Alternative Application Technique for the MANTA Vascular Closure Device for Percutaneous Large-Bore Arterial Access Closure: The Fluoroscopic DOT Technique

Abstract

Background:

Vascular complications are a cause of increased morbidity and mortality when performing percutaneous procedures requiring large-bore arterial access. MANTA vascular closure device (VCD) is currently the only large-bore VCD using an intraluminal foot plate and an extraluminal collagen plug. The traditional depth locator approach might be compromised in; emergent cases without the required measurements, cases of hematoma formation, or other patient, procedure, or operator-specific variables. Furthermore, this technique can be used for postclosure in cases without the required measurement of depth. We describe vascular outcomes using fluoroscopy (fluoroscopic DOT technique) rather than traditional depth locator approach for vascular closure with the MANTA VCD.

Methods:

Fifty patients who underwent transcatheter aortic valve implantation (TAVI) were retrospectively analyzed using fluoroscopic DOT technique with 18F MANTA VCD between May and August 2021. All patients >18 years of age who qualified for transfemoral TAVI were included. Access was obtained with ultrasound guidance with vessel diameter of at least > 6 mm and free from anterior vessel wall calcification. Patient related factors and primary outcomes of access site bleeding and acute flow-limited limb ischemia requiring intervention were prospectively analyzed. Furthermore, 1 patient who failed hemostasis with suture-mediated VCD had successful hemostasis with fluoroscopic DOT technique as dry postclosure after balloon aortic valvuloplasty.

Results:

In total, 50 patients were analyzed with a mean age of 81 years and majority were male (56%). Majority had comorbidities of hypertension (88%) and hyperlipidemia (94%), 24% had peripheral arterial disease, 38% coronary artery disease, and 58% were former smokers. Importantly, 40% were obese with an average body mass index (BMI) of 29 kg/m². There were no bleeding or ischemic limb complications post MANTA VCD deployment using the fluoroscopic DOT technique. Furthermore, none of the patients required peripheral intervention from index procedure to 1 month post verified during their 1-month post TAVR follow-up.

Conclusion:

Fluoroscopic DOT technique using the MANTA VCD is highly reproducible and allows hemostasis in a predictable manner for procedures requiring large-bore arterial access in the absence of MANTA depth measurement.

Keywords

vascular closure devices vascular access aortic valve endovascular treatment/therapy peripheral vascular disease

Introduction

Obtaining predictable and complete hemostasis is paramount to percutaneous procedures requiring large-bore arterial access such as transcatheter aortic valve replacement (TAVR), abdominal endovascular aneurysm repair (EVAR), mechanical circulatory support (MCS), or minimally invasive valve surgery. Bleeding complications related to large-bore arterial access is associated with increased in-hospital mortality, length of stay, and increased cost.¹ Transfemoral access is the preferred first-line approach for TAVR and is associated with 20% relative risk reduction in mortality in comparison with surgical aortic valve replacement.² Although the incidence of vascular complications and bleeding have decreased overtime from adoption of better practices, smaller delivery sheaths, and operator experience, they are still associated with increased length of stay and higher 1-year mortality (HR 2.31 [95% CI, 1.20–4.43] p=0.012).^3–5 A recent observational study of 34 893 patients undergoing TAVR at 445 hospitals showed 9.3% of patients to have a vascular complication and 7.6% with in-hospital bleeding events. Vascular complications were associated with increased 30-day death (HR 2.23 [95% CI, 1.80–2.77]), death (adjusted HR 1.17 [95% CI, 1.05–1.30]) and rehospitalization (adjusted HR 1.14 [95% CI, 1.07–1.22]) at 1 year. Whereas, vascular bleeding events were also related to increased 30-day death (HR 3.71 [95% CI, 2.94–4.69]), death (HR 1.39 [95% CI, 1.23–1.56]), and hospital readmissions at 1 year (HR 1.19 [95% CI, 1.11–1.27]).⁶ Hence, achieving adequate hemostasis free from vascular complications becomes paramount to improve both long- and short-term outcomes with large-bore arterial access related procedures.

