 95% CI, 0.44-0.91) following the procedure. There were no significant differences in all-cause mortality, major or minor bleeding, and major or minor vascular complications between plug-based and suture-based closure devices. Plug-based vascular closure devices were associated with a shorter length of stay and lower risk of device failure following large-bore arteriotomy procedures without differences in mortality, bleeding, or vascular complications than suture-based closure devices.