Читать книгу Interventional Cardiology - Группа авторов - Страница 63

Large bore arterial sheaths (12–14 Fr) can be required for certain interventions such as retrograde balloon aortic valvuloplasty or, more recently, retrograde transcatheter aortic valve replacement (14–24 Fr). Such large bore arterial sheaths are historically associated with need for prolonged compression to achieve hemostasis, prolonged bed rest prior to mobilization (up to 12–24 hours in certain cases), and high risk of recurrent bleeding and need for transfusion. Transfusion rates after manual compression following balloon aortic valvuloplasty have been in the range of 25%. Preclosure is a technique using the Perclose or ProStar device to “preload” the suture around the puncture site prior to access with the large bore sheath to allow for subsequent suture closure at removal of the large arterial sheath. After puncture, a standard 6–8 Fr sheath is inserted and subsequently exchanged over the wire to introduce a Perclose or ProStar device. Deployment of the needle is performed with the standard manner to preload the suture around the arteriotomy. The suture is not tightened. A wire is reintroduced into the device over which an exchange is made with the subsequent large bore arterial sheath. At completion of the procedure requiring the large bore sheath, the sheath is removed and closure performed by tightening of the preloaded sutures. With this technique, a 6 Fr Perclose system had been successful in closing 12 Fr arteriotomies and a 10 Fr ProStar system had been successful in closing 14 Fr arteriotomies. In a non‐randomized comparison, this technique had been successful in significantly reducing length of hospital stay and almost eliminating the need for blood transfusions after retrograde arterial balloon aortic valvuloplasty [52,53]. Several novel devices for large vessel closure are under development. There are mainly three approaches of new technology to manage percutaneous closure following large bore vascular access: suture‐based, suture and plug/sealant, and ipsilateral/contralateral graft placement. There are a number of products under investigation that are entering the commercial market such as Manta (Essential Medical).