{'fraction_non_alphanumeric': 0.028617277346884195, 'fraction_numerical': 0.006418828563787109, 'mean_word_length': 5.285714285714286, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Re: “The Use of Vascular Closure Devices Outside the Catheterization Laboratory After Neurointerventional Procedures Is Safe and Effective: Evidence From a Retrospective Study” by Khatri et al.

The article by Khatri et al. highlights the reactive rather than proactive approach to the use of vascular closure devices (VCDs) by some users. In their introduction, they enumerated several situations in which VCD use is not preferred in the catheterization laboratory: an elevated activated clotting time (ACT), rapid patient turnover to accommodate emergent procedures, and the need for immediate post-procedure neuroimaging or neurological examination, short-term arterial blood pressure monitoring, or secure access when a repeat procedure is considered. There are several issues that we would like to address regarding these situations and the authors’ technique. First, not using VCDs in antegrade femoral punctures seems to be a rather baseless contraindication steeped in the history of the Instructions for Use (IFU) rather than any scientific rationale; it is ‘‘off-label’’ simply because no one has sought to make it otherwise. At our institution, the vast majority of lower limb interventions in the femoropopliteal-crural segments are via antegrade punctures, and we routinely use a 6-F Angio-Seal VCD (St. Jude Medical, St. Paul, MN, USA) when a 6-F sheath has been inserted. We have also employed ‘‘undersizing’’ for procedures such as endovascular popliteal aneurysm repair using the Multilayer Aneurysm Repair System (Cardiatis, Isnes, Belgium). We use a 6-F Angio-Seal following a 7-F sheath or an 8-F Angio-Seal after a 9-F sheath because the footprint of the collagen plug is actually large enough to cover the respective defects. All such patients would have had a bolus of heparin prior to intervention, but we have had few bleeding complications with ~200 such deployments: one heparin hyper-responder treated successfully with protamine and one patient who bled despite a successful deployment but responded to pressure hemostasis. Second, avoiding the use of VCDs in order to promote higher turnover seems entirely counterintuitive. Use of VCDs obviously reduces manual compression time and increases patient turnover, gains that would seem to outweigh moving the patient from the angiography suite to have a groin pressed elsewhere, with the attendant risks of failed hemostasis. Similarly, a high ACT is effectively a coagulopathy that needs to be corrected accordingly. Third, contrast injection prior to VCD deployment to confirm common femoral artery (CFA) puncture is rather excessive; simple ultrasound-guided puncture nullifies the need for either plain (as often suggested in some IFUs) or contrast-based screening. If groin punctures were planned adequately using ultrasound, or even magnetic resonance angiography in the appropriate patient, to screen the vascular anatomy, such defensive practices would be unnecessary. We routinely undertake ultrasound-guided CFA punctures that eliminate anatomical doubt from the equation and reduce the need for angiographic guidance. In our institution, MRA has all but eliminated diagnostic angiography. Prior imaging, such as CTA/MRA or duplex immediately before the procedure, will allow sizing the vessels to document whether VCD usage is appropriate or not and also indicate whether one is dealing with a high femoral bifurcation, with a higher risk of direct superficial femoral artery (SFA) or even inadvertent profunda femoris artery (PFA) puncture. Appropriate puncture of the CFA with sheath introduction into the SFA should not require any further imaging prior to Angio-Seal deployment, as is our practice. Indeed, in a J ENDOVASC THER 2012;19:689–690 689