Vascular access and closure management for electrophysiological interventions in 2025: a Clinical Consensus Statement of the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions of the ESC, and the ESC Working Group on Cardiovascular Surgery

Figures

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

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  Figure 2. The ultrasound probe has been inserted in a sterile cover together with contact gel and is held by the non-dominant hand vertically 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).

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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.

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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.

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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 woggle 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.

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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.

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

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

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