Clinical Images

Post-Close Technique for Arteriotomy Hemostasis After Impella Removal

Mohammad Thawabi, MD;  Marc Cohen, MD;  Najam Wasty, MD

Mohammad Thawabi, MD;  Marc Cohen, MD;  Najam Wasty, MD

J INVASIVE CARDIOL 2019;31(6):E159.

Key words: hemostasis, new technique, Perclose device, post-close technique

Utilization of large-bore sheaths has increased dramatically with the advancement of hemodynamic support devices. The “pre-close” technique is widely used to achieve hemostasis after device removal. However, this technique might fail or be deferred in certain situations, such as planned extended hemodynamic support or in emergencies. Employment of the Perclose vascular closure system (Abbott Vascular) in arteriotomies larger than 8 Fr might not be successful, as the device foot does not catch the vessel’s anterior wall. We describe a simple “post-close” technique for large arteriotomies (13-14 Fr), after removal of Impella 2.5 or CP systems (Abiomed) from the common femoral artery, using two Perclose devices.

If the Impella peel-away or another compatible sheath is in place, the Impella device is removed. However, if the repositioning sheath is in use, artery reaccess can be achieved utilizing the wire port inlet, if available, or an access-site salvage technique. After device removal, two 0.035˝ guidewires are inserted together through the existing sheath or the newly inserted sheath after artery reaccess. The sheath is then removed and an 8 Fr sheath is inserted over each wire in a side-by-side fashion (Figure 1A). At this point, hemostasis should be adequate as the two 8 Fr sheaths, positioned side-by-side, have a perimeter similar to the 13-14 Fr arteriotomy (Figure 1B). The first sheath is then removed while maintaining the wire in place. With the second sheath in place, a Perclose device is advanced side-by-side to the sheath and deployed at the 12 o’clock position (Figures 1C and 1D). The second sheath is then removed and another Perclose is deployed. The wire is removed after hemostasis is confirmed (Figure 1E). A final angiogram can be done if contralateral access is available (Figure 1F).

In conclusion, the post-close technique, using two Perclose devices, is an option after Impella device removal.

From the Department of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 3, 2018.

Address for correspondence: Mohammad Thawabi, MD, Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ 07112. Email: