2025+EHRA／EAPCI／ESC临床共识声明：电生理干预的血管通路和关闭管理

Graphical Abstract

 A standardized step-by-step approach to vascular access during electrophysiological procedures: Begin by identifying patients at higher risk for vas-cular complications and consider alternative access routes in cases of inferior vena cava interruption. Allow the patient to drink clear fluids and adopt an uninterrupted anticoagulation strategy when feasible. Choose the access site based on procedural needs and patient anatomy, giving preference to ultrasound-guided puncture to improve accuracy and reduce complications. At the end of the procedure, select the most appropriate closure technique- manual compression, figure-of-eight suture, or a vascular closure device-based on access site, sheath size, and patient-specific factors.

Keywords

● Vascular access● Electrophysiology procedures● Ultrasound-guided access● Vascular closure

Table of contents

1.Introduction 2

2. Vascular anatomy 3

2.1. Femoral access.

2.2.Internal jugular and subclavian access.3

2. Transheptatic access

3. Vascular access procedure.

3.1.Pre-procedural considerations 4

3.2.Periprocedural anticoagulation 4

3.3. General techniques

3.4.Specific site considerations and site selection.

3.5.Surgical access.

4. Vascular closure techniques $\boxed{7}$

4.1. Manual compression $\boxed{7}$

4.1.1. Compression devices $\ldots$ 7

4.2.Suture techniques $\ldots$ 7

4.3. Vascular closure devices 7

4.3.1. Active vascular closure devices 7

4.3.1.1. Suture-based $\ldots$ 7

4.3.1.2. Clip-based.

4.3.2. Passive vascular closure devices 8

4.3.2.1. Collagen plugs

4.3.2.2. Sealals 8

4.4. Clinical evidence and outcomes of vascular closure devices in electrophysiology procedures

4.5.Early ambulation and early discharge considerations.\boxed 9

5.Complication avoidance and management.9

6.Specific scenarios-tips and tricks.11

7.Training requirements $\ldots$ 12

8.Economical aspects $\ldots$ 12

9.Gaps in evidence and future perspectives 14

10.Key messages $\ldots$ 14

11.Table of clinical advice$\longdots$14

Supplementary material 14

Acknowledgements $\ldots$ 14

1.Introduction

Vascular access is a fundamental aspect of all electrophysiology(EP)procedures, enabling the placement of diagnostic and therapeutic ca-theters, essential for arrhythmia management. Over recent years, ad-vancements in imaging and vascular closure techniques have significantly improved the safety and efficiency of EP procedures. ${}^{1}$ As it remains such a central element of daily workflows--and

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unfortunately an important driver of complications in all procedure types-a collaborative team of electrophysiologists and vascular specia-lists has developed this document, integrating current evidence, and providing practical guidance on vascular access management. Key sec-tions include comprehensive review of ultrasound use for vascular ac-cess, strategies for managing challenging vascular anatomies, and techniques for minimizing complications. The document also addresses the use of various vascular closure devices and methods, providing clin-ical advice based on available evidence and expert opinion. Additionally,special considerations for paediatric patients and those with anatomical variations are covered, ensuring comprehensive care for all patient po-pulations. The aim of this document is to support clinicians in their everyday practice by providing practical and actionable advice that con-solidates all aspects of vascular access into a single, comprehensive re-source. By offering evidence-based clinical advice and expert insights, it seeks to enhance procedural safety and streamline the adoption of best practices for vascular access in EP procedures.

The clinical advice provided at the end of this document was categor-ized in accordance with guidance from the EHRA scientific documents committee. The strength of published evidence was quantified in three strata based on the underlying reference material (a group for >1 high-quality RCT or a metanalysis of high-quality RCTs, a group for high-quality observational data only and a group for evidence falling between those two definitions). Consensus opinion was obtained by private vot-ing within the entire writing group and was labelled as 'consensus' if>70% of the writing group supported the advice and as 'strong consen-sus' if >90% of the writing group supported the advice.

2. Vascular anatomy

2.1. Femoral access

Venous drainage from the lower limb flows from the popliteal vein to the superficial femoral vein. This vein then connects proximally with the deep femoral vein to form the common femoral vein. The great saphe-nous vein joins the common femoral vein at this level. Above the inguin-al ligament, the common femoral vein continues as the external iliac vein and unites with the internal iliac vein to form the common iliac vein.

The femoral triangle, crucial for femoral access, is a subfascial space bordered superiorly by the inguinal ligament, medially by the adductor longus and laterally by the sartorius muscle. Within this triangle the femoral vein lies alongside the femoral artery, nerve, and lymphatics.At the upper inguinal level, the vein typically runs medially to the artery either in parallel or with lumen overlap≤50%.2 However, at a lower inguinal level, anatomical relationships of the femoral vessels vary sub-stantially with the vein coursing posterior to the artery with major lu-men overlap(>50%) in 24% of cases, while in 6% of cases the vein travels completely lateral to the artery.2 These relationships have pro-found clinical implications for the safety of femoral vascular access based on anatomic landmarks only and explain the higher risk of ar-teriovenous fistula at more inferior puncture sites, in particular for ven-ous access guided by palpation alone.

Several variants of the inferior vena cava(IVC) may be encountered impeding access to the right atrium via the typical femoral-iliac-IVC route.3 The most common variant is the absence of the hepatic seg-ment of the IVC with azygos continuation(estimated prevalence~0.6%).4 In variation, venous blood caudd or at the renal vein le-vel is shunted via the azygos/hemiazygos vein, bypassing the absent hep-atic IVC segment, reaching the right side of the heart via the superior vena cava(SVC). In several cases, hepatic vein drainage to the right at-rium remains intact, allowing for a percutaneous transphatic access route if needed(see below). Figure 1 provides a schematic overview of vascular access sites relevant to EP procedures and their relative location.

 Figure 1 Schematic of relative locations of vascular access relevant for EP procedures.

2.2. Internal jugular and subclavian access

The internal jugular vein(IJV) collects blood from the head and neck. It originates in the posterior part of the jugular foramen and descends within the carotid sheath, lying anterolateral to the carotid artery and the vagus nerve.5 The key anatomical landmarks for accessing the IJV are the two heads of the sternocleidomastoid muscle, which form a tri-angle with the clavicle as its base.

The subclavian vein (SV) starts beneath the middle third of the clav-icle, lying anterosuperior to the subclavian artery over the first rib. It joins the ipsilateral IJV posterior to the end of the clavicle and becomes the brachiocephalic or innominate vein. At the junction with the IJV, the left SV receives the thoracic duct, while the right SV receives the right lymphatic duct. As with femoral access, the use of anatomical landmarks alone for IJV or SV access carries a risk of complications by inadvertent puncture of the artery or other nearby structures.

