Femoral Hemostasis

To the Editor:

This letter is in reference to the “Percutaneous Hemo-static Puncture Closure Devices” section in the article “Update on Endovascular Treatment of Peripheral Vascular Disease” by Drs. Krajcer and Howell, ¹ which appeared in the last issue of the Texas Heart Institute Journal. The authors present a good overview of the new femoral closure devices, as well as some of the benefits promised by their manufacturers. However, no mention is made of the increased risk of complication and the higher cost associated with the use of these invasive closure devices, or of the early ambulation benefits currently being achieved with manual or mechanical compression instead.

Deployment of percutaneous hemostatic puncture closure devices is an additional procedure, with the attendant risk of higher complication rates. Eidt and colleagues ² found a “marked increase in arterial oc-clusive complications requiring surgical repair” and recommended that vascular surgeons become familiar with the closure devices in order to achieve precise repair of the complications. Cura's group ³ reported an overall rate of complications similar to that of manual compression but a much higher rate of severe complications (for example, retroperitoneal bleeding and infection) in patients undergoing interventional catheterization. Carey and associates ⁴ noted 1) higher rates of total complications with Angio-Seal and VasoSeal devices compared with those of manual compression techniques, and 2) the presence of groin infections with all closure devices, in contrast to the occurrence of no infections with the use of manual compression.

The cost of invasive closure devices (estimated between $150 and $250) is much higher than that of manual or mechanical compression. The total cost, when hospital overhead and handling are included, is still higher when these devices are used.

Early ambulation after completion of the catheterization procedure, which is a key benefit associated with the invasive closure devices, has been achieved without their use. Wood and co-authors ⁵ concluded that ambulation 2.5 hours after 6-F diagnostic catheterization is safe and feasible with either manual or mechanical compression. Vlasic and Almond ⁶ found that ambulation 2 hours after 5-F catheterization was safe using manual or mechanical compression. Likewise, Koch and coworkers ⁷ concluded that 2 hours following interventional catheterization with low-dose heparin using 6-F guiding catheters, ambulation was feasible and safe with the use of manual compression.

Given the higher risks and costs associated with invasive closure devices, their use should be critically evaluated against the use of proven, lower-cost methods of achieving femoral hemostasis.