MANTA VCD is a vascular closure device using an intraluminal footplate and extraluminal collagen plug (like ANGIO-SEAL) approved for large-bore vascular closure in 2019.⁷ This study’s institution has switched to 100% MANTA VCD use for transfemoral TAVR procedures with an average of 250 procedures performed annually. Rapid, predictable, and complete hemostasis can be accomplished in majority of the TAVR cases where MANTA VCD is used. The first step of MANTA VCD is use of the MANTA depth locater, marked by centimeters (cm), to be advanced into femoral arteriotomy site for measurement of appropriate vessel depth which will be used at the end of procedure for final deployment steps. However, certain anatomic and patient-related factors can produce significant variability in this crucial measurement step and may lead to deployment at an improper level and therefore associated vascular complications. The device encompasses a radiopaque marker which locks the sliding suture knot that initially compacts the extravascular collagen plug and is a landmark used for future interventions. From operator experience, the initial depth finder measurement can be significantly variable from the final depth measurement due to patient and procedure-related factors such as intraprocedural hematoma formation, patient obesity, ioban film causing device movement, or operator skin pressure during depth finder step. A retrospective single center analysis of the fluoroscopic DOT technique taking advantage of the radiopaque marker was synthesized to allow for more precise and predictable deployment than the depth locater method. An additional advantage of this technique is its ability to be employed as dry postclosure in cases where either suture-mediated VCD have failed or when emergent large-bore arterial access procedures are performed; ie, MCS for cardiogenic shock.

Methods

A single-center retrospective study was conducted of 50 patients, >18 years of age, who underwent transfemoral TAVR with either Medtronic Evolut PRO or Edwards Sapien 3 Ultra for whom hemostasis was achieved with 18F MANTA VCD using fluoroscopic DOT method alone without the depth locator between May 2021 and August 2021 with prospective data obtained. While at the time, these patients consented to the procedure, obtaining written informed consent from the patients whose chart will be reviewed was not required as this study met the FDA’s criteria for consent to be waived, according to its guidance document IRB Waiver or Alteration of Informed Consent for Clinical Investigations Involving No More than Minimal Risk to Human Subjects (July 2017). Common femoral artery access was obtained with ultrasound guidance with a minimum lumen diameter of >6 mm and free from anterior wall calcification. Patient-related factors extracted included age, gender, body mass index (BMI), and cardiovascular comorbidities (eg, smoking status, hypertension, hyperlipidemia, diabetes mellitus, peripheral artery disease [PAD], prior stroke, coronary artery disease [CAD] with percutaneous coronary intervention [PCI], coronary artery bypass graft [CABG], congestive heart failure [CHF]). Primary outcome was major vascular complications (flow-limiting stenosis/dissection or active bleeding) requiring additional surgical or endovascular intervention as assessed by digital subtraction angiography (DSA) from contralateral access site in an ipsilateral oblique angle of at least 25. Minor complications of bleeding or pseudoaneurysm requiring manual compression or non-flow-limiting dissection/stenosis requiring imaging or clinical follow-up was also assessed. Any peripheral intervention from index procedure to 1-month post TAVR follow-up was also evaluated.

Procedure and Device Description

MANTA VCD is available in 2 sizes, 14F and 18F, and allows reduced time to hemostasis with use of 10F-20F devices or sheaths with an outer diameter (OD) between 12F and 25F. The device consists of an absorbable collagen pad, stainless-steel locking component, and an absorbable polymer anchor connected by a nonabsorbable suture.

The first step involves use of the MANTA depth locator to locate the common femoral artery (CFA) access site. After obtaining CFA access and placing a 6F or 8F sheath, the MANTA depth locater (8F size) is inserted until steady pulsatile arterial blood flow is noted. Next, keeping the skin at neural position, the depth locater is slowly withdrawn until blood flow stops taking note of the visible cm marker at which blood flow ceases and adding 1 cm. This measurement is the marketed instructions for use (IFU) for final MANTA VCD deployment. After completion of procedure, the large-bore arterial access sheath is removed, and the MANTA introducer and sheath assembly placed hubbed into the arteriotomy site. The introducer is removed and the delivery tube inserted until a click is audible. MANTA handle and sheath are withdrawn corresponding to the measurement as assessed by the depth locater during step 1. The handle on the level is rotated back until a click is audible and the device withdrawn at least 45 degrees until yellow/green is seen at tension window. The blue lock tube is advanced lightly allowing the radiopaque lock to secure implant. Tension is increased on the MANTA closure handle until an audible click is heard completing device deployment (Figure 1).