The superior approach for ablation is the most frequently used strat-egy in case of obstruction of the IVC.6 Left atrial access and ablations have been effectively performed via the SVC.7 Additionally, ablation of right ventricular tachycardia in patients with repaired congenital heart disease and without femoral access has also been successfully car-ried out.8

2.3. Transhepatic access

The hepatic veins are large intraparenchymal veins which drain into the IVC at the level of the diaphragm, approximately 2 cm caudal to the right atrium.They are usually three in number and named as right hepatic vein(RHV),middle hepatic vein(MHV),and left hepatic vein(LHV).The RHV enters the IVC separately, but the MHV and the LHV may share a com-mon trunk in 65-85% of patients. When the IVC route is not patent due to congenital abnormalities or surgical ligation, transpheatic access can

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offer an alternative route to the right atrium, providing a‘familiar ap-proach' for transeptal access when it is needed. With meticulous plan-ning, the procedures can be carried out successfully, with a low risk of complications.6,10,11 As there are specific considerations to this approach in terms of anatomy and post-procedural management that are unique to the transepatic access(e.g. coil-based closure), consultation with opera-tors experienced in the procedure, potentially from other fields such as interventional radiology, is of great added value.

3. Vascular access procedure

3.1. Pre-procedural considerations

Pre-procedural preparation is essential for EP procedures but fre-quently overlooked. Identifying patients with potential vascular access challenges, such as known peripheral vascular disease, dialysis, pre-existing vascular access(e.g. portal catheter), anatomical obstacles such as large ingulal herniations or limb deformations, previous ab-dominal surgery or previous failed access, is crucial for procedural op-timization. A review of previous imaging studies(mostly computed tomography(CT) and magnetic resonance imaging(MRI), commonly performed for different indications, is essential to help the operator performing the procedure with planning.

The use of ultrasound-guided(USG) techniques and awareness of prior vascular access difficulties can significantly improve success rates,even in difficult or previously unsuccessful cases. Early identification of high-risk patients allows the team to prepare appropriate equipment and adjust procedural schedules to better accommodate complex cases.

Poor patient hydration, a common and modifiable risk factor, can complicate vascular access. Patients are often kept' nil by mouth' for several hours before a procedure, leading to fluid depletion. While guidelines recommend restricting oral fluid intake within 2 h of surgery to minimize the risk of gastric reflux, evidence supporting this is limited.Allowing patients to drink clear fluids until the time of the procedure has been shown to improve patient satisfaction without compromising safety.12,13

Obese patients may present additional challenges for safe vascular ac-cess due to poor ultrasound penetration and tissue compression of deep structures. Pre-procedural identification of these challenges allows for appropriate planning, including considering general anaesthesia, where Valsalva manoeuvres may be easier to employ. In some cases, tissue

strapping or even postponement of the procedure for weight loss may be necessary. See Table 1 for a summary.

3.2. Periprocedural anticoagulation

Management of periprocedural anticoagulation is critical for ensuring the safety of EP procedures, particularly regarding vascular access. To balance the haemorrhagic and thromboembolic(TE) risk, careful con-sideration of procedural and patient characteristics is needed.

The optimal management strategy for periprocedural anticoagula-tion in the setting of catheter ablation of AF has been covered in the recent consensus statement on catheter and surgical ablation of AF.In brief, uninterrupted anticoagulation should be used with either direct oral anticoagulants(DOACs) or warfarin during AF ablation proce-dures. Furthermore, implementation of a minimally interrupted DOAC anticoagulation strategy(skipping a single dose on the day of the procedure) is also reasonable prior to AF catheter ablation.

For patients on vitamin K antagonists(VKA), an uninterrupted strat-egy is guideline recommended because heparin bridging has been shown to be associated with higher TE and bleeding risk during AF ablation. 14,15 For those with DOACs, an uninterrupted strategy has been proven to be non-inferior to uninterrupted VKAs in several ran-domized controlled trials. ${}^{15-21}$ Overall, meta-analysis of these trials showed fewer major bleedings with DOACs than with VKAs while bleeding was lower in fully interrupted DOACs(4%) than in uninter-rupted(6%) or minimally interrupted DOACs(7%).22,23 However,use of uninterrupted DOACs was associated with similar TE rates and significantly less(56%) silent cerebral lesions.23,24 Although elderly patients(>75 years old) with comorbidities have a higher bleeding and TE risk, these event rates are lowered by an uninterrupted DOAC strategy,especially with apixaban.25 Thus, uninterrupted DOAC ther-apy should be the preferred strategy for EP procedures.26,27

Although not mandatory, many operators administer low-dose hep-arin even for right-sided procedures. For left-sided interventions,antic-oagulation with unfractionated heparin should be administered after femoral access and ideally before transseptal puncture, aiming for an ac-tivated clotting time of 300-400 s.14 This strategy reduces the rate of cerebral lesions that have been reported after left-sided ablations.For ablation in the pericardial space, no heparin administration is needed. Epicardial access though should be obtained before heparin in-fusion or after reversal with protamine.29,30 Before epicardial access, a minimally interrupted strategy may be useful, involving the discontinu-ation of NOACs 48 h prior to the procedure and withholding VKA until

Table 1 Summary of pre-procedural considerations

|Strategy|Description| |---|---| |Patient assessment|Comprehensive evaluation of patients to identify those with specific vascular access issues enables targeted procedural optimization| |Risk identification|Early recognition of high-risk patients allows teams to prepare appropriate equipment and adjust procedural schedules to accommodate complex cases, potentially rescheduling if needed(e.g. supratherapeutic INR)| |Peripheral cannulation|Difficult in patients with diabetes, prior chemotherapy, obesity. Use imaging or place a central venous catheter if needed| |Ultrasound-guided techniques|Utilizing USG access techniques improves success rates, particularly in patients with difficult vascular anatomy or a history of failed access attempts| |Hydration management|Ensuring adequate patient hydration before the procedure can reduce complexity during vascular access, as fluid depletion can make cannulation more challenging| |Special considerations for obese|For patients with obesity, pre-procedural planning may include the use of general anaesthesia to improve access success.|

INR, international normalized ratio; USG, ultrasound-guided techniques.

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the international normalized ratio is<1.5.31 Finally, administration of protamine at the end of the procedure was associated with faster haemostasis and ambulation, and similar complications to no rever-sal.32-34 It was also associated with adverse reactions and significant hypotension(1%).35 Thus, more recent studies with modern access and closure techniques, have questioned this strategy.36-39 These data support the use of protamine, especially in cases of access pro-blems,40 but also show that modern techniques may obviate the need for protamine and highlight the need for further studies.Post-procedural anticoagulation is based on the TE risk and should be resumed 4-6h after the procedure if no contraindication arises.31 In that case, withholding OAC or using heparin can be tailored to the patient specific TE/bleeding risks.

3.3. General techniques

Until recently, venous puncture for EP procedures was predominantly performed using traditional anatomic landmark-guided methods(e.g.femoral artery pulsation, inguinal ligament). As vascular access compli-cations are the most common complications following catheter abla-tion, techniques aimed at increasing safety were evaluated. Real-time USG venipuncture, first used for the placement of central venous ca-theters, has been associated with reduced procedure time and vascular complications compared to the standard anatomic landmark-guided ap-proach.41 Similarly for femoral venous access in catheter ablation,which often involves multiple sheaths and higher anticoagulation levels,there is substantial evidence that USG venipuncture significantly re-duces complications, mainly due to fewer inadvertent arterial punctu-res and puncture attempts.42 Given the lack of adverse effects or additional cost, the use of USG vascular access is a key component of the clinical advice throughout this document.

