DOI: 10.4244/EIJV15I1A4

Improving our knowledge about a new plug-based vascular closure device

Didier Tchétché1, MD

The year 2019 has ushered in new insights concerning transcatheter aortic valve implantation (TAVI). We learnt that this treatment could be equal or even superior to surgery in low-risk patients in terms of mortality, stroke, rehospitalisation and bleeding1,2. This reflects the improvement observed since the first-in-man case in 2002. We have witnessed a constant evolution in the devices utilised with better profiles, repositionability, more stable deployment, sealing features and a wider range of treatable annuli3. Various aspects of the procedure have also evolved during the last decade including (non-exhaustively) the use of cerebral protection devices, radial artery as the accessory access site and pacing through the left ventricle wire4.

TAVI-related complications have improved over time thanks to refinements in technology and the growing experience of operators. One of the aspects of the procedure that has remained immutable is vascular closure devices (VCD) for the main arterial access. Prostar® and ProGlide® (Abbott Vascular, Santa Clara, CA, USA) have been extensively used, despite their inherent limitations, because there was no alternative. Efforts have been made to understand which of them was the most efficient, without clear conclusions5. In the PRAGMATIC initiative, vascular complications were mainly driven by the failure of these closure devices6. We all agreed that improvements were needed in this regard. The MANTA™ vascular closure device (Essential Medical Inc., [now Teleflex], Morrisville, NC, USA) was recently introduced and has rapidly gained interest in a number of European centres. It consists of a bioresorbable toggle and a large collagen plug7. Low rates of vascular complications and bleeding were reported with this novel VCD8. Propensity-matched analyses demonstrated lower major vascular complication rates with MANTA as compared to ProGlide in patients undergoing TAVI9,10. MANTA seems to be an improvement compared with the historical VCD utilised so far. Apart from its efficiency in preventing major vascular complications, what may strike one is its ease of use, with a reasonably short learning curve and reproducible haemostatic and angiographic results.

However, as no device is perfect, we need to improve our understanding about its real performance in large-scale daily practice, its scope of application, limitations and potential complications. Personally, I would use the MANTA as a bail-out tool for torrential bleeding post failure of preclosure with suture-based devices. Ali and colleagues recently reported a similar case11. Echographic guidance could be of tremendous help in such rescue situations, in order to confirm the position of the toggle within the common femoral artery before deployment of the collagen plug (Figure 1).

Figure 1. Echographic identification of the location of the MANTA toggle within the arterial lumen (yellow arrow) before deployment of the collagen plug.

In this issue of EuroIntervention, two reports answer important questions we may have concerning this novel VCD. Kroon et al12 demonstrate for the first time the successful use of MANTA for a fully percutaneous right axillary TAVI.

The transaxillary approach has been explored since the early days of TAVI because of its similarity, in terms of outcomes and recovery, with transfemoral procedures. This access route has even become the first alternative to transfemoral TAVI, as compared to apical or direct aortic techniques13. Right axillary TAVI being technically more challenging than left access, partly because of the vascular tortuosity which has to be overcome, securing the arteriotomy closure is of paramount importance for a fully percutaneous approach. This report from Kroon et al is reassuring in this regard. A stepwise approach has to be applied but the potential superiority of MANTA for haemostasis over the previously available VCD could be an asset for the right axillary technique.

As no VCD is 100% efficient, besides this exciting expansion of the indication for MANTA, Wong et al14 describe a potential complication that may occur and the way to use it as a bail-out tool.

The team discusses the potential reason for the occurrence of this event and its prevention. It reminds us that this closure device can lead to potential complications inherent to plug-based platforms. Given the dreadful impact of vascular complications and bleeding on survival, understanding the optimal use of MANTA and the prevention/rapid treatment of related vascular complications provides important information for the medical community. Both teams should be congratulated for their contributions that clearly improve our knowledge about the MANTA VCD. Have a good read!

Conflict of interest statement

The author has no conflicts of interest to declare.


References

Volume 15 Number 1
May 20, 2019
Volume 15 Number 1
View full issue


Key metrics

Suggested by Cory

10.4244/EIJV14I15A262 Feb 7, 2019
New large-bore closure technology: time to plug in?
van Gils L and Van Mieghem NM
free

Image – Interventional flashlight

10.4244/EIJ-D-18-00700 May 20, 2019
Plug-based closure in completely percutaneous right-sided transaxillary transcatheter aortic valve implantation
Kroon H et al
free

Image – Interventional flashlight

10.4244/EIJ-D-18-01171 May 20, 2019
Percutaneous management of an embolised MANTA large bore arteriotomy closure device
Wong Y-H et al
free

TECHNICAL REPORT

10.4244/EIJV12I7A147 Sep 18, 2016
MANTA, a novel plug-based vascular closure device for large bore arteriotomies: technical report
van Gils L et al
free
Trending articles
152.9

Clinical research

10.4244/EIJ-D-20-01125 Oct 20, 2021
An upfront combined strategy for endovascular haemostasis in transfemoral transcatheter aortic valve implantation
Costa G et al
free
47.8

NEW INNOVATION

10.4244/EIJ-D-15-00467 Feb 20, 2018
Design and principle of operation of the HeartMate PHP (percutaneous heart pump)
Van Mieghem NM et al
free
39.1

Clinical research

10.4244/EIJ-D-22-00558 Feb 6, 2023
Permanent pacemaker implantation and left bundle branch block with self-expanding valves – a SCOPE 2 subanalysis
Pellegrini C et al
free
38.95

State-of-the-Art

10.4244/EIJ-D-23-00912 Oct 7, 2024
Optical coherence tomography to guide percutaneous coronary intervention
Almajid F et al
free
X

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

EuroPCR EAPCI
PCR ESC
Impact factor: 7.6
2023 Journal Citation Reports®
Science Edition (Clarivate Analytics, 2024)
Online ISSN 1969-6213 - Print ISSN 1774-024X
© 2005-2024 Europa Group - All rights reserved