Description of Fluoroscopic DOT Technique

Micropuncture arterial access was performed using modified Seldinger technique with ultrasound guidance for all 50 patients using 0.021-inch needle and fluoroscopic image saved with the 0.018-inch guidewire inserted at the CFA access level. Ultrasound guidance was used to ensure that no anterior CFA calcification was noted at needle site entry and that the CFA minimal lumen diameter was >6 mm on preprocedure gated computed tomographic scan. Next, after completion of the large-bore arterial access procedure, steps for assembly of MANTA device including sheath and delivery tube are followed as described earlier. Next, the MANTA handle and sheath are withdrawn first in parallel to the lower extremity under fluoroscopic until the radiopaque dot corresponds to the level of the 0.021″ micropuncture needle and wire entry at the arteriotomy site. The handle is then pulled back, and the device tube is withdrawn at 90° angle to ensure adequate foot plate contact with vessel wall until green/yellow square is seen on the handle, the blue lock is advanced lightly, and device is pulled back with tension until the audible click is heard completing closure deployment (Figure 2).

With standard IFU method, the MANTA introduction sheath is 1 cm inside the vessel from the arteriotomy site. Although, with fluoroscopic DOT technique, the introduction sheath is 2.5 cm inside the vessel from the arteriotomy site, thus is 1.5 cm deeper than IFU method.

Results

A total of 50 patients were analyzed retrospectively, with a mean age of 81.4 years, of which 28/50 (56%) were male. The mean BMI was 29 kg/m², range (16.6–40.03 kg/m²), and obesity as identified by BMI of greater than 30 kg/m² was present in 20/50 (40%) of patients. Majority had comorbidities of hypertension (88%), hyperlipidemia (94%), were former smokers (58%), and 17/50 (34%) had diabetes. Equal number of patients had chronic obstructive lung disease and chronic kidney disease (10/50, 20% each), and majority had either CAD with PCI or prior CABG (29/50 or 58% total). CHF was present in 30% of patients, while prior stroke history in 10% and concomitant PAD in 12/50 (24%) (Table 1). Primary outcome of major vascular complications (flow-limiting stenosis/dissection or active bleeding) requiring additional surgical or endovascular intervention as assessed by DSA from contralateral access site was seen in none of the patients using the fluoroscopic DOT technique (Table 1). Furthermore, there were no minor vascular complications requiring conservative treatment measures; ie, no additional manual compression performed after standard full dose protamine at the conclusion of procedure for bleeding, pseudoaneurysm or monitoring/presence of non-flow-limiting dissection or stenosis. Although DSA was performed till approximately 3 to 5 cm below the level of CFA bifurcation, there was no evidence of distal embolization assessed by patients’ symptoms or manual distal lower extremity pulse palpation or Doppler assessment pre- and postprocedure. Finally, none of the 50 patients required any peripheral angiogram or intervention from index procedure to 1-month post-TAVR follow up.

Table 1.

Baseline Demographics, Clinical Characteristics and Vascular Outcomes of Subjects (N=50).

Demographic
Age in years (range)	81.42 (59–92)
Gender	Male, 28 (56%)
Body mass index (kg/m²)	28.99 (16.6–40.03)
Risk factors and co-existing conditions
Obesity	20 (40%)
Current smoker	0
Former smoker	29 (58%)
Hypertension	44 (88%)
Hyperlipidemia	47 (94%)
Diabetes mellitus	17 (34%)
Peripheral artery disease	12 (24%)
Previous stroke	5 (10%)
CAD with PCI	19 (38%)
CABG	10 (20%)
CHF	15 (30%)
COPD	10 (20%)
CKD	10 (20%)
Primary outcomes: vascular complications (N=50)
Vascular bleeding requiring intervention	0
Flow-limiting limb ischemia requiring intervention	0

Continuous data are presented as mean (range). Category data are given as frequency (percentage).

Abbreviations: CABG, coronary artery bypass graft; CAD, coronary artery disease; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention.

As illustrated, with the fluoroscopic DOT technique, the foot plate is 1.5 cm deeper than the IFU method, and this did not correlate to any clinical adverse outcomes.