Ideal ultrasound probes for USG venipuncture are high-frequency linear transducers with a range of 10-15 MHz, which provide high-resolution images with limited depth penetration, making them ideal for superficial targets such as vascular access. It is useful to ensure that the probe marker aligns with the ultrasound screen to correlate needle movements with the image and ensure anatomical relationships between vascular structures are correctly represented. The initial ad-ministration of local anaesthetic agents may decrease the quality of the ultrasound image; thus, it may be preferable to administer them at the end of the ablation procedure in case general anaesthesia is used. Alternatively, a short waiting period to allow diffusion of the an-aesthetic may be useful.

Before venipuncture a good understanding of the regional anatomy is obtained by a pre-procedural scan(Figure 2 and Supplementary material online, Video S1). Arteries and veins have a similar appearance on a greyscale ultrasound image, but they are usually readily distin-guished using visual inspection alone. Typically, an artery has identifiable layers in its vessel wall, commonly with calcifications, and exhibits a pul-satile aspect which is synchronized with the heart rate. Veins in contrast usually appear with a monolayer wall, rarely show calcifications and are either non-pulsatile or show a fluctuation in diameter which does not track the heart rate. Finally, veins should readily and fully collapse under probe pressure, while arteries remain circular due to their resistance to compression. A Valsalva manoeuvre can be very helpful to further con-firm the dynamic nature of venous diameter. Colour Doppler may also be used to distinguish between artery and vein if needed but is not rou-tinely performed.

Care should be taken to perform femoral vascular puncture with a safe distance(≥1cm) below the inguinal ligament to avoid accidental bleeding into the retroperitoneal space. The safest site for femoral ven-ous puncture is at the common femoral vein, proximal to the saphe-nous intake and with a safe margin to the inguinal ligament.Practically, this can be achieved by puncturing distal to the femoral ar-tery bifurcation, which is easily visualized along the femoral vein in the

 Figure 2 The ultrasound probe has been inserted in a sterile cover together with contact gel and is held by the non-dominant hand ver-tically to the femoral vessels to obtain a short-axis view. The operator needs to move the transducer along with the needle advancement to follow its tip towards to the puncture site(creeping technique).

short-axis view. To ensure a safe needle trajectory, the puncture site should ideally be at a point where the vein and the artery lie side-by-side. The needle insertion point(distance from the probe) is es-timated from the measured vessel depth, the angle of needle insertion and the desired vessel puncture site. Femoral venous cannulation is commonly performed by using a short-axis view, where the image plane is perpendicular to both the course of the vessel and the needle(Figure 3, Supplementary material online, Video S2). This approach al-lows for easy visualization of adjacent vessels and structures.However, novice users may find it challenging to keep the needle tip in view as they advance it-it will not be possible to image the entire length of the needle and the ultrasound image of the tip and mid-portion of the needle look similar on the ultrasound screen, potentially leading to excessive advancement. To achieve safe and successful can-nulation, the operator needs to follow the needle tip with the probe using a creeping technique until it punctures the vein and/or use con-tinuous negative pressure on the syringe to identify vessel entry. It helps to keep the needle in the central portion of the probe to enable its tracking and use gentle back-and-forth movement. Alternatively, a long-axis view can be used where the image plane is parallel to the course of the vessel, allowing visualization of the longitudinal course of the vessel

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 Figure 3 Short-axis view at the level of femoral artery bifurcation where the needle tip can be followed during venous puncture.

and the full length of the needle in its trajectory to the vessel(see Supplementary material online, Video S3). Advantages of this approach are better depth control and intuitive needle movement in the field of view. However, the longitudinal view does not allow appreciation of lat-eral relationships to surrounding structures, leading to a potentially higher risk of puncturing the adjacent artery.43 Dedicated training for either approach is therefore necessary.

The maximal number of sheaths that can be safely introduced in a single femoral vein varies depending on patient and procedural factors.In practice, inserting more than three sheaths in a femoral vein is gen-erally avoided, especially when larger sheaths are required for large-diameter catheters. Observational studies have shown that insertion of more than three sheaths ipsilaterally is associated with increased risk of deep vein thrombosis following catheter ablation procedures.The use of bilateral grain puncture reduces the number of sheaths in-troduced on each side and may limit the associated risk of deep vein thrombosis. However, the latter should be weighed against the need to immobilize both legs resulting in significantly increased patient discomfort.45

For femoral artery puncture, the ideal site is located just proximal to the bifurcation. Care must be taken to avoid puncturing calcified seg-ments to ensure optimal haemostasis after sheath removal, especially if closure devices are intended to be used. The long-axis view is espe-cially valuable for femoral artery puncture as it precisely displays the re-lationship between the bifurcation and the needle trajectory.

3.4. Specific site considerations and site selection

The introduction of USG vascular access represents a fundamental evo-lution in the field of interventional procedures, offering a safer and fas-ter access method with fewer complications. This technique should be universally adopted as the standard of care.42,47 However, adoption has been inconsistent; a recent Italian survey revealed that while 46 out of 103 respondents had experience with USG access, only a fraction used it routinely.48

The jugular or subclavian approaches are less frequently employed49 but remain valuable alternatives, especially when IVC access is compro-mised.6Superior access routes also enable transseptal punctures, albeit with increased fluoroscopy times and a higher risk of operator radiation exposure.7,50 Specific complications, such as pneumothorax or hae-motherax,also present challenges with these approaches.

Recent reviews on alternative approaches for patients with ob-structed or absent IVC indicate a preference for azygos or hemiazygos vein access(24%), followed by transhepatic(14%), and retrograde

aortic(10%) approaches.6 Azygos or hemiazygos veins are cannulated using a puncture of the femoral veins. In the transhepatic approach, the needle can be introduced into the hepatic vein under ultrasound or fluoroscopic guidance.11,51

In paediatric patients, the limitations imposed by smaller vessel sizes necessitate reduced use of diagnostic catheters and/or alternative ac-cess strategies. The internal jugular and subclavian veins become crucial access sites for catheter placement, addressing the challenges of coron-ary sinus cannulation from femoral routes. The use of appropriately sized catheters and specialized techniques becomes even more critical in this demographic,emphasizing the necessity for tailored approaches in paediatric EP.52-54

Femoral arterial access is frequently used in everyday practice for retrograde left ventricular access, particularly for ablation of premature ventricular contraction or ventricular tachycardia mainly originating from the base of the heart and less commonly for mapping of ventricu-lar insertions of accessory pathways.55 An increased risk of subclinical systemic embolization with retrograde LV access compared to trans-septal LV access was shown in a randomized trial,56 that reported high-er rates of asymptomatic brain injury, assessed by a>30% increase in S100B levels post-procedure. Recently, the TRAVERSE trial, presented during the 2024 ACC, also indicated lower rates of acute cerebral injury on post-procedure MRI associated with a transseptal approach(28% vs.45%,P=0.036 in the intention-to-treat analysis, data presented but un-published),highlighting the need for careful consideration of safety as-pects when selecting between the antegrade/transetpsal vs. the retrograde/transaortic approach. Beyond the highlighted indications,comprehensive management of femoral artery access is strongly influ-enced by sheath size and its discussion falls beyond the scope of this consensus document.

