Optimizing Large-Bore Vascular Access: Strategies to Prevent Complications in Endovascular Interventions

Large-bore vascular access (LBA), whether arterial or venous, is essential for an increasing number of advanced percutaneous procedures, including structural heart interventions, mechanical circulatory support, and interventional electrophysiology. However, managing these access points poses significant challenges, with vascular complications (VCs) linked to worse patient outcomes, including increased morbidity and mortality.

This article highlights critical strategies to optimize large-bore access management, reduce complications, and improve procedural success.

Why Large-Bore Access Matters

Devices requiring ≥12 French (Fr) sheaths are now standard in many high-risk procedures. Despite advancements in techniques and technologies, vascular complications remain a significant concern, including bleeding, hematomas, and arterial or venous damage.

Effective management of large-bore access sites requires a comprehensive approach, from optimal puncture techniques to innovative hemostasis strategies. A robust plan for preventing and addressing VCs is critical to improving patient outcomes.

1. Femoral Artery Puncture: Precision is Key

The common femoral artery (CFA) is the preferred site for large-bore arterial access due to its anatomical advantages. Optimal puncture requires:

• Targeting below the inferior epigastric artery and above the artery bifurcation.
• Avoiding punctures below the bifurcation, which increases the risk of pseudoaneurysms and arteriovenous fistulas, and above the inguinal ligament, which raises the risk of retroperitoneal bleeding.

Ultrasound Guidance: Studies consistently show that ultrasound guidance improves procedural success, reduces complications, and minimizes major bleeding compared to traditional palpation techniques. Complementing this with fluoroscopic confirmation can further improve accuracy.

2. Vascular Closure Devices: Suture vs. Plug-Based

Hemostasis is a critical step in large-bore access management. Two primary types of vascular closure devices (VCDs) are available: suture-based and plug-based systems.

• Suture-Based Devices (e.g., ProGlide): These devices are effective for arterial sheaths up to 26-Fr. Preclosure techniques with ProGlide significantly improve hemostasis and reduce VCs. However, high atherosclerotic burden or calcified vessels may limit their efficacy.
• Plug-Based Devices (e.g., MANTA): Plug-based devices are simpler and faster to deploy, often achieving hemostasis in under 2 minutes. However, they are associated with higher VC rates in some trials, particularly in cases of severe calcification or suboptimal placement.

Combination Techniques: Recent studies suggest combining suture- and plug-based systems can leverage the benefits of both approaches, particularly in challenging anatomies.

3. Emergency and Prolonged Access

For emergency procedures or when prolonged large-bore sheath insertion is necessary, preclosure techniques may not be feasible. Alternative methods include:

• Dry-Seal Techniques: Balloon occlusion using contralateral femoral access to maintain hemostasis during sheath removal.
• Crossover Techniques: Inflating a balloon proximal to the arteriotomy to facilitate closure without major bleeding.

4. Bail-Out Strategies for Vascular Complications

Despite meticulous planning, VCD failure can occur, leading to complications such as acute limb ischemia or severe bleeding. Effective bail-out strategies include:

• Endovascular Interventions: Utilizing contralateral or transradial access, operators can deploy long-shaft balloons or covered stents to manage complications.
• Hybrid Techniques: Pledget-assisted hemostasis has emerged as a promising solution for challenging cases where suture-based devices fail.

5. Managing Large-Bore Venous Access

Although venous access is less prone to complications than arterial access, bleeding and other VCs remain concerns, especially with larger sheaths. Subcutaneous sutures, such as the figure-of-eight or purse-string technique, have proven superior to manual compression for venous hemostasis. Additionally:

• ProGlide is FDA-approved for venous access up to 29-Fr, offering safe and effective closure for large-bore venous sheaths.

Conclusion

Optimizing large-bore vascular access requires a multidisciplinary approach that integrates preprocedural planning, advanced puncture techniques, and tailored hemostasis strategies. By leveraging innovations in VCDs and applying robust bail-out techniques, clinicians can reduce complications and improve outcomes in high-risk percutaneous interventions.

The management of large-bore arterial and venous access continues to evolve, with newer strategies promising even better results. As the field progresses, sharing best practices and evidence-based techniques will remain critical to advancing patient care in endovascular interventions.

What are your thoughts on managing large-bore vascular access?

Citation: https://doi.org/10.1161/CIRCINTERVENTIONS.124.014156