Discussion

Novel use of the fluoroscopic DOT technique for MANTA VCD deployment can allow precision and predictability in vascular closure, especially when procedure-, operator-, and patient-related factors can skew the MANTA depth finder measurements performed at the start of procedure. Outcomes of 50 patients undergoing transfemoral TAVR procedure using this technique showed no vascular complications of flow-limiting dissection or bleeding requiring endovascular or surgical intervention. Evidence from this observational study shows that a high level of predictability and MANTA VCD deployment can be achieved while maintaining a low rate of vascular complications. With the fluoroscopic DOT technique, the foot plate is 1.5 cm deeper within the vessel than with using manufacturers IFU method, and this did not correlate with any clinical adverse outcomes. On the contrary, this method can be advantageous in obese patients, those with intraprocedural hematomas or unexpected device movement; ie, ioban film, operator hand pressure, or combination of obesity and hematoma. Furthermore, while none of the patients in this study had external iliac artery stents or heavily calcified CFA vessels, knowledge of this technique and depth difference can allow the operator to deploy the vascular closure carefully under fluoroscopy taking account of the relevant patient-specific anatomy or the fluoroscopic dot can be placed 1 to 1.5 cm distal to the arteriotomy site. This approach allows more operator control and precision in deployment based on patient anatomy and overcomes other unexpected procedure related factors.

Evidence for MANTA VCD

The SAFE MANTA pivotal clinical study was a prospective, single-arm, multi-center investigational study of 341 patients where MANTA VCD was used for TAVR and large-bore endovascular procedures with mean effective sheath OD of 22F (7.3 mm). Mean time to hemostasis was only 65+157 seconds, technical success rate is 97.7%, and single device deployed in 99.6% of cases. Vascular complications occurred in 4.2% of cases as identified by the valve academic research consortium-2 (VARC-2); 3 with bleeding (1.1%), 2 requiring surgical repair (0.8%), and 2 requiring PTA (0.8%).⁸ Aside from achieving sooner time to hemostasis, MANTA VCD also appears to have less vascular complications. A single center experience of 578 patients undergoing transfemoral TAVR comparing MANTA VCD to proglide concluded that MANTA VCD was associated with less vascular complications 10.7% vs 19.0% in the PVCD group (p=0.011). MANTA VCD was also associated with lower major and life-threatening bleeding (0.5% vs 4.4%, p=0.009 and 0% vs 2.3%, p=0.032), respectively.⁹ Steps to improve safety and reduce vascular complications have been accomplished with used of ultrasound (US) guidance. In a recent publication by Miyashita et al of 378 patients, use of US guidance for vascular access and MANTA VCD deployment had a 6.1% (23) vascular complication rate (1.9% major and 4.2% minor). Further anterior CFA calcification was found to be an independent factor for major vascular complications (57.1%) related to incomplete apposition of toggle.¹⁰ In another retrospective comparison study, MANTA VCD deployed without US guidance or conventional (C-MANTA) and 246 consecutive patients where US was used (US-MANTA) were propensity matched. Significantly less major vascular complications occurred in US-MANTA than C-MANTA (1.5% vs 7.4%, p=0.03) and they also had significantly less access site related life-threatening or major bleeding (2.2% vs 8.2%, p=0.028).¹¹

MANTA VCD has been extended in application to obtain hemostasis for percutaneous axillary TAVR implantation, decannulation of venoarterial extracorporeal membrane oxygenation (VA-ECMO), in addition to minimally invasive valve surgery.^12–15 However, it is important to note that the SAFE MANTA study selected patients without morbid obesity, severe calcification, or severely scarred femoral access area. While femoral artery calcification is best avoided with careful assessment by computed tomographic angiography during preplanning stage for TAVR, patient-related factors such as obesity and access vessel depth are difficult to preplan and navigate intraprocedurally. Thus, techniques to bring precision and predictability to unavoidable patient-related factors can be paramount to reduce vascular complications.

Benefits for Use of Fluoroscopic DOT Technique With MANTA VCD

Obesity and small femoral artery diameter with deep arteriotomy or greater vessel depth from skin puncture site appear to be strong patient-related variables associated with large-bore arterial access VCD failures.^16,17 The initial MANTA depth locator measurement can be significantly different than the measurement toward the end of the procedure where this depth measurement is used for final deployment. A deeper arteriotomy site has been associated with increased MANTA-related vascular access site complications.¹⁶ Additionally, anterior CFA calcification,¹⁰ peripheral artery disease and vessel diameter < 6 mm,¹⁸ low or high arteriotomies,¹⁹ female gender, left CFA access, vessel angulation, and at least moderate anterior vessel calcification^16,20 have all been independently associated with manta related vascular complications.