Pericardial access has gained importance, especially for the ablation of VTs.Innovations since its original description by Sosa et al. have aimed at minimizing risks associated with the dry puncture technique. ${}^{57}$ Novel strategies, such as the SAFER approach, which integrates right ventricular angiography, puncture during sustained apnoea, and real-time needle visualisation through electroanatomical mapping, have enhanced safety and efficacy. Additionally, the advent of pericardial carbon dioxide insuf-flation techniques highlights ongoing innovation in access strategies, offer-ing alternatives based on local expertise and available resources. ${}^{58}$

Moreover, incorporating advanced imaging techniques, including CT and MRI, into procedural planning and execution has opened new fron-tiers in vascular and epicardial access.59 These imaging modalities offer detailed anatomical insights, facilitating a more informed approach to access site selection and catheter navigation, ultimately improving pro-cedural outcomes and patient safety.60,61

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3.5. Surgical access

Surgical access of femoral vessels may be appropriate when introducing large bore devices or to prevent potential vascular complications like pseudoaneurysom or dissection, especially in cases of calcified femoral arteries. It may also be a better option for patients with complex anat-omy, such as vessel tortuosity or a high take-off of the deep femoral ar-tery, which can raise the risk of retroperitoneal bleeding and complicate percutaneous gyro insert.47,62

For procedures requiring haemodynamic support with extra-corporate membrane oxygenation(ECMO), like unstable ventricular arrhythmia, support during ablation has shown a reduction in the ar-rhythmic burden at long term follow-up. 63 While surgical femoral ac-cess is considered the reference approach for VA-ECMO, a total percutaneous USG approach is possible for elective settings and was associated with fewer local infections and fewer sensory-motor compli-cations at the expense of increased vascular complication risks in large retrospective studies. 64,65

Surgical exposure of the femoral vessels is performed by a 2-3 cm suprainginal skin incision, to avoid wound dechiscence and infection,and runs parallel to the inguinal ligament. The incision is centred over the femoral vessels and should be USG to identify the common femoral artery above the bifurcation and the femoral vein. After gentle dissec-tion of soft tissues, the fascia lata is interrupted taking care not dam-aging the Cloquet lymph node to avoid lymphode after the procedure. Once the femoral vessels are exposed and heparin is given,purse-string sutures with polypropylene are performed. Venous cannu-lation is performed with a 25 Fr multistage venous cannula inserted through the femoral vein into the right atrium, and the correct position achieved with the Seldinger technique under transcesophageal echo-cardi-cardiographic guidance. A 16-20 Fr arterial cannula(depending on pa-tient's size) is inserted in the common femoral artery via Seldinger technique and ECMO is established66(see Supplementary material online, Video S4).

If femoral arteries are not suitable for cannulation(calcified vessel or peripheral vessel disease), ECMO or other large bore access(e.g.Impella) can be established through the right subclavian artery(see Supplementary material online, Video S5).

Finally, surgical access is also considered in case of bail out option for failed access or for bleeding complications. For the latter, it is essential to keep a guidewire in situ and insert a vascular dilator to control the bleeding, thereby maintaining an access route to the intraluminal space beyond the bleeding site to allow vascular access for repairing the ves-sel, potentially using endovascular tools.

After surgical cut-down for arterial access, conventional vessel su-tures are used for closure, but this method increases the risk of wound infections and iatrogenic nerve damage.67 Compared to surgical cut-down and closure, VCDs have been associated with fewer groin com-plications and shorter procedural time.68

4. Vascular closure techniques

The optimal vascular haemostasis technique depends on factors like vessel type(vein or artery), vessel site(e.g.femoral, jugular, subclavian),number of sheaths, and maximal sheath calibre. Generally, vascular ac-cess site haemostasis can be achieved by manual compression, suture techniques and vascular closure devices.

4.1. Manual compression

For arterial access sites, a simple rule is to compress the site at supra-systolic pressure for a duration corresponding to three times the French size of the sheath being removed(i.e. 18 min for a-French sheath).For femoral venous sites, no such rule exists. However,large calibre venous sheaths typically require a minimum of 10 min of

manual compression especially when associated with periprocedural anticoagulation. Typically, after successful compression a bandage is applied to provide further compression while bed rest is needed for variable duration of at least several hours, depending on procedure type and institutional practice.

4.1.1. Compression devices

Specialized mechanical compression devices have been developed for different access sites, FemoStop(Abbott Vascular, Santa Clara, CA,USA) or ClampEase(Pressure Products, Ranco Palos Verdes, CA,USA) for femoral artery,TR Band(Terumo Corporation, Tokyo,Japan), PrecludeSYNC(Merit, Jordan, UT) or TRAcelet(Medtronic)for radial and ulnar arteries or the Safe-Guard family of devices(Merit, Jordan, UT) that can accommodate different access sites.

4.2. Suture techniques

Suture-based vascular closure techniques use the perivascular skin and subcutaneous tissue to apply external compressive forces over the ve-notomy. For femoral venous access site closure, subcutaneous suture techniques include the purse-string suture and the figure-of-eight(or Z-stitch) suture. The figure-of-eight stitch involves making two criss-crossing passes of the needle through the tissue on either side of the sheath insertion. When the suture is tightened, it pulls the tissue to-gether in an overlapping pattern, resembling the shape of the number 8. The purse-string suture involves passing a continuous stitch through the skin at 4 or 5 points around the sheath, creating a constricting loop with the ends left free, making it particularly suitable for large-bore ac-cess closure. Modifications of classical sutures include the'three-way stopcock suture technique', a figure-of-eight stitch where a stopcock pulls the skin by rotating the lever(Figure 4, Supplementary material online, Videos S6 and S7), and the'Woggle', a purse-string variant using a tension collar and suture lock for adjustable tension without knot-ting. These techniques allow for adjustable suture tensioning by pulling(or releasing) the end of the sutures until haemostasis is achieved(Figure 5).

4.3. Vascular closure devices

With the increase in procedure volume and the growing use of larger vascular sheaths, the vascular closure device(VCD) market has rapidly expanded since the early 1990s to assist the physician in achieving haemostasis. Commonly used VCDs are summarized in Table 2.While originally developed for closure of arterial access, several VCDs have been studied for venous closure as well and are discussed as such below.

When discussing VCDs, it is helpful to categorize them systematically based on their mechanisms of action. We can consider two main cat-ories: active closure devices, which physically close the arteriotomy using a suture or nitrol nclip, and passive closure devices, which deploy a plug, sealant, or gel at the arteriotomy site without actively closing the arteriotomy(Figure 6).

