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Procedure guide

Percutaneous Access, Sheaths & Closure Devices

Think ACCESS → PROFILE → CLOSURE. Use real-time ultrasound to target the front wall of a compressible CFA over the femoral head; check the artery against the actual outer profile of the sheath or delivery system; and decide the closure strategy before upsizing. A good closure device cannot rescue a poor puncture. For percutaneous EVAR, ESVS recommends ultrasound-guided access (Class I A).

Written September 23, 2026 · Mr Razhan K Ali

1. Purpose & indications

What it achieves: a controlled hole in the artery (the arteriotomy) through which wires, catheters and devices can pass, and a reliable seal of that hole at the end without an open operation.

Indications

  • Retrograde CFA access (needle pointing towards the head): diagnostic angiography, iliac and aortic work, EVAR/TEVAR, contralateral "up-and-over" limb interventions.
  • Antegrade CFA access (needle pointing towards the feet): ipsilateral femoropopliteal and below-knee interventions.
  • Closure device rather than manual compression: mainly to shorten haemostasis and mobilisation,[2–4] and for large-bore access where a planned closure strategy is required.[1,5] A closure device does not make an uncorrected coagulopathy safe: correct reversible bleeding risk where appropriate and remain within the device IFU.

Think again — relative contraindications and alternatives

  • Calcified CFA: in the IPER registry, femoral calcification was the only independent predictor of percutaneous EVAR access failure; other series likewise identify CFA calcification as an important determinant of failure.[1,7,17] With heavy anterior-wall calcification, target a softer segment or consider the other groin or an open cut-down. Previous groin surgery is not a contraindication in experienced centres.[8]
  • Device-specific access-site limits — check the IFU: for the devices discussed here, high puncture above the IEA/inguinal ligament, puncture at or below the bifurcation, posterior-wall entry and multiple punctures may be contraindications, warnings or situations in which safety is not established.[9–11]
  • Percutaneous vs cut-down for EVAR: choose on patient factors and operator preference — ESVS Recommendation 60, Class IIa, Level B.[1]
  • If femoral access is not possible: alternative upper-extremity access (brachial, axillary or radial) depends on the procedure and device. If brachial access is chosen, a recent observational meta-analysis found more intervention-requiring access complications with percutaneous than open brachial exposure (RR 3.63; low-certainty evidence).[12]

2. Anatomy & planning

Beginner's toolkit — the words you need

TermPlain meaning
ArteriotomyThe hole you make in the artery wall.
SheathA short tube with a one-way (haemostatic) valve and a side-arm. It sits in the artery so wires and devices can go in and out without bleeding or tearing the arteriotomy.
French (F)1F = ⅓ mm. Catheters are generally sized by outer diameter; introducer-sheath French size usually describes the nominal inner lumen. The arterial hole depends on the outer profile, which varies by device. Always check the manufacturer’s stated profile.[5,13]
Guidewire sizeMeasured in inches: 0.035" (standard working wire), 0.018" (micropuncture, small vessels), 0.014" (fine distal work).
Needle gauge (G)Higher number = thinner needle. Micropuncture needles are 21G.
Micropuncture setTypically a 21G needle, 0.018" wire and small coaxial dilator. It gives you a small first hole that is easier to abandon and compress if the target is wrong.
Closure device (VCD)A device that seals the arteriotomy. Mechanisms differ: suture (ProGlide), anchor + collagen (Angio-Seal), inner/outer discs (FemoSeal), or a dedicated large-bore anchor + collagen system (MANTA).
PreclosePlacing ProGlide sutures at the start, before a large sheath goes in, then tying them at the end.[5]
Small-bore / large-boreThere is no universal cut-off. The practical point is whether closure needs a pre-planned large-bore strategy. For ProGlide arterial access above 8F, the label requires at least two devices using preclose.[9]
Retrograde / antegradeNeedle and sheath pointing towards the heart / towards the feet.