Operator- or procedure-related factors that lead to variability in MANTA depth finder measurement from start of procedure to the end include unintentional compression of skin by operator during depth locator measurement or during deployment process, iatrogenic hematoma accumulation during procedure related to device and sheath exchanges increasing skin to vessel depth distance (as shown in Figure 2), and sheath or depth locator entrapment or compression related to ioban film at the groin site which is commonly employed in OR setting to improve sterility. The fluoroscopic DOT technique allows precise and predictable MANTA VCD deployment at the large-bore arteriotomy site potentially overcoming these patient-, operator-, and procedure-related unpredictable factors. The operator theoretically has better control of the deployment process with knowledge of this technique and distance to the fluoroscopic dot to allow for more accurate deployment in setting of factors that can lead to variability in depth measurement. Although, with the technique, the foot plate is deployed 1.5 cm deeper than IFU method, this did not lead to any clinically significant adverse outcomes. The operators found the fluoroscopic DOT technique to be a reliable method to ensure proper MANTA VCD deployment as shown in these 50 patients who were free of any bleeding or ischemic limb complications and continue its use in daily practice.

Fluoroscopic DOT Technique for Dry/Postclosure Technique or in Cases of Failed Suture-Mediated VCD

Application of fluoroscopic DOT technique can be extended for use as dry field/postclosure during emergent cases or in cases where initial suture-mediated VCD fails. Dry field technique refers to emergency situations where emergent insertion of MCS is required without deployment of time consuming proglide sutures in preclose fashion. Postclosure options in these instances include balloon tamponade for 30 to 60 minutes or covered stent deployment which are both time and cost inefficient and commit a patient to unnecessary covered stent deployment at the CFA site.²⁰ While other techniques using either PVCD or ANGIO-SEAL (Terumo Interventional Systems, Somerset, NJ) of various size and numbers have been reported in case reports or small case series, they lack predictability and have not been performed in large numbers in a prospective manner to be considered a reliable method to achieve adequate hemostasis at a high success rate.^21–24 Hence, this technique can also be successfully employed as postclosure in emergent MCS insertion cases such as Impella (Abiomed, Danvers, MA) or VA-ECMO as long as the initial arterial puncture site is known.

Limitations

Although the MANTA fluoroscopic DOT techniques appears to be a reliable technique to achieve hemostasis for large-bore arterial access in a predictable manner overcoming patient- and procedure-related variable factors, further validation in a randomized, prospective manner in a larger patient population is warranted. The fluoroscopic DOT technique was performed in the anterioposterior (AP) projection and was successful, using oblique perpendicular projections can improve outcomes with this technique, especially in patients with high or low CFA bifurcation. Additionally, validity of this technique as postclosure in emergent MCS or other emergent large-bore arterial access in larger series of patients is indicated as it can significantly improve vascular closure predictability and success rate in such cases.

Conclusion

The fluoroscopic DOT technique for MANTA VCD use after TAVR is a safe alternative to the standard application of the MANTA VCD. In addition, this technique can potentially be used for postclosure, for example, after emergent MCS insertion or failed suture mediated VCD. Further prospective studies using this technique in a larger patient population and validation of this technique as postclosure is warranted.

Footnotes

Acknowledgements

This is an original manuscript and has not been previously published or submitted to another journal.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sehrish Memon

References

Redfors

Watson

McAndrew

, et al. Mortality, length of stay, and cost implications of procedural bleeding after percutaneous interventions using large-bore catheters. JAMA Cardiol. 2017;2(7):798–802.

Siontis

GCM

Overtchouk

Cahill

, et al. Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis. Eur Heart J. 2019;40(38):3143-3153.

Leon

Smith

Mack

, et al. Transcatheter or surgical aortic valve replacement in intermediate-risk patients. N Engl J Med. 2016;374:1609–1620.

Tchetche

Van der Boon

Dumonteil

, et al. Adverse impact of bleeding and transfusion on the outcome post-transcatheter aortic valve implantation: insights from the Pooled-RotterdAm-Milano-Toulouse In Collaboration Plus (PRAGMATIC Plus) initiative. Am Heart J. 2012;164(3):402–409.