4.3.1. Active vascular closure devices

4.3.1.1. Suture-based

Suture-based VCDs were among the first developed, designed to mi-mic open surgical closure by percutaneously deploying sutures on ei-ther side of the arteriotomy, which are then pulled together to achieve haemostasis. The Perclose ProGlide(Abbott Vascular, Santa Clara, CA) is approved for venous closure and compatible with 5-21 F arterial sheaths[up to 26 F outer diameter(OD)] and 5-24 F venous sheaths(up to 29 F OD). The latest version, ProStyle(Abbott Vascular), offers improvements over ProGlide, including stronger needles for better penetration,reduced plunger spring force for smoother deployment, and added lubrication to decrease deploy-ment force. When using suture-based closure devices it is of crucial

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 Figure 4 Step-by-step guide: performing a figure-of-eight stitch with a 3-way stopcock. The steps including a 3-way stopcock are optional(see text).For a traditional knot, after Step 4 tie both wire ends over the skin to achieve haemostasis.1-(optional) Insert the wire: begin by threading the wire into one end of the 3-way stopcock; 2-First pass: guide the wire under the skin and the venous sheath; 3-Cross the sheath: direct the wire across the venous sheath; 4-Second pass: pass the wire under the skin again, this time looping over the venous sheath; 5-(optional) Reinsert the wire: insert the wire back into the same end of the 3-way stopcock; 6-(optional) Tighten the stitch: pull both ends of the wire upward while gradually removing the venous sheath; 7-(optional) Achieve haemostasis: slowly turn the 3-way stopcock lever to apply tension, ensuring proper haemostasis.

importance to deploy the device before sheath insertion when using a sheath size of 9 F or greater. Advantages of suture-based VCDs in-clude complete physical closure of the arteriotomy, allowing unre-stricted re-access and reducing concerns about anticoagulation.Disadvantages are a steep learning curve and the risk of luminal distor-tion due to the suture closure.

4.3.1.2. Clip-based

The StarClose SE(Abbott Vascular) deploys a 4-mm nitlinol clip over the arteriotomy and requires a sheath exchange but leaves nothing intravascularly.The metallic clip remains in place indefinitely.

4.3.2. Passive vascular closure devices

This class of VCD deploys a plug, sealant, or gel over the arteriotomy site without physically closing it. Haemostasis is achieved because the material expands when deployed in the subcutaneous tissues, and collagen-based plugs also accelerate the clotting cascade.

4.3.2.1. Collagen plugs

The Angio-Seal(Terumo Corporation, Tokyo, Japan) is the most widely used VCD, employing an intravascular anchor to secure an extravascular collagen plug over the arteriotomy. All components are fully absorbed within 60-90 days. The device's intravascular anchor secures the plug,promoting haemostasis without compression but carries a risk of distal embolization, especially if re-entry is required within 90 days.

The Vascade system(Haemonetics, Boston, MA, USA) is a fully extravascular, bioasorbable femoral closure device, that combines a

collapsible disc with a thrombogenic resorbable collagen patch, provid-ing both mechanical and physiological haemostasis. The Vascade MVP is specifically designed for mid-bore 6-12 F ID(Max 15 F OD), multi-access venous closure following catheter ablation.

The use of two VCDs, whether suture-based, plug-based, or a com-bination of both, is an established technique for percutaneous closure of large-bore access,69 as in the case of electrophysiological procedures requiring mechanical circulatory support.

4.3.2. Sealants

The Mynx(Cordis; Milpitas, CA, USA) family of devices delivers a poly-ethylene glycol sealant to the extravascular space over the arteriotomy site.The sealant expands by up to 300% when deployed, sealing the vessel without enhancing coagulation. This closure method requires no sutures,clamping, or metal implants and dissolves within 30 days. It does not re-quire sheath exchange and is also approved for closing femoral veins.

4.4. Clinical evidence and outcomes of vascular closure devices in electrophysiology procedures

Vascular closure devices have no absolute contraindications. Relative contraindications include dense arterial calcifications in the access ves-sel, entry above the inguinal ligament, small access artery site and the presence of an ipsilateral stent. In the case of suture or plug-mediated VCDs, the intravascular wire or anchor may become entangled in the stent strut, making it difficult to achieve haemostasis. To reduce

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 Figure 5 The panels above illustrate the two main classical suture techniques. Below, two modified techniques are shown:(left) the modified figure-of-eight technique with a 3-way stopcock and (right)the wogle technique (a purse-string method with a tension collar and suture lock), both enabling adjustable tension without requiring knotting. Dash lines represent the suture passing under the skin.

<BeginOfPara>The risk of VCDs for venous puncture has increased in recent years,

The use of VCDs for venous puncture has increased in recent years,particularly with large-bore sheaths and the rise of same-day discharge strategies. In the AMBULATE trial, the Vascade MVP, significantly re-duced time to ambulation and time to haemostasis without increasing complications. ${}^{70}$ The ProGlide system reduced time to discharge, im-proved patient satisfaction, and lowered costs compared to overnight stays. ${ }^{71,72}$ Recent randomized data confirm this trend, also showing fewer minor vascular access complications [7(11.1%) vs.15(24.2%);P=0.063]. ${ }^{73}$ VCDs have also been successfully used in pulse field abla-tion workflows with 16.8 F OD sheaths. ${ }^{74}$ A strategy involving device deployment immediately after vascular access, without tightening the su-tures, demonstrated lower re-bleeding rates and faster haemostasis com-pared to a strategy where the device is deployed after the procedure. ${ }^{75}$

4.5. Early ambulation and early discharge considerations

The use of closure techniques beyond manual compression has led to a vast expansion of procedure types now deemed appropriate for early ambulation and same-day discharge. Suture techniques allow early am-bulation at virtually no additional disposable cost, although some form of spontaneous haemostasis(and therefore bedrest for a few hours) is still needed, which can be further accelerated using VCDs if so desired(e.g. patient preference, scheduling/operational reasons). These shor-tened workflows have led to indirect changes that further stand to im-prove periprocedural safety. For example, foley catheter insertion for AF procedures has become unnecessary in most settings due to shor-tened total supine time. In addition, routine protamine administration is no longer considered useful after suture closure despite heparin admin-istration. Finally, while anatomical features/body and habitus and body mass

<EndOfPara>index (BMI) can make manual compression challenging, these features do not typically impact the efficacy of suture closure or VCDs, enabling standardized discharge workflows for the majority of patient profiles.

5.Complication avoidance and management

Several previous observational studies reported on the utility of ultra-sound guidance in catheter ablation of different substrates, including AF.76-79 A recent meta-analysis evaluated the safety of USG femoral vein access compared to the traditional anatomic landmark guidance in all EP procedures.42 Nine studies (1 randomized controlled trial and 8 observational), with 7858 participants (3743 in the USG group,4115 in the control group), were included. Overall vascular complica-tion rates in all EP procedures were significantly decreased in the USG group compared to the control group (1.2% vs. 3.2%, RR: 0.38,95% confidence interval: 0.27-0.53). Of interest, one randomized study included in this analysis documented additional benefits of USG, such as shorter puncture time, higher first-pass success and less extra puncture attempts or inadvertent arterial punctures.77 The magnitude of this ef-fect was consistent among trainees and experienced operators. Similar results were described when a mixed population of venous and arterial access patients was studied.80 Interestingly, patients with BMI>30 kg/m2 showed larger benefit from a USG vascular access. Other studies found age 78 or female gender 81 as significant predictors of vascular complications.

