The Effect of a Percutaneous Arterial Closure Protocol On Complications After Endovascular Interventions in Vascular Surgery Patients

Objective: Access complications following percutaneous femoral access are a significant source of morbidity and cost in patients undergoing peripheral vascular interventions. For this reason, we designed and implemented an arterial closure protocol for use in patients with peripheral vascular disease.
Methods: We included all patients in our vascular surgery practice undergoing peripheral arterial interventions via percutaneous retrograde femoral access. The Pre-Protocol phase was a four-month observational period to study practice patterns and define a uniform closure protocol. During the Post-Protocol phase, we implemented an arterial closure protocol, with closure device use guided by sheath size, arterial calcification, and previous groin scarring (see Figure). Our main outcome measures were major complications (need for operation, transfusion, or thrombosis) or minor complications (access site bleeding or hematoma). Outcomes were compared between the two phases using chi-squared analysis.
Results: In the Pre-Protocol phase, we enrolled 140 arterial punctures in 119 patients, and in the Post-Protocol Phase, we enrolled 91 punctures in 68 patients. While 24 minor complications occurred in the Pre-Protocol phase, only 6 minor complications occurred in the Post-Protocol phase (17% vs. 7%, p<0.02). Closure device use decreased with protocol implementation (57% to 32%, p<0.01), but closure device failures also decreased from 23% to 7% (p<0.01). Between the Pre- and Post-Protocol phases, average sheath size remained similar (sheaths over 6F 6% vs 8%, respectively, p=0.55), percentage of patients receiving heparin did not change significantly (57% vs, 43%, p=0.08), and other patient characteristics did not significantly change.
Conclusions: Percutaneous arterial closure can be improved by use of a standardized pathway based on selective closure device use guided by sheath size, arterial calcification, and previous access scarring.