Plug-based bailout after failed suture-based large-bore vascular access closure: one more arrow in the quiver for experienced hands?

Despite a continuous decline in procedure-related complications during transcatheter aortic valve implantation (TAVI) procedures over the last decade, vascular complications represent a persisting challenge even in contemporary, lower-risk patients1. From a conceptual standpoint, two main strategies have been pursued to achieve safe and effective large-bore arteriotomy closure: i) a percutaneous dual suture-based closure technique, including subsequent modifications of placement technique2; and ii) use of plug-based vascular closure devices (VCD) specifically designed for large-bore arterial access closure. Recently, the randomised MASH3 and CHOICE-CLOSURE4 trials have reported clinical outcomes following different vascular access closure strategies in patients undergoing TAVI. A pure plug-based vascular closure technique using the MANTA VCD (Teleflex) was associated with numerically higher rates of access site-related vascular complications compared to a primary suture-based strategy using the double ProGlide (Abbott) technique in the MASH trial and with a significantly higher rate of access site- or access-related vascular complications in the larger CHOICE-CLOSURE trial34. In the latter trial, major access site-related vascular complications were observed in <4% of patients, indicating that the primary endpoint was...