Observational data suggest that simple suture closure technique(Z or figure-of-eight stitch) may obviate the need for protamine ad-ministration by achieving haemostasis after venous sheath removal.36,38 Two small randomized controlled trials have demonstrated the clinical efficiency of the suture technique, showing reduced time in the EP lab,earlier ambulation, and a lower rate of access site complications when using large(≥10 F) sheaths.82,83

The mode of failure and complications of VCDs vary by type and include bleeding, pseudoaneurysm formation, arterial obstruction,and infection. Collagen plugs most commonly cause bleeding and pseu-daneourysm formation when the plug fails to reach the adventitial sur-face of the arteriotomy, often due to inadequate tissue dilation or femoral scarring. Additional risks include intravascular deployment and vessel dissection, particularly in small vessels. All VCDs can poten-tially cause femoral artery occlusion, either through the anchor plate or the suture engaging the intima on the posterior wall.

Vascular closure devices approved for venous closure have shown significant decrease in time to ambulation, total post-procedure time,time to discharge eligibility time to haemostasis and opioid use, with in-creased patient satisfaction and no increase in complications.7037 Observational data shows a potential for complication reduction and cost containment using closure devices although these observations have not yet been confirmed in randomized trials.70,71,73,84

Sheath size significantly impacts bleeding and complication risks dur-ing femoral access. ${}^{85}$

For arterial haemostais, VCDs have improved patient comfort and reduced time to haemostasis and ambulation after percutaneous pro-cedures. Meta-analysis of earlier studies demonstrated comparable complication rates in comparison with manual compression, with low occurrence of major complications. Although the risk of infections(0.6% with VCDs vs. 0.2% with MC) and thrombotic complications(0.3% with VCDs vs. none with MC) is slightly higher when compared to MC. ${}^{86}$ However, studies after 2005 reported reduced complications,especially haemostomas with AngioSeal or FemoSeal devices. ${}^{87}$

For early recognition of vascular complications, some centres adopted a strict protocol for their pre-discharge assessment, aiming to detect complications at the potential preclinical stage using ultrasound.

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Table 2 Main vascular closure devices (VCDs) available on the market

|Product|Manufacturer|Mechanism of action|FDA approved use|Puncture size(F)|Comments| |---|---|---|---|---|---| |Perclose ProStyle/ ProGlide|Abbott|Suture|Femoral artery and vein|5-21(artery) 5-24(vein)|Provides secure repair with pre-tied polypropylene monofilament suture, ability to maintain wire access, minimal intravascular footprint with no re-access restrictions; broadest indication for both femoral arterial and venous access| |Prostar XL|Abbott|Suture|Femoral artery|8.5-10|Provides secure repair with two braided sutures, ability to maintain wire access with minimal intravascular footprint| |StarClose SE|Abbott|Extravascular nitinol clip|Femoral artery|5-6|Utilizes an extravascular nitinol clip to provide immediate repair; haemostasis can be challenged and confirmed on the table| |Exoseal|Cordis|Extravascular sealant|Femoral artery|5-7 artery|Deployed through existing procedural sheath (up to 12 cm) without impeding arterial blood flow, with two visual indicators; polyglycolic acid plug material, fully absorbable within 60-90 days text-gen deployment system with two-button operation, compatible with the procedural sheath (up to 12 cm), tension indicator providing visual confirmation of device position; polyethylene glycol, dissolves in 30 days| |Vascade MVadeMVP|Haemonetics|Extravascular bioabsorbable collagen plug|Femoral vein|6-12 inner diameter (max OD 15)|Developed from the xueing intervascular nitinol clip to provide minimal exposure, but a remostasis can be 8e, 2e| |Vascade|Haemonetics|Extravascular bioabsorbable collagen plug|Femoral artery and vein|5-7|Utilizes an extravascular nitinol clip to provide minimal exposure, this extravascular, bioostasis can be 8e, 3e| |Angio-Seal VIP|Terumo|Extravascular bioabsorbable collagen plug|Femoral artery|≤6; ≤8|Haemostasis is achieved by sealing the arteriotomy with an anchor and collagen plug held together by a suture. All implantable components resorb within 90 days.| |FemoSeal|Terumo|Mechanical seal (intra and extravascular) with 3 bioabsorbable components (inner and outer disk held together by sutures)|Femoral artery|57|Suture and polymer discs sandwich the arteriotomy. All components reabsorb within 90 days| |Manta|Teleflex|Extravascular bioabsorbable collagen plug (reabsorbable collagen and anchor)|Femoral artery|10-20 inner diameter (12- 25 OD)|Specifically designed for large-bore femoral artery access sites; no pre-closure needed. Deployment with auditory and visual cues for reliable closure. The 14 F device is for 10-14 F access sites (max OD 18 F), and the 18 F device is for 15-18 F access sites (max OD 25 F)|

OD, outer diameter.

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 Figure 6 Vascular closure devices (VCDs), main mechanisms of action. From left to right: two active devices (suture-based and clip-based), and two passive devices (collagen plug-based and sealant-based). See text and Table 2 for details of mechanisms.

Recently, smart phone applications are being tested for telemonitoring of the patients and for tracking complications during the follow-up.

Percutaneous interventions can lead to various vascular complica-tions, such as arteriovenous fistula, arterial pseudoaneurysm,retroperi-toneal bleeding, haematoma, and infection. Early detection of these complications is essential for effective management and better patient outcomes.

The occurrence of a femoral pseudoaneurysm can be clinically suspected by the presence of a pulsatile mass, a palpable thrill, or an audible murmur. Ultrasound imaging confirms the diagnosis. Small pseudoaneurysms(less than 2 cm) may thrombose spontaneously.91 Ultrasound-guided compression is a common first-line treatment but carries a substantial risk of recurrence, especially in patients receiving anticoagulants.92 Alternate treatment options include surgical repair and percutaneous therapy with echo-guided thrombin or collagen injection, coil embolization or stent placement. Therapy selection depends on pseudoaneurysm and patient characteristics. Ultrasound-guided thrombin injection is a minimally invasive procedure per-formed under local anaesthesia and has a success rate of 91-100%.It is typically the preferred treatment for pseudoaneurysms measuring 1.5 to 6.5 cm in diameter and with a neck width less than 1 cm.Thrombin injection is disfavoured in pseudoaneurysms with a wider neck due to a higher risk of embolization and in multi-lobed pseudoa-neurysms because of associated technical challenges. Surgical repair is considered as second treatment option due to inherent risk of com-plications and its use is limited in pseudoaneurysms with large neck,rapid expansion, skin necrosis, infection, or compression of neigh-bouring structures. Endovascular treatment is best suited for patients with comorbidities and high surgical risk.

