Vasim Farooq (Department of Cardiology, Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK) and others report in Circulation Cardiovascular Interventions that the use of a vascular closure device after transfemoral percutaneous coronary intervention (PCI) is associated with a minor short-term mortality benefit compared with manual compression. They add that a more pronounced benefit was observed in certain subgroups of patients, such as those with acute coronary syndromes, at high risk of bleeding.
The authors report that “given the potential association of vascular closure devices with a reduction in vascular-related complications”, they hypothesised that the uniform use of the devices in patients in undergoing transfemoral PCI “may confer a potential short-term mortality benefit” compared with manual compression, “particularly in higher-risk patients”. Therefore, the aim of their study was to assess the short-term (30-day) mortality of patients undergoing transfemoral-based PCI treated with vascular closure devices compared with those undergoing femoral-based PCI treated with manual compression in a national, all-comers PCI registry.
Reviewing data from the British Cardiovascular Intervention Society (BCIS) database, Farooq et al identified 271, 841 patients who underwent transfemoral PCI between 2006 and 2011. Of these, 109,001 underwent haemostasis with manual compression and 162,844 underwent haemostasis with a vascular closure device. The authors report that the patients in the vascular closure device group were significantly younger, more likely to be male, and had fewer comorbidities. They add that these patients were less likely to present with ST-segment elevation myocardial infarction (STEMI), cardiogenic shock, or complex coronary artery disease.
The rate of 30-day mortality was significantly lower among patients in the vascular closure device group compared with those in the manual compression group. However, Farooq et al report: “After propensity score correction, the mortality benefit for vascular closure devices was substantially reduced but remained significantly lower for vascular closure devices compared with manual compression.” According to the propensity score-corrected analysis, 30-day mortality was 1.8% vs. 2% for manual compression (p=0.0037)—it was 1.4% vs. 2.4% (p<0.0001), respectively, in the uncorrected analysis.
The authors examined data for specific subgroups and report: “Notably, there was a lower 30-day mortality associated with vascular compression devices compared with a manual compression in females (p=0.037 for the difference), presentation with acute coronary syndromes/acute myocardial infarction (p=0.027 for the difference), and recent thrombolysis (p=0.0001 for the difference).” However, they add that “conversely” vascular closure devices conferred a benefit for patients without cardiogenic shock but not for those with cardiogenic shock.
“The use of vascular closure device was associated with a minor 30-day prognostic benefit after propensity score correction, findings which were much more pronounced in females, presentation with acute coronary syndrome or patients who had been recently administered thrombolytic therapy,” Farooq et al conclude.
They add that while evidence from the BCIS database indicates that PCI with the transradial approach “remains safer” even when a vascular closure device is used during transfemoral PCI, “the maintenance of skills to safely conduct femoral-based PCI is of absolute importance”. Farooq et al explain that maintaining transfemoral skills is important because “the femoral approach to PCI is still widely practised” and recent evidence suggests “that radial operators have potentially more vascular-related complications in femoral-based PCI compared with predominately femoral-based operators.”
Study author Magdi El-Omar (Manchester Heart Centre, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, UK) told Cardiovascular News: “Based on our findings, my default is to always consider using a vascular closure device to achieve haemostasis following transfemoral procedures, unless there are specific contraindications.”