Sanborn TA， Ebrahimi R， Manoukian SV， McLaurin BT， Cox DA， Feit F， Hamon M， Mehran R， Stone GW.
Evanston Northwestern Healthcare， Ill， USA. tsanborn@northshore.org
Abstract
    BACKGROUND: The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial demonstrated that bivalirudin monotherapy significantly reduces major bleeding compared with heparin (unfractionated or enoxaparin) or bivalirudin plus a glycoprotein IIb/IIIa inhibitor in acute coronary syndromes. Whether vascular closure devices (VCD) impact these results is unknown. Therefore， this study sought to determine whether VCD impact major access site bleeding (ASB) in patients with acute coronary syndromes undergoing early invasive management by the femoral approach.
    METHODS AND RESULTS: Major ASB in ACUITY was defined as ASB requiring interventional or surgical correction， hematoma > or =5 cm at the access site， retroperitoneal bleeding， or hemoglobin drop > or =3 g/dL with ecchymosis or hematoma <5 cm， oozing blood， or prolonged bleeding (>30 minutes) at the access site. Stepwise logistical regression was performed to identify the independent determinants of ASB. Of 11 621 patients undergoing angiography with or without percutaneous coronary intervention by the femoral approach， 4307 (37.1%) received a VCD and 7314 (62.9%) did not. Rates of major ASB were lower with VCD compared with no VCD (2.5% versus 3.3%， relative risk， 0.76; 95% CI， 0.61 to 0.94; P=0.01) and were lowest in patients treated with bivalirudin monotherapy and a VCD (0.7%). Stepwise logistic regression revealed that a VCD (odds ratio， 0.78; 95% CI， 0.61 to 0.99; P=0.04) and bivalirudin monotherapy (odds ratio， 0.35; 95% CI， 0.25 to 0.49; P<0.0001) were both independent determinates of freedom from major ASB.
    CONCLUSIONS: In patients with acute coronary syndromes undergoing an early invasive management strategy by the femoral approach， the use of a VCD， bivalirudin monotherapy， or both minimizes rates of major ASB