The management of arteriovenous fistula varies depending on its size, associated symptoms and haemodynamic and local sequelae.Echo-guided compression should be implemented as a first-line therapy due to its non-invasive nature. One-third of femoral arteriovenous fis-tulae close spontaneously within one year. In case of persistent arterio-venous fistulae,associated limb damage or substantial left to right shunt,endovascular or surgical treatment is required with the latter being considered the gold standard.93

Retroperitoneal bleeding is a rare but serious complication that sig-nificantly increases the risk of adverse cardiovascular outcomes and mortality. It is more likely to occur with high femoral arterial puncture,above the inguinal ligament, preventing adequate vessel compression.

 Figure 7 Schematic display of manipulations to improve access to the vein. A, artery V, vein.

 Figure 8 Pictogram illustrating needle impact on venous access.From left to right venous compression with the needle, start of nega-tive pressure and pullback allowing vessel entry. A,artery V,vein.

Clinical symptoms may be subtle including abdominal, flank and back pain, and physical findings may be unremarkable. Therefore, a high degree of clinical suspicion and vigilance is necessary. Contrast-enhanced com-puted tomography serves as the primary imaging modality for diagnosing retroperitoneal haemora. Treatment approach vary from supportive care to vessel embolization or surgery and should be individualised.

6. Specific scenarios-tips and tricks

As indicated before, maintaining good hydration is paramount for suc-cess. If not necessary, patients should not fast before procedures. In cases of inadequate hydration, intravenous fluid supplementation with 0.9% saline or Ringer's lactate(0.5-1 L) can be administered to ex-pand and visualise the veins. Valsalva manoeuvres or abdominal pres-sure along with abduction, external rotation of the leg and knee flexion can also help to expose and access the veins(Figure 7).94-96

In case of collapsed veins due to fasting or bleeding, utilizing ultra-sound becomes crucial. Colour Doppler and compression tests help to identify the vein and differentiating it from the artery, reducing the risk of accidental arterial puncture. Needle visualization can be enhanced by observing tissue movement(gentle back-and-forth

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Table 3 Tips and tricks for vascular access in challenging situations

|Category|Tips and tricks| |---|---| |Hydration|● Maintain good hydration ● Avoid fasting if possible ● Use IV fluids (0.9% saline or Ringer's lactate)| |Vein exposure|● Valsalva manoeuvre/abdominal pressure ● Leg abduction, external rotation, knee flexion ● Vein identification: ● Colour Doppler and Compression tests ● Needle visualization: ● Tremor technique (gentle back-and-forth movements) ● Echogenic needles ● Get access by retracting the needle with negative pressure| |Vessel kinking|● Use a stiff wire or the catheter for straightening the vein ● Consider coiled/long sheaths ● Change insertion site if needed ● Consider alternative access sites (jugular, subclavian, or transhepatic)| |Inferior access obstruction|● Consider alternative access sites (jugular, subclavian, or transhepatic)| |Arterial femoral access|● Use ultrasound for common femoral artery cannulation ● Consider superficial femoral artery access if bifurcation is high ● Use long sheaths in elderly or patients with atherosclerosis|

movements, 'tremor' technique) or using echogenic needles. ${ }^{97,98}$Advancing the needle in a dry vein may cause the walls to collapse and lead to an inadvertent puncture through both walls. Retracting the needle with negative pressure, can separate the walls, allowing blood withdrawal and confirming intravascular access (Figure 8).

After successful vascular access, vessel kinking can hinder further ad-vancement. One approach is to use a stiff wire or catheter for straigh-tening the vein out('stenting') and maintain patency. If kinking persists,changing the insertion side or employing coiled (coil-wire design) or long sheaths can provide more support. In case of persistent obstruc-tion of inferior access, presence of IVC filters or vessels aresia, con-sider alternative access via the jugular or SV, but also transtheatic access as described in Section 3.

For arterial femoral access, ultrasound is useful for visualizing the femoral bifurcation and identifying femoral calcification or the relation-ship to the femoral head. ${}^{99}$ In cases of high bifurcation, superficial fem-oral artery access may be an option, though it carries a higher risk of pseudoaneurysm. ${}^{100}$ Long sheaths can help reduce the risk of arterial dissection in all patients and especially those who are>65 years or have known atherosclerotic disease or tortuous vasculature. Table 3 lists a summary of practical tips to consider for optimizing vascular ac-cess success rate.

7. Training requirements

Proficiency in vascular access and closure is a critical skill set in cardiac EP, directly affecting patient safety and procedural outcomes. A

$^{text}$ structured training is essential to ensure practitioners can perform with confidence and precision. ${}^{101}$

A solid knowledge of vascular anatomy forms the foundation for suc-cessful vascular access. Trainees need to be proficient in recognizing and navigating key access sites, such as the femoral, subclavian, and jugu-lar veins, as well as the femoral artery.

Incorporating USG vascular access into the EP training curriculum is crucial due to its discussed clinical advantages. While specific training re-quirements for US-guided access in EP are yet to be established, drawing from intensive care practices suggests incorporating 50 supervised plus 50 independent US-guided femoral venous access cases as a potential target for training. ${}^{102}$ Specific research suggests the actual learning curve may be much shorter and a plateau is already observed after a mean of 6 cases.Additionally, training should include exposure to US-guided access to other vascular sites, such as the femoral artery, subclavian, and jugular veins, to ensure a comprehensive skill set for various clinical scenarios.

Trainees should master haemostasis techniques, including manual compression and suture methods. They should become familiar with VCDs, gaining broader exposure through external rotations in other catheterization labs.

Simulation-based training is a valuable component of EP education,offering a risk-free environment where trainees can develop and refine their skills. ${}^{104,105}$ The use of 3D anatomical models, and virtual or aug-mented reality platforms allows for a realistic practice of procedures,from initial access to complication management. ${}^{106,107}$ This approach not only builds technical proficiency but also enhances decision-making skills under simulated clinical pressures, bridging the gap between the-oretical knowledge and practical application.

8. Economical aspects

Vascular complications occur in 2-4% of EP procedures and contribute significantly to healthcare costs. ${}^{108}$ Although many complications can be managed conservatively, they trigger further evaluation (ultrasound,CT scan) and therapeutic interventions (USG compression, thrombin injection, transfusion, surgical repair, covered stents, etc.), leading to in-creased direct costs and indirect costs such as increased length of stay and reduced availability for treating other patients. ${ }^{109}$

After AF ablation, invasive treatment of complications occurs in 0.6-0.9% of patients, mostly for pseudoaneurysms after failed com-pression attempts(30% of cases).110 Direct costs can reach 500€,but indirect costs due to prolonged hospitalization and repetitive interventions can reach up to 15 544E. As a result, the average cost,ir-respective to complications, is estimated to be 150€ per patient treated without ultrasound.109 In contrast, ultrasound use has been associated with a 66% reduction in complications111 and higher first-pass access-rates both for trainees and experts.77 This was also partially achieved by omitting the femoral arterial line. Taken together, these strategies could save enough money(approximately 5000€) to off-set the costs of ultrasound machines and staff-training with 1000 treated AF-patients.109 Additionally, early thrombin therapy(rather than serial du-plex scans) in patients with pseudoaneurysms after cardiac catheterization could achieve similar savings by expediting patient discharge.112 Similar savings are expected by earlier thrombin injection for vascular complica-tions after an EP procedure. Thus, vascular access should be performed under ultrasound guidance with systematic monitoring for potential com-plications and appropriate equipment, checklist and team support to en-sure rapid response.79,113

