Editorial a comparison of vascular closure devices commonly used in interventional radiology which medical device ejercicios hernia discal lumbar

Vascular closure devices (VCDs) were first introduced in the 1990s. Shorter haemostasis and early mobilisation led to their broad uptake, particularly in cardiology, but it was not until 2004 that metanalyses of their efficacy and safety were first published. In patients undergoing coronary angiography, VCDs were found to be as effective as manual compression in achieving haemostasis, but there was no significant difference in the incidence of complications.1 In fact some analyses had suggested a higher incidence of haematoma and pseudoaneurysm with VCDs, but this was not statistically conclusive.1 However, outcomes in cardiology patients are not necessarily applicable to interventional radiology (IR) patients (where radial access is less frequently used, and antegrade femoral punctures are more common), and it was not until 2011 that the first systematic review of VCDs in IR patients was published by Das et al.2 The conclusions were limited by heterogeneity between studies, and the need for more level 1 randomised controlled trials (RCTs) was emphasised.

Overall there was no difference in incidence of complications with VCDs relative to manual compression, but there was a non-significant trend towards fewer complications with Angioseal (St Jude Medical, Minnnesota).

Despite this somewhat equivocal evidence, there continues to be growth in use of VCDs among IRs, driven seemingly by convenience and perceived cost-savings associated with earlier haemostasis and shorter time to ambulation. New innovative and mainly extra-luminal approaches to arteriotomy closure are continually emerging, all striving for higher technical success rates and fewer complications than manual compression (for example, Mynx by AccessClosure, Boomerang by Cardiva Medical, FISH by Morris Innovative, and Fastseal by Vascular Closure Systems), in addition to newer generations of the more established devices such as Angioseal (Abbott Vascular, California). A recent editorial by Dr Douglas Muir discussed suture-based VCDs used in large bore arteriotomy procedures such as EVAR or TAVI. In this editorial we focus on the three VCDs we most commonly use in our institution for arteriotomy closure, namely Angioseal, ExoSeal (Cordis Corporation, Florida) and StarClose (Abbott Vascular, California) devices. We discuss briefly the evidence base for each device, and describe our own experiences in their use.

• Angioseal, with an intra-luminal anchor and extravascular collagen plug is the most established VCD with the broadest evidence base. It has a technical success rate of up to 97%,3 and a trend towards fewer complications than manual compression. A potential drawback is the intra-luminal footplate, which in our experience can result in iatrogenic intra-luminal stenoses and occlusions, particularly when used off-label.

• Exoseal, as a more recent device, lacks a broad evidence base. With a reasonably high technical success of 94%, its main benefit is an extra-luminal bioabsorbable closure plug. Drawbacks include a slightly cumbersome positioning mechanism, and a recommended 6 hour time to ambulation. We avoid its use in the obese.

• StarClose, featuring an extraluminal nitinol clip implant, appears to have lower technical success (~87%) and may have a higher rate of complications than other VCDs. Its benefit of an extra-luminal closure mechanism is offset by the permanent implantation of a nitinol clip.