The target: the CFA "safe zone"

  • The CFA runs from the inguinal ligament to its bifurcation into the SFA and profunda. Aim for the front wall of the CFA over the femoral head: the head is a bony backstop for compression and for closure devices (established principle).
  • Too high (above the lowest border of the IEA): the artery has left the groin and lies behind the peritoneum, so bleeding tracks into the retroperitoneum and cannot be compressed. In one PCI series, every retroperitoneal bleed followed an arteriotomy above the lowest border of the IEA.[15]
  • Too low (SFA, profunda or bifurcation): smaller artery, no bony backstop and the vein close by, so pseudoaneurysm and arteriovenous (AV) fistula are more likely; ProGlide, Angio-Seal and FemoSeal must not be deployed here.[9–11] Low, high and high-middle arteriotomies together accounted for 71% of access complications (OR 28.7).[15]
  • The skin crease is not the inguinal ligament. In obese patients the crease can lie well below the bifurcation. Use ultrasound to see the artery and fluoroscopy to see the femoral head (established principle).
  • Ultrasound helps most when the bifurcation is high (over the femoral head): CFA cannulation 82.6% vs 69.8% in FAUST.[1,16]

Planning checklist (duplex or CT)

CheckWhat matters
Anterior-wall calciumThis is one of the most useful predictors of trouble. In IPER it was the only independent predictor of percutaneous EVAR access failure (OR 1.69); 50–75% circumferential calcium predicted conversion in a separate re-do-groin series.[7,8]
Artery size + device profileUse the closure-device IFU and the actual sheath/delivery-system outer profile. ProGlide has no safety data below 5 mm; FemoSeal should not be used if CFA lumen is <5 mm; Angio-Seal has limited safety in arteries <4 mm.[9–11] ESVS Table 13 shows that EVAR access-vessel requirements vary widely between grafts.[1]
Bifurcation + veinA high bifurcation leaves a short CFA. See both artery and vein on ultrasound so a low or transvenous puncture is not mistaken for a safe CFA stick.[16]
Previous groin surgeryNot an automatic contraindication in experienced hands; one series reported similar technical success in re-do and untouched groins.[8]

3. Setup

  • Consent: bleeding or haematoma, pseudoaneurysm, AV fistula, arterial injury or limb ischaemia, infection and, for large-bore percutaneous access, conversion to open groin repair (3.2% of access sites in the IPER registry).[7]
  • Baseline: record distal pulses (or Doppler signals) before you start, so any change after closure is recognised. Check the antithrombotic plan and clotting as per local policy.
  • Position and prep: supine. Prep both groins for large-bore work — the other groin is your bail-out route.
  • Kit: ultrasound with a linear probe and sterile cover; micropuncture set; 0.035" J-wire; sheath of the planned size; closure device selected after confirming anatomy by the imaging required by its IFU; local anaesthetic.
  • Imaging: fluoroscopy available from the start to mark the femoral head; standard radiation protection.
  • Anticoagulation: heparin as the procedure requires; access itself does not need it.

4. Perform — step by step

A. Small-bore access (up to 8F)

  1. Scan. Transverse ultrasound: find the CFA, follow it down to the bifurcation, look for anterior-wall plaque and note where the vein lies. Mark the femoral head on fluoroscopy (for example, with a clamp tip).
  2. Anaesthetise. Local anaesthetic to the skin and down to the artery.
  3. Puncture. Under real-time ultrasound, track the needle tip into the front wall of the CFA over the femoral head. Use an angle that allows a controlled single-wall entry; avoid the back wall.[9] Arterial backflow suggests entry, but imaging and free wire passage must confirm that access is correctly positioned.
  4. Wire. Pass the 0.018" wire; it must run freely. Check on fluoroscopy that it goes up the iliac artery. Resistance means stop — forcing a wire causes dissection.[6]
  5. Upsize. Make a small skin nick, pass the coaxial dilator, exchange for a 0.035" wire and insert the sheath over the wire. Flush the sheath.
  6. Confirm the access site before device closure. Answer three questions: Is the entry in the CFA? Is it below the IEA and above the bifurcation? Is the artery large and soft enough for the chosen device? Use femoral angiography when required or indicated by the device IFU; ultrasound/fluoroscopy may also contribute depending on the device and case.
  7. Do the procedure.
  8. Close (algorithm below), then check haemostasis and distal pulses.