Généreux

Webb

Svensson

, et al. Vascular complications after transcatheter aortic valve replacement: insights from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial. J Am Coll Cardiol. 2012;60:1043–1052.

Sherwood

Xiang

Matsouaka

, et al. Incidence, temporal trends, and associated outcomes of vascular and BLEEDING complications in patients undergoing transfemoral transcatheter aortic valve replacement. Circ Cardiovasc Interv. 2020;13(1):e008227.

Premarket approval (PMA). accessdata.fda.gov. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P180025. Accessed August 29, 2021.

Wood

Krajcer

Sathananthan

, et al. Pivotal clinical study to evaluate the safety and effectiveness of the MANTA percutaneous vascular closure device. Circ Cardiovasc Interv. 2019;12(7):e007258.

Dumpies

Kitamura

Majunke

, et al. Manta versus Perclose ProGlide vascular closure device after transcatheter aortic valve implantation: initial experience from a large European center. Cardiovasc Revasc Med. 2022;37:34–40.

10.

Miyashita

Moriyama

Laine

Incidence and predictors of access site vascular complications following ultrasound-guided MANTA closure deployment. J Endovasc Ther. 2021:15266028211059446. doi:10.1177/15266028211059446.

11.

Moriyama

Dahlbacka

Vähäsilta

, et al. The efficacy of the ultrasound-navigated MANTA deployment following transfemoral transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2019;12(24):2564–2566.

12.

De Palma

Rück

Settergren

, et al. Percutaneous axillary arteriotomy closure during transcatheter aortic valve replacement using the MANTA device. Catheter Cardiovasc Interv. 2018;92(5):998–1001.

13.

Schaefer

Schirmer

Schofer

, et al. Transaxillary transcatheter aortic valve implantation utilizing a novel vascular closure device with resorbable collagen material: a feasibility study. Clin Res Cardiol. 2019;108(7):779–786.

14.

Montero-Cabezas

van der Meer

van der Kley

, et al. Percutaneous decannulation of femoral venoarterial ECMO cannulas using MANTA vascular closure device. Can J Cardiol. 2019;35(6):796e9–796e11.

15.

Schaefer

Sarwari

Reichenspurner

, et al. A novel plug-based vascular closure device for percutaneous femoral artery closure in patients undergoing minimally-invasive valve surgery. Front Cardiovasc Med. 2021;8:682321.

16.

Nuis

R-J

Wood

Kroon

, et al. Frequency, impact and predictors of access complications with plug-based large-bore arteriotomy closure—a patient level meta-analysis. Cardiovasc. Revasc Med. 2021;36:106969.

17.

Berti

Bartorelli

Koni

, et al. Impact of high body mass index on vascular and bleeding complications after transcatheter aortic valve implantation. Am J Cardiol. 2021;155:86–95.

18.

Moccetti

Brinkert

Seelos

, et al. Insights from a multidisciplinary introduction of the MANTA vascular closure device. JACC Cardiovasc Interv. 2019;12(17):1730–1736.

19.

Nan Wiechen

Kroon

Hokken

, et al. Vascular complications with a plug-based vascular closure device after transcatheter aortic valve replacement: predictors and bail-outs. Catheter Cardiovasc Interv. 2021;98(5):E737–E745.

20.

Kmiec

Zerdzitzki

Schmid

, et al. Evaluation of the MANTA vascular closure device in transfemoral TAVI. Thorac Cardiovasc Surg. 2021. doi:10.1055/s-0041-1730972.

21.

Chaudhuri

A “post-close” technique for femoral hemostasis after percutaneous EVAR using an ultra-low-profile endoprosthesis system. EJVES Short Rep. 2015;29:18–20.

22.

Thawabi

Cohen

Wasty

Post-close technique for arteriotomy hemostasis after impella removal. J Invasive Cardiol. 2019;31(6):E159.

23.

Lichaa

Wollmuth

Tayal

Dry field closure of large-bore access with iliac artery angioplasty through the ipsilateral sheath: the single-access dry-closure technique. J Invasive Cardiol. 2021;33(7):E516–E521.

24.

Hirst

Kapur

NK.

A novel post-closure method for haemostatic removal of the Impella CP pump. ICR. 2019;14(3)(suppl 1):A24.