1. “Pre-Close” Technique: A Step-by-Step Description
Zvonimir Krajcer, MD
Program Director- Peripheral Vascular Interventions
Department of Cardiology, St. Luke’s Episcopal Hospital and
Texas Heart Institute, Houston, TX

2. Disclosures
On the speaker’s bureau for W.L. Gore, Endologix, Medtronic, Volcano, Abbott Vascular
Training courses for: W.L. Gore, Endologix, Medtronic, Volcano, Abbott Vascular, BARD
Consultant for W.L. Gore, Endologix, Medtronic, Abbott Vascular
Off-label use of some products may be discussed

3. CFA Access Management for EVAR and TEVAR
Depend on:
Patient selection

4. Pre-procedural Evaluation
Use CT to determine CFA suitability for
‘Pre-close’
Suitable CFA Access Site
Not Suitable Access Site!
Not Suitable Access Site!
The only preoperative evaluation that is usually required is the thin-collimated computerized tomography (CT) with 3-dimensional reconstruction. This test measures all the parameters necessary to determine the suitability for percutaneous endovascular aneurysm repair. Appropriate device lengths and diameters are chosen on the basis of this test. Information is obtained on the femoral access sites and aortic accessibility through the iliac vessels. This test also determines the iliofemoral artery diameters, vessel tortuosity, degree of calcification, and specific location of the femoral bifurcation.
Reference:
Morasch MD. Percutaneous thoracic and abdominal aortic aneurysm repair. Ann Vasc Surg. 2005;19:
[Morasch, 2005](/p585/col2/para2)

5. Tested Vascular Access Closure Devices for EVAR,TEVAR& TAVR
ProGlide™
Prostar XL ™
Prostar XL™
ProGlide™
Profile
10 F 6F
Suture(s)
Tevdek, braided
Monofilament
Knot
Operator tied
Pre-formed
No. of devices
1 for sheaths up to 24 F
2 for sheaths up to 24 F
Caution: The use of suture-mediated closure devices for endovascular aneurysm repair is off-label in the US

6. ‘Pre-close’ Technique
Micropuncture kit
Fluoroscopy
Duplex (USN)
Doppler needle
FA Angiogram
Micropuncture needle
Micropuncture introducer

7. ‘Pre-close’ Technique with ProGlide
Advance first ProGlide over 0.035” guidewire until pulsatile bleeding from side port
Remove the wire 1

8. ‘Pre-Close’ Technique with ProGlide2 3
Rotate 30o medially 4
Deploy suture

9. ‘Pre-close’ Technique with ProGlide
Deploy the second Proglide rotating it 30o laterally
Insert 7/9 Fr sheath for hemostasis
Tag sutures and leave for later closure
Repeat the same for contralateral side
2 ProGlides
Fo reach acces
site

10. ‘Pre-Close’ Technique with ProGlide
After completion of EVAR or TEVAR pull up on the rail to remove slack at the arteriotomy
Tighten down knot with knot pusher, then lock suture
Remove wire when hemostasis is achieved
Cut the suture
Reverse heparin -(selectively)
Manual pressure 5 min

11. ‘Pre-close’ Technique with ProGlide
If ProGlide misdeploys (1-5%) on entry, remove it and place a new one
In obese patients, make sure you are intraluminal (may require compressing skin)
Be careful not to prematurely lock the pre-formed knot

12. Over the wire Device (wire port)
‘Pre-close’ Technique with Prostar XL™ One device is sufficient for sheath sizes up to 24F!
Over the wire
Device
(wire port)

13. ‘Pre-close’ Technique with Prostar XL™
The device is gradually advanced through a 1 cm skin incision at 45° by rotating the hub in a CW or CCW direction to achieve a blunt dissection of the subcutaneous tissues
45°
The risk of vascular complications was 3.7% with percutaneous access as compared with 15.1% with surgical repair. With percutaneous access, a reduced incidence of groin infections, neuropathies, and hematomas was noted, along with a reduced need for embolectomy.
Reference:
Mussa FF, Mitchell JH, Naoum JJ, Krajcer Z, Lumsden AB. Fellows debate: access for EVAR. Endovascular Today Web site. Available at: Accessed February 13, 2006.
[Mussa, 2006](/p81/col1/para1)

14. ‘Pre-close’ Technique with Prostar XL™
Deploy the needles when pulsatile flow
appears in the marker lumen

15. Remove Prostar XL™ Needles
‘Pre-close’ Technique with Prostar XL™
Remove Prostar XL™ Needles
Remove the needles and cut the sutures

16. ‘Pre-close’ Technique with Prostar XL™
Two green & two white sutures are then secured with separate hemostats
Prostar XL device is then retracted until the wire port is visible
The .035 guide wire is then advanced through a wire port & the Prostar XL device is removed
The risk of vascular complications was 3.7% with percutaneous access as compared with 15.1% with surgical repair. With percutaneous access, a reduced incidence of groin infections, neuropathies, and hematomas was noted, along with a reduced need for embolectomy.
Reference:
Mussa FF, Mitchell JH, Naoum JJ, Krajcer Z, Lumsden AB. Fellows debate: access for EVAR. Endovascular Today Web site. Available at: Accessed February 13, 2006.
[Mussa, 2006](/p81/col1/para1)

17. ‘Pre-close’ Technique with Prostar XL™
The risk of vascular complications was 3.7% with percutaneous access as compared with 15.1% with surgical repair. With percutaneous access, a reduced incidence of groin infections, neuropathies, and hematomas was noted, along with a reduced need for embolectomy.
Reference:
Mussa FF, Mitchell JH, Naoum JJ, Krajcer Z, Lumsden AB. Fellows debate: access for EVAR. Endovascular Today Web site. Available at: Accessed February 13, 2006.
[Mussa, 2006](/p81/col1/para1)
After completion of EVAR, 2 white and 2 green sutures are separated & sliding knot technique is used by looping the non-rail suture 5 times around the rail suture

18. ‘Pre-close’ Technique with Prostar XL™
Reintroduce
the Dilator
Introduce
.035 SS Hydrophilic wire

19. ‘Pre-close’ Technique with Prostar XL™
The sheath and the dilator are slowly retracted over a super stiff hydrophilic guide wire , while advancing the sliding knot

20. ‘Pre-close’ Technique with Prostar XL™
Hemostasis is achieved with advancing the knot with a knot pusher and locking the knot by pulling on the non-rail suture

21. How to Resolve a Problem with Suboptimal Hemostasis
Technical success can be achieved in 97% of patients!
Maintain arterial access with .035 super stiff hydrophilic wire!
Advance a dilator (11-18F) & sheath to achieve hemostasis!
Compression device is useful
Reverse heparin
Local thrombin helps with minor bleeding
If above measures fail, surgical exposure and direct repair is needed

22. Thank You