Since most of the costs for EP procedures are due to hospitaliza-tion, ${}^{114}$ rapid haemostasis with VCDs can lead to faster ambulation,shorter length of stay, less medication, fewer additional interventions(urinary catheters) and even same-day discharge. ${}^{71,72,115,116}$ The use of closure devices or figure-of-eight/Z-stitch can facilitate this better than manual compression. ${}^{82,117-120}$ Together, these techniques can

Vascular access and closure management for electrophysiological interventions in 2025

13

 ● Compress for a duration of $\cdot$ Useful if $\geq 10 F$ sheath 3-times the sheath Fr size. Not given

● Established for arterial sites

● Vein can be useful in same-day-discharge strategy

Figure 9 Vascular access flowchart. A step-by-step guide for vascular access site preparation, selection, puncture, and closure.

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T. De Potter et al.

reduce health-care costs while reducing patient discomfort.121 In sum-mary,incorporating USG access and effective closure techniques in EP interventions is cost-effective. Minimizing complications and systemat-ically monitoring performance measures is crucial to improve cost-effectiveness and patient outcomes.

9.Gaps in evidence and future perspectives

While ultrasound guidance has demonstrably reduced complications in EP,significant knowledge gaps remain, hindering the optimisation of vascular access practices.

Current research largely focuses on comparing vascular closure de-vices against longer observation periods, often within single centres.This approach, while informative, suffers from limited generalizability due to the inherent biases and idiosyncrasies of local protocols.Additionally, comparing one closure technique to another against an ag-gressive mobilization protocol may artificially inflate the impact of de-vices on patient flow, neglecting the influence of sedation and other factors. Furthermore, the rarity of serious complications with ultra-sound guidance necessitates large-scale studies to evaluate the impact of further innovations.

A crucial gap exists in understanding how vascular access devices truly impact patient flow and recovery. We lack knowledge on the optimal timing for early mobilization beyond the limitations imposed by vascular access itself. Similarly, the influence of pre-procedural hydration and other patient factors(e.g. obesity, anticoagulation)on first-attempt access and complications remains unexplored.Head-to-head comparisons of different devices and sheath combina-tions are also scarce, hindering informed decision-making in diverse clinical scenarios.

Current research often overlooks patient-reported outcomes like bruising, despite their significant impact on experience and satisfac-tion. Integrating these subjective measures would provide a more holistic understanding of patient well-being. Valuable insights can also be gleaned from vascular management practices in other speci-alities like interventional cardiology or radiology, fostering cross-disciplinary collaboration and knowledge exchange. Standardized data collection and sharing across teams and centres would further accelerate knowledge generation and benefit patients across the board.

The increasing adoption of the Z-suture closure method means that new technologies require rigorous evaluation beyond apparent ease-of-use and perceived effectiveness. Potential downsides like bleeding and pain, often hidden by the excellent post-procedural haemostasis of the z-suture, can negatively impact patient flow and experience. Robust evidence is essential before adopting new tech-nologies, especially when established methods provide a high baseline standard.

Future research should focus on tailoring vascular access strategies to individual patient characteristics and risk profiles. This personalized approach holds the promise of optimising patient care and minimizing complications. By actively addressing these knowledge gaps and foster-ing collaborative research efforts, we can pave the way for robust,patient-centred, and evidence-based guidelines for vascular access in EP, ultimately leading to safer, more efficient, and less invasive proce-dures with improved patient outcomes.

10.Key messages

Techniques for vascular and pericardial access in EP laboratories con-tinue to evolve, driven by technological advancements and a better understanding of anatomical complexities. The integration of

$\text{ultrasound guidance, innovative access and closure techniques, and}$ $\text{personalized approaches for paediatric patients represents the fore-}$front of this evolution. As the field progresses, continuous learning and adaptation to emerging technologies and techniques will remain essential for clinical electrophysiologists, ensuring optimal patient care and procedural success. There is room for a standardized work-flow which can reduce vascular access complications by implementa-tion of training protocols, use of imaging and appropriate selection of tools and techniques. Based on available evidence such a workflow should be able to reduce complications by several orders of magni-tude compared to existing practice and be able to demonstrate its cost-effectiveness by focusing on the cost of the total patient journey(Figure 9).

11. Table of clinical advice

||Category of evidence|Strength of evidence| |---|---|---| |Advised TO DO||| |Use ultrasound for all percutaneous vascular|Published data|META and RCT42,76-79| |access to avoid||| |complications||| |Use suture-based closure technique for earlier|Published data|Small RCT82,83| |ambulation and reduction of access site complications||| |when using large(≥10F)||| |sheaths||| |Use VCDs if minimum time to abulation is desired|Published data|Observational and RCT70-74| |May be appropriate TO DO||| |Use heparin for right-sided|Opinion|Consensus(>70%| |procedures||agreement)| |Allow oral hydration before|Opinion|Consensus(>70%| |the procedure||agreement)| |Advised NOT TO DO||| |Do not interrupt(>8 h) anticoagulation for Afb|Published data|META and RCT15-24| |ablation with the purpose of bleeding risk reduction||| |In case of suture closure, Opinion consider not to give|Opinion|Strong consensus (>90% agreement)| |protamine for heparin|Published data|Observational ${}^{36,38}$| |reversal|||

Supplementary material

Supplementary material is available at Europace online.

Acknowledgements

The authors wish to thank the EHRA Scientific Document Committee for their contribution to this document: Prof Katja Zeppenfeld, Prof Jens

Vascular access and closure management for electrophysiological interventions in 2025

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Cosedis Nielsen,Dr Luigi di Biase,Prof. Label Deisenhofer,Prof Kristina Hermann Haugaa, Dr Daniel Keene, Prof Christian Meyer, Prof Pet Peichl, Prof Silva Priori, Dr Alireza Sepehi Shamloo, Prof Markus Stuthlinger, Prof Jobi Teltt Hansen, Prof Arthur Wilde

Conflict of interest: TJRDP declares being Chairman for the EHRA selection Committee. MF declares speaker's fees's from Medtronic,Abbott, Boston Scientific, Biosense Webster(&J); and being present on ad-visory boards from Boston Scientific. MF is the founder& CMO of Echopoint. Medical; director& CSO from Rhythm AI Ltd; founder&Shareholder of Epicardio Ltd; and received consultancy fees from Arta Health Ltd, Cathodivin Inc. Mfo holds a patent US116475782 Ultrasound Probe. HR reports consultancy and speaker fees from Medtronic. RT is a consultant for Abbott, Boston Scientific, Biotomier and Biosester Webster and received speaker honoria payment support for meetings or travel from Biosense Webster, Medtronic, Boston Scientific and Abbot Medical and research support from Abbott medical. None of the remaining authors declare any conflicts of interest.

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