B. Large-bore access — choose the closure before you upsize

Large-bore closure is a planning decision, not an end-of-case rescue.

  1. Complete steps A1–A6 with a small sheath and confirm the arteriotomy is suitable.
  2. Choose the planned strategy before the large sheath goes in:
    • ProGlide preclose: for arterial sheaths >8F, the label requires at least two devices using preclose. A common practical orientation is approximately 10 and 2 o’clock.[5,9]
    • MANTA: measure puncture depth with the dedicated depth locator before step-dilation/large-bore sheath insertion; then use the MANTA sheath/device sequence at closure.[36]
    • Open exposure or another strategy: use when anatomy or the planned closure-device IFU is unsuitable.
  3. If using ProGlide: protect both sutures during upsizing. At the end, withdraw the sheath over a wire, tighten the sutures and assess haemostasis before removing the wire.
  4. If using MANTA: follow its device-specific over-the-wire deployment sequence. It is not an improvised rescue if the required depth measurement was never performed.[36]
  5. Confirm a dry groin and unchanged distal perfusion before finishing.

C. Antegrade access

The arterial target is the same (CFA over the femoral head), but the needle travels towards the feet, so the skin entry is higher, near the level of the inguinal ligament. Use ultrasound or fluoroscopy to steer the wire into the SFA rather than the profunda. Entering the SFA too low or the external iliac too high are the classic errors (established principle).

Closure methods compared

MethodHow it sealsSheath size (IFU)Leaves behind · re-accessDo not use
Manual compressionFirm pressure at the arterial puncture against the femoral head until haemostasis is secure. Duration depends on sheath size, anticoagulation and local protocol.[6]Small-boreNothing · no restrictionLarge-bore arteriotomy or when prolonged compression is impractical; correct clinically important coagulopathy rather than using a VCD as a substitute
Angio-Seal (Terumo)Absorbable anchor inside the artery and a collagen sponge outside, joined by a self-tightening suture — a "sandwich"6F and 8F versionsAll resorbed within 90 days · within 90 days, re-enter 1 cm proximal[10,20]Artery under 4 mm; puncture at or below the bifurcation[10]
FemoSeal (Terumo)Resorbable inner seal inside and outer locking disc outside, held together by a resorbable multifilament7F or smallerDiscs degrade within 18 months, filament over 2–3 years · within 18 months, re-puncture at least 1 cm proximal[11]CFA lumen under 5 mm; puncture at or below the bifurcation or above the inguinal ligament[11]
ProGlide (Abbott)Needles pass a monofilament polypropylene suture through the arterial wall; the knot is pushed down onto the arteryArterial 5–21F; above 8F, at least two devices and precloseA polypropylene suture only (no intraluminal anchor) · no re-access restriction[9]Puncture above the IEA or inguinal ligament, in the SFA, profunda or bifurcation; back-wall or multiple punctures; no safety data under 5 mm[9]
MANTA (Teleflex)Dedicated large-bore system: intraluminal polymer anchor + extravascular collagen, secured by suture/lock. Depth must be measured before large-bore dilation.For 10–20F devices/sheaths (12–25F outer diameter), subject to the current local IFU.[36]Anchor/collagen are absorbable; a radiopaque lock and non-absorbable suture remain. The guidewire stays until haemostasis. Re-access away from the existing device as the IFU directs.[36]Not an automatic rescue for an unsuitable puncture or an unplanned failed-suture closure; use only when the access and pre-measured depth meet its IFU.[36]

