Femoral venous hemostasis after atrial fibrillation ablation: Is figure-of-eight suture the way to go?

Catheter ablation of atrial fibrillation has been widely accepted as an effective therapy for drug refractory symptomatic atrial fibrillation (AF) or as first line therapy in select patients with symptomatic paroxysmal AF [1,2]. Several factors impact procedural outcomes and associated complications including patient characteristics, procedure volume and operator technique [3,4]. The risk of complications from catheter ablation of AF have been reported to be between 5 and 7%, with vascular complications being most common (2e4%) [2e4]. Venous sheaths ranging from 6 to 15 F are routinely used to access the femoral veins. Given the overall thromboembolic risk (0.5e5%) and periprocedural cerebral emboli (up to 10%) during AF ablation, most operators have shifted their approach to one of uninterrupted anticoagulation with more aggressive anticoagulation during the procedure to maintain an activated clotting time (ACT) > 300 seconds [3,5,6]. The evidence thus far suggests no difference in the complication rates between uninterrupted Vitamin K antagonists (VKA) and novel oral anticoagulants (NOAC) [7e9]. While the incidence of thromboembolic events is on the decline, the rate in femoral vascular complications continues to be a source of considerable distress for the patient and the physician [3,7]. Althoughmost are not life-threatening, these events prolong hospital stay, increase patient discomfort and at times may require vascular surgery intervention. Operators worldwide, therefore, have been paying special attention towards ensuring safe venous access and uncomplicated hemostasis post procedure. The published rate of groin hematoma associated with ablation procedures is as high as 13% with the incidence of femoral pseudoaneurysm and arteriovenous fistulae being 0.93 and 0.54% respectively [10,11]. Existing data points to the ultrasound guided vascular access as being fast, safe and effective in anticoagulated patients with the potential to reduce the rate of complications [12,13]. An important and sometimes challenging aspect of post procedure care is achieving adequate hemostasis particularly when uninterrupted anticoagulation is a goal. Manual compression, while being the standard method of achieving hemostasis, may require prolonged hold time, partial reversal of anticoagulation as well as post-procedure bed rest of 4e12 hours [14]. The figure of eight (FO8) suture was first described with structural heart disease interventions in children but more recent reports point to this technique being a cost-effective hemostatic method after catheter ablation of AF [14e16]. The technique involves caudal (deep) to cranial (superficial) suture around the sheath(s) insertion site(s) including the subcutaneous tissue but avoiding the femoral vessels to plug the venotomy [14]. Issa and