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Vascular access and closure in coronary angiography and percutaneous intervention

Nature Reviews Cardiology volume 10, pages 27–40 (2013)Cite this article

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Abstract

The key feature defining transcatheter cardiovascular interventions is that access to the vessels and heart is achieved by arterial puncture with a needle, rather than surgical incision with a scalpel. However, arteriotomy and vessel closure are performed without direct visualization of the arterial wall, which risks vessel damage and bleeding. Vascular closure devices offer the potential for enhanced control of access-site haemostasis and reduced complications in comparison with manual compression. However, although randomized clinical trials have shown reductions in time to haemostasis and ambulation, the data do not demonstrate consistent reductions in access-site complications or improvements in clinical outcomes. Another approach to increase the safety of percutaneous procedures is to use radial, rather than femoral, arterial access, a strategy that has polarized opinions among cardiologists. Clinical trial data show a clear reduction in access-site bleeding and complications with radial access, at the expense of a marginal increase in markers of procedural efficiency. However, randomized trials have not demonstrated improved clinical outcomes with radial access. The lack of impact on prognostically relevant bleeding events could explain this null finding, although the setting of primary percutaneous coronary intervention could be an exception. Ongoing, iterative improvement in catheter technologies, as well as in adjuvant antiplatelet and antithrombotic therapies, are likely to underlie the difficulty in demonstrating clear outcome benefits with different vascular access and closure strategies.

Key Points

  • The feasibility and success of transcatheter therapeutics are heavily dependent on the related issues of vascular access and arteriotomy closure

  • Manual compression remains the most frequently used modality for closure of vascular access after diagnostic catheterization or percutaneous intervention; however, a range of vascular closure devices (VCDs) are available

  • Randomized trial data show that the use of VCDs results in reduced time to haemostasis, ambulation, and hospital discharge

  • Rates of access-site bleeding and complications, as well as overall clinical outcomes, are not improved by use of VCDs

  • Worldwide, the femoral artery approach is the most-common vascular access modality for coronary angiography and intervention; however, uptake of radial access has increased rapidly in the past 10 years

  • Radial artery access reduces access-site bleeding and complications at the expense of a slight increase in metrics of procedural efficiency when compared with femoral access; overall clinical outcomes are not different

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Figure 1: Vascular closure devices.
Figure 2: Risk of pseudoaneurysm after diagnostic angiography or intervention from meta-analysis of randomized trials comparing VCD and manual compression, overall and according to type of device.
Figure 3: Time to haemostasis after diagnostic angiography or intervention from meta-analysis of randomized trials comparing VCD and manual compression, overall and according to type of device.
Figure 4: Anatomy of the radial artery.
Figure 5: Anatomy of the common femoral artery.
Figure 6: Clinical outcomes from an updated meta-analysis of randomized trials of radial versus femoral access, including pre-RIVAL studies, the RIVAL trial and the combined dataset.

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  1. Deutsches Herzzentrum, Technische Universität, Lazaretstrasse 36, Munich, 80636, Germany

    Robert A. Byrne, Salvatore Cassese, Maryam Linhardt & Adnan Kastrati

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Byrne, R., Cassese, S., Linhardt, M. et al. Vascular access and closure in coronary angiography and percutaneous intervention. Nat Rev Cardiol 10, 27–40 (2013). https://doi.org/10.1038/nrcardio.2012.160

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