Choosing the closure

  1. Is the puncture suitable? CFA, below the IEA, above the bifurcation, adequate diameter, and no prohibitive anterior-wall calcium.[7,9–11]
    • No → do not force a closure device outside its IFU. Use compression only for a genuinely compressible small arteriotomy; otherwise make an early control/repair plan.
    • Yes → choose by arteriotomy size and the strategy planned before upsizing.
  2. Small-bore: manual compression or a small-bore VCD (e.g. Angio-Seal, FemoSeal, ProGlide) according to anatomy, IFU and operator familiarity. VCDs shorten haemostasis/ambulation but do not consistently reduce major complications.[2,3]
  3. Large-bore: use the strategy planned before the large sheath was inserted — suture preclose, a planned large-bore device such as MANTA, or surgical exposure.[36] Comparative ProGlide–MANTA randomised data are mainly TAVI, not EVAR, so do not turn them into a universal vascular rule.[18,21,31]
  4. Finish: groin soft/dry and distal perfusion unchanged.

Evidence behind the decisions

QuestionWhat matters
Ultrasound for femoral access?Yes for percutaneous EVAR: ESVS Recommendation 61, Class I A.[1] FAUST also reduced first-pass failure, venepuncture and access complications, with the clearest CFA-placement benefit when the bifurcation was high.[16]
Percutaneous or cut-down for EVAR?ESVS Recommendation 60: choose by patient factors and operator preference (Class IIa B).[1] Randomised evidence does not show clear superiority for major outcomes, although percutaneous access can reduce wound morbidity and procedure time.[28–30]
VCD or manual compression for small-bore access?VCDs shorten haemostasis and mobilisation. They do not consistently reduce major vascular complications, and no small-bore device is best across every outcome.[2–4]
Which large-bore closure?Plan it before upsizing. ProGlide preclose and MANTA are both established strategies, but direct randomised comparisons are mainly from TAVI, not EVAR.[18,21,31]
Ultrasound-guided device deployment?Promising but not yet a guideline standard. A 2025 meta-analysis found fewer access complications with ultrasound-guided closure deployment (OR 0.49), with low-certainty evidence.[14]

5. Technical pearls & pitfalls

  • Ultrasound for the artery, fluoroscopy for the bone. Ultrasound shows plaque, bifurcation and vein; fluoroscopy shows the femoral head.
  • The skin crease lies. Do not use it as the arterial landmark.
  • Calcium matters. Target a soft anterior-wall segment. In IPER, CFA calcification was the only independent predictor of percutaneous EVAR access failure; treat that as cohort evidence, not a universal law.[7]
  • One clean front-wall puncture. Back-wall and repeated punctures make closure less reliable and may put some devices outside their IFU.[9–11]
  • If the wire will not run, stop. Never solve resistance with force.[6]
  • Confirm before closure. Use the imaging required by the device IFU; femoral angiography is especially useful when site, bifurcation or plaque is uncertain.
  • French size is not the whole story. The arterial defect follows the outer profile, not simply the nominal sheath number.[13]
  • Plan large-bore closure before upsizing. ProGlide needs preclose above 8F; MANTA needs depth measurement before large-bore dilation.[9,36]
  • Keep a safety wire until haemostasis when the chosen large-bore strategy allows; do not surrender your bailout route early.
  • Document the device and future-access precautions. Angio-Seal and FemoSeal have explicit re-access rules; MANTA has device-specific re-intervention guidance.[10,11,36]
  • Learning is about puncture quality, not a magic case number. A pooled coronary analysis suggested improvement after >20 ultrasound-guided cases, but that is not an EVAR sign-off threshold.[25]

6. Completion

Before leaving the room:

  • Groin: soft, dry, no expanding swelling.
  • Limb: pulses/Doppler signals back to baseline.
  • Closure: device-specific end point achieved as the IFU describes.
  • Wire: if the strategy uses a safety wire, remove it only after haemostasis is secure.
  • Record: side, puncture site, sheath/delivery profile, closure device and any future-access restriction.
  • Plan: observations and mobilisation documented.

