Chief Medical Editor's Page
New Tools for an Old Problem
In 1951, Sven Seldinger, MD, introduced his technique in which percutaneous access to the arterial tree was made possible without the need for a surgical cutdown. Ever since then, manual compression of the puncture site has been, and still is, the gold standard for access site closure. The term gold standard implies that it is the best available option, but in no way does it mean that it is a perfect option without room for improvement. Manual compression probably will continue to be the gold standard for certain conditions, such as a low-profile puncture made in a healthy vessel without ongoing anticoagulation. However, more challenging conditions are being encountered with increased frequency. This is due to a number of factors, including the use of larger sheaths, an aging patient population (often with hypertension and other comorbid conditions), more frequent use of GP IIb/IIIa antagonists and anticoagulation regimen, and the availability of advanced endovascular devices that allow us to treat sicker patients in whom the femoral artery is often diseased. Under such suboptimal conditions, manual compression was the gold standard simply because there were no alternative options. This point is well made by David Allie, MD, who has made an important and interesting observation regarding the shortcomings of manual compression. In this month’s issue of Endovascular Today, we highlight the issues related to access site closure and the devices that are available, as well as those that are on the horizon. In addition, we are fortunate to have Zoltan Turi, MD, the true authority in this field, contribute an insightful editorial that will give our readers a good understanding of the current issues that are present, and where this field is headed in the future.
The field of endovascular devices, including access site closure devices, is advancing rapidly, with new devices being introduced on a monthly basis. However, there are no satisfactory means for the physician to obtain updated information regarding this dynamic field. A traditional peer-reviewed journal is obviously not suited for the dissemination of such information. Although educational meetings and symposiums offer updated information, they are not always easy for a busy physician to attend. One of the missions of Endovascular Today is to provide timely information that may otherwise be difficult to obtain. This was one reason why we chose to present this topic in the current issue. We hope that this month’s feature articles will provide readers with an overview of issues related to access site closure and serve as a catalogue of various access site closure devices.
It is true that the first-generation access site closure devices were not very sophisticated, and therefore, the expected benefit of closure devices, namely improved safety, patient comfort, and cost effectiveness were not apparent. In addition, although rare, new and more severe complications, such as distal embolization, arterial dissections and infection were encountered with these early devices. Some users may have been dissatisfied and even discouraged with the performance of first-generation devices, but progress will continue and the newer devices described in this issue will hopefully address these problems and realize the expected benefit. We hope that this issue of Endovascular Today will help our readers keep up with the rapid advancements made in this exciting field.