Sofortige Blutstillung der Arteria femoralis nach Herzkatheter: aktueller Stand der Verschlusssysteme

Zusammenfassung

Für diagnostische Herzkatheter und Koronarinterventionen ist die A. femoralis mit über 95 % der meist benutzte Zugang. Die Blutstillung der A. femoralis nach erfolgter Katheteruntersuchung mittels manuellen „Abdrückens” und anschließendem Anlegen eines Druckverbandes führt jedoch zur unbequemen, mehrstündigen Immobilisierung der Patienten.

Seit der Einführung des ersten femoralen Verschlusssystems 1991 haben zahlreiche Verschlusssysteme das Konzept der signifikanten Verringerung der Hämostasezeit bei gleichzeitiger Steigerung des Wohlbefindens der Patienten unter Beweis gestellt. Es gibt 24 arterielle Verschlusssyteme mit unterschiedlichen Konzepten, wie z. B. reines Kollagen, Kollagen+Thrombin, Kollagen+Anker, Gefäßnaht, Scheiben, hämostatische Pflaster, Klammern und andere. Die vier z. Zt. gebräuchlichsten Systeme sind Angio-Seal^® (46 %), Perclose^® (32 %), VasoSeal^® (14 %) und Duett^® (3 %). Für alle diese vier Verschlusssysteme wurde ihre Wirksamkeit in jeweils einer prospektiven, randomisierten, kontrollierten Multicenterstudie unter Beweis gestellt. Basierend auf zehn Vergleichsstudien mit überwiegenden bzw. ausschließlichen Koronarinterventionen an 8832 Patienten wurde die Wirksamkeit und Sicherheit der Verschlusssysteme analysiert. Eine gesicherte Überlegenheit des einen oder anderen Verschlusssystems konnte jedoch nicht abgeleitet werden. Erfreulicherweise zeichnet sich in den letzten Jahren der Trend ab, dass Verschlusssysteme im Vergleich zur manuellen Kompression die Rate an peripheren Komplikationen reduzieren. Somit sind arterielle Verschlusssysteme zunehmend kosteneffizient. Verschlusssysteme sollten immer dann eingesetzt werden, wenn längere Liegezeiten in Rückenlage vom Patienten nicht gut toleriert werden können, Glykoprotein IIb/IIIa Inhibitoren eingesetzt werden oder eine rasche Entlassung vorgesehen ist. Bei peripherer arterieller Verschlusskrankheit, sehr dünnkalibrigen Gefäßen insbesondere mit relevanten Plaques in der A. femoralis sollten Verschlusssysteme in der Regel nicht verwendet werden. Arterielle Verschlusssysteme nach Femoralispunktion sind heute ein wichtiger Bestandteil der invasiven Kardiologie.

Summary

The femoral approach is the most commonly used route for diagnostic cardiac catheterization and coronary interventions today. Manual compression and pressure bandages usually lead to immobilisation of the patient for several hours and may result in significant discomfort. Since the introduction of the first femoral closure device in 1991, many devices have proven their efficacy in significantly reducing time to hemostasis while simultaneously improving patient comfort. Twenty four closure device systems with different concepts are on the market, e. g. pure collagen, collagen + thrombin, collagen + anchor, vascular suture, hemostatic patches and pads, staples and more. The four predominantly used are Angio-Seal (46 %), Perclose (32 %), VasoSeal (14 %) and Duett (3 %). The effectiveness of all four systems has been proven in a prospective, randomized, controlled multicenter trial each. Efficacy and safety were analyzed using data from ten comparative studies in 8832 predominantly or exclusively interventional patients, however none of the closure systems proved to be superior.

Fortunately, recent years have shown a trend toward a reduction in local complications by vascular closure devices compared to manual compression. Closure devices are thus becoming increasingly cost effective. Vascular closure systems should be preferred when the prolonged supine position is not tolerated, a protein IIb/IIIa-inhibitor was used during the procedure, or early discharge of patient is anticipated. In the presence of peripheral vascular disease, small diameter of the femoral vessels or stenotic lesions in the femoral artery, closure devices should be used with caution. Closure systems for immediate femoral puncture site hemostasis are now an important tool of invasive cardiology today.

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