7. Complications & rescue

ComplicationWhyRecogniseAct
Groin haematomaAccess-site bleeding, often worsened by repeated puncture or anticoagulationSwelling/bruising; tense or expanding if significantCompress over the CFA/femoral head, reassess haemodynamics and antithrombotics; duplex if persistent, pulsatile or unexplained. Escalate if expanding or skin-threatening.
Retroperitoneal bleedHigh, non-compressible arteriotomy above the IEA/inguinal ligament[15]Hypotension, back/flank/lower abdominal pain, falling haemoglobin — often with a deceptively soft groinResuscitate and call for vascular/endovascular help. CTA if stable; if unstable or bleeding persists, move directly to angiographic/endovascular or open control.
PseudoaneurysmFailed haemostasis or an unsuitable/low puncturePulsatile lump or bruit; duplex shows a neck with to-and-fro flowObserve selected small, stable, asymptomatic lesions with reliable follow-up. For suitable lesions requiring treatment, ultrasound-guided thrombin injection is generally more effective than compression.[33–35] Escalate for infection, expansion, compression symptoms, limb ischaemia or failed percutaneous treatment.
AV fistulaNeedle traverses vein then artery, usually with a low/blind puncture[6]Continuous bruit/thrill; confirm with duplexObserve selected asymptomatic lesions; repair if symptomatic, enlarging or haemodynamically important.[34]
Dissection / stenosis / occlusionWire/sheath trauma or closure across a small/diseased artery[4,6]New pain, pallor, cool limb, lost pulses or new claudicationImage promptly; balloon/stent or open repair according to lesion and CFA/profunda involvement.
Closure failureWrong site, calcium, back-wall/multiple puncture, or device deployment failure[5,7,9]Persistent arterial bleeding or loss of distal flowKeep control and use the rescue algorithm below.
InfectionForeign material at the access site; uncommon[4]Pain, erythema, discharge or abscessImage and treat with antibiotics; established device-site infection may require debridement/removal.

The groin that will not stop bleeding

  1. Call for help; keep control. Preserve existing wire access. Compress a genuinely compressible CFA puncture, assess haemodynamics and check distal perfusion.
  2. Identify the problem. Wrong puncture level? Closure failure? Arterial disruption? Flow-limiting stenosis/occlusion?
  3. If wire access remains and the anatomy is suitable, use the planned/compatible device bailout within its IFU. Otherwise obtain temporary proximal control — for example an occlusion balloon from the opposite side — and move to definitive repair.[9,36]
  4. Repair to the lesion: balloon tamponade, selected covered stent or open repair may be appropriate. Avoid sacrificing the profunda or compromising future CFA access unless necessary.

8. Postoperative management

  • Observe: groin, haemodynamics and distal limb perfusion. Mobilisation depends on sheath size, closure method and local protocol.
  • Escalate: new swelling/bleeding, bruit, back or flank pain, hypotension, falling haemoglobin or a cold limb. Use duplex for a groin lesion; CTA for suspected retroperitoneal bleeding when the patient is stable enough.
  • Discharge: give bleeding/infection advice and document the closure device and any future-access restriction.
  • Why use a VCD? Mainly faster haemostasis and mobilisation — not a guaranteed reduction in major vascular complications.[2–4]

9. Remember / 60-second mental rehearsal

Mental rehearsal

  1. ACCESS: ultrasound the CFA, bifurcation, plaque and vein; use the femoral head as your bony landmark.
  2. PUNCTURE: one controlled front-wall entry; if the wire does not run freely, stop.
  3. PROFILE: know the actual sheath/delivery-system outer diameter and whether the artery can accommodate it.
  4. PROVE: CFA? below IEA? above bifurcation? adequate diameter? acceptable anterior-wall calcium?
  5. PLAN LARGE-BORE BEFORE UPSIZING: ProGlide preclose, pre-measured MANTA, or open/alternative access.
  6. CLOSE: follow the exact device IFU and preserve wire access until haemostasis where the strategy permits.
  7. CHECK: dry groin, baseline pulses/signals.
  8. DOCUMENT: closure device and future-access precautions.

