Original title: Comparative safety of vascular closure devices and manual closure among patients having percutaneous coronary intervention. Reference: Gurm HS et al. Ann Intern Med. 2013; Epub ahead of print.
The use of percutaneous closure devices in patients who undergo coronary angioplasty by femoral access is controversial and its use has gradually changed over time.
This record analyzed the results of the 85048 angioplasties performed by the femoral approach in 32 centers between 2007 and 2009. The most frequently used devices in the registry were the Angio- Seal (St. Jude Medical, Minneapolis, MN) with 56.5%, Perclose (Abbott, Santa Clara, CA) with 9.7% and Starclose (Abbott) with 9.5 %. Out of all those patients, 28 528 (37%) received percutaneous closure devices; these were younger and less likely to have comorbidities or primary angioplasty than those who received manual compression. Given these differences in the baseline characteristics of both groups we decided to use propensity score having 68874 patients in the final analysis.
In patients receiving closure devices a reduction of vascular complications was observed (OR 0.78, CI 95% 0.67 a 0.90; p= 0.001). And the need for transfusions post procedure (OR 0.85, IC 95% 0.74 a 0.96; p= 0.011), compared to those in which manual compression was performed to remove the introducer. Within vascular complications, closure devices reduced the risk of hematoma (the most common vascular complication OR 0.69; CI 95% 0.58 a 0.82; p< 0.001) and Pseudoaneurysm
(OR 0.57; CI 95% 0.41 a 0.78; p= 0.007) but increased the risk of retroperitoneal bleeding (OR 1.57; CI 95% 1.13 a 2.16; p= 0.001). This benefit was seen in all subgroups except for patients with a body mass index below 25 kg/m2 and those who had received IIBIIIB glycoprotein inhibitors. Intra-hospital mortality was similar between groups.
Conclusion:
Percutaneous closure devices were associated with a significant reduction in vascular complications and the need for transfusions in this great record of coronary angioplasty by femoral access. The above benefit is lost in patients who received glycoprotein inhibitors or had normal or underweight and should be counterbalanced by the increase in retroperitoneal hematomas.
Editorial comment:
The small but significant increase in retroperitoneal hematomas with closure devices is not a minor detail because it is one of the most serious vascular complications. Obese patients are most benefited by the closure devices but do not forget that so are the radial access.
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