Key numbers

ItemRemember
1 French⅓ mm — but check the outer profile of the actual sheath/device.
ESVS EVAR accessRec 60: percutaneous vs cut-down by patient/operator factors — IIa B. Rec 61: ultrasound guidance for percutaneous EVAR — I A.[1]
ProGlideArterial 5–21F; above 8F requires at least two devices + preclose.[9]
Angio-Seal6F/8F; if re-accessing within 90 days, puncture 1 cm proximal.[10,20]
FemoSeal≤7F; CFA ≥5 mm; if re-puncturing within 18 months, stay ≥1 cm proximal.[11]
MANTALarge-bore: depth measurement before step-dilation; 10–20F devices/sheaths (12–25F OD) within its IFU.[36]

FRCS viva prompts

  1. Where exactly do you puncture the CFA, and why?
  2. Why is the outer sheath/device profile more important than the nominal French number for access planning?
  3. A patient is hypotensive with back pain and a soft groin after femoral access — what are you worried about?
  4. If you plan ProGlide closure for a 20F EVAR system, what must happen before the large sheath goes in?
  5. When would you abandon percutaneous CFA access and choose cut-down or another route?
  6. Why can’t MANTA simply be chosen at the end after an unplanned failed suture closure?

Memory hook: Access → profile → closure. Puncture well; plan before you upsize.

References

  1. Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2024;67(2):192–331. doi:10.1016/j.ejvs.2023.11.002
  2. Robertson L, Andras A, Colgan F, Jackson R. Vascular closure devices for femoral arterial puncture site haemostasis. Cochrane Database Syst Rev. 2016;3:CD009541. doi:10.1002/14651858.CD009541.pub2
  3. Schulz-Schüpke S, Helde S, Gewalt S, et al. Comparison of vascular closure devices vs manual compression after femoral artery puncture: the ISAR-CLOSURE randomized clinical trial. JAMA. 2014;312(19):1981–7. doi:10.1001/jama.2014.15305
  4. Noori VJ, Eldrup-Jørgensen J. A systematic review of vascular closure devices for femoral artery puncture sites. J Vasc Surg. 2018;68(3):887–99. doi:10.1016/j.jvs.2018.05.019
  5. Lee WA, Brown MP, Nelson PR, Huber TS. Total percutaneous access for endovascular aortic aneurysm repair ("Preclose" technique). J Vasc Surg. 2007;45(6):1095–101. doi:10.1016/j.jvs.2007.01.050
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  8. Meertens MM, Tenorio ER, Lemmens CC, et al. Safety of percutaneous femoral access for endovascular aortic aneurysm repair through previously surgically exposed or repaired femoral arteries. J Endovasc Ther. 2023;30(5):730–8. doi:10.1177/15266028221092980
  9. Abbott Vascular. Perclose ProGlide Suture-Mediated Closure System. US FDA labelling / PMA P960043. Accessed 25 September 2026.
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  11. Terumo Medical Corporation. FemoSeal Vascular Closure System. Current manufacturer IFU and Summary of Safety and Clinical Performance. Accessed 25 September 2026.
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  25. d'Entremont MA, Seto AH, Alrashidi S, et al. Ultrasound-guided transfemoral access for coronary procedures: a pooled learning curve analysis from the FAUST and UNIVERSAL trials. Circ Cardiovasc Interv. 2024;17(8):e013817. doi:10.1161/CIRCINTERVENTIONS.123.013817
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  31. Abdel-Wahab M, Hartung P, Dumpies O, et al. Comparison of a pure plug-based versus a primary suture-based vascular closure device strategy for transfemoral transcatheter aortic valve replacement: the CHOICE-CLOSURE randomized clinical trial. Circulation. 2022;145(3):170–83. doi:10.1161/CIRCULATIONAHA.121.057856
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