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Hands On with the CELT Closure Device

Author Thomas "T.J." Turner covers Hands On with the CELT Closure Device on BackTable VI

Thomas "T.J." Turner • Updated Nov 8, 2024 • 96 hits

The evolution of endovascular closure devices has significantly improved procedural efficiency and patient experience. Introduced in 2018, the CELT closure device represents a notable advancement in long line of closure device tech, offering improved predictability and fewer complications, especially in challenging cases like antegrade superficial femoral artery (SFA) interventions. Given its favorable safety profile, the CELT device has become a preferred option for peripheral artery disease (PAD) interventions, uterine fibroid embolizations, and carotid artery stenting, significantly reducing the need for radial access in a growing number of clinical settings.

In this article, vascular and interventional radiologist Dr. Omar Saleh and vascular and endovascular surgeon Dr. Syed Hussain give an introduction to the CELT device for arterial closure. The interventional duo also discuss the pros and cons of this type of arterial closure technology. We’ve provided the highlight reel here, and you can listen to the full podcast below.

The BackTable Brief

• The CELT closure device offers more predictable deployment results and fewer complications compared to older devices, particularly in challenging cases like antegrade superficial femoral artery (SFA) interventions, according to Drs. Hussain and Syed.

• The device can be used for a variety of cases including PAD interventions, uterine fibroid embolizations, and carotid artery stenting.

• Deployment techniques for CELT vary between retrograde and antegrade access, emphasizing the importance of ultrasound and fluoroscopy for precise placement and minimal complications.

• CELT's advantages include rapid hemostasis, ambulation, and discharge times—often under 31 minutes—enhancing patient throughput and satisfaction, especially in outpatient settings.

• Despite its benefits, CELT requires technical proficiency to avoid complications such as plaque dislodgement, with careful consideration needed for multiple device placements to ensure procedural success.

Hands On with the CELT Closure Device

Table of Contents

(1) The Evolution of Closure Devices

(2) When to Use Closure Devices

(3) Deploying the CELT Closure Device

(4) Pros & Cons of the CELT Closure Device

The Evolution of Closure Devices

The evolution of endovascular closure devices in interventional radiology has significantly impacted both procedural efficiency and patient experience, especially in outpatient settings. Initially, arterial closure devices were popular choices over manual compression hemostasis, despite their limitations and associated complications, such as scarring and nerve damage.

Over time, the introduction of newer devices has provided more reliable options for various procedures. The CELT device, introduced in 2018, represents a notable advancement, offering greater predictability and fewer complications, particularly in challenging cases like antegrade SFA. Additionally, the shift towards smaller French access and the use of alternative routes such as radial and pedal has further diversified procedural approaches, ultimately enhancing patient outcomes and satisfaction in the hands of the right operator.

[Dr. Aaron Fritts]
I know there's a big movement in IR right now to go 100% IR, but it is nice to have those diagnostic skills for when you're in those transitional periods. There's different opinions out there, right? It gets heated actually sometimes. All three of us have experience in the OBL setting. Mine was very brief. It was a couple of years. Closure devices are especially important in the outpatient setting, for patient experience, for peace of mind, when you're doing any sort of arterial cases, groin femoral access cases. I want to ask both of you guys, how have they evolved and changed during your career? Omar, since you're a little bit more junior than Saeed, let's start with you.

[Dr. Omar Saleh]
I think in my residency, we were using Angio-Seal, which was fine. I didn't think I had any issues. Then in my fellowship, we started using Perclose. That's like, back in 2012, 2013, we used pretty much Perclose for everything. I like both of them. I was a pretty heavy Perclose user for a long time, probably for 10 years. Then as things are going at OBL, try to do more different types of procedures like antegrade SFA, things like that.

It was hard for me technically to use that. Then I tried, other devices like Mynx , back to Angio-Seal and then recently, CELT probably like two years ago, CELT. That's my involvement in the closure device space. Then in addition to that, using small French access, like 4vFrench for a lot of things, Radial, Pedal, things like that. A lot has changed, a lot of new devices and things have come out in the last few years that have made more things possible.

[Dr. Aaron Fritts]
Yes. Sayed, tell us about how it's evolved in your practice using closure devices.

[Dr. Syed Hussain]
When I started training, Angio-Seal was the only thing that was really available on the market at the time, besides the Boomerang device, which I don't know if either one of you is familiar with. It was a balloon occlusion device. You take a 6 French hole or an 8 French hole or whatever, and you make it into a small 2 French hole, and then you hold pressure on a 2 French opening. That's what I was trained with. We didn't use a whole lot of closure devices when I first started training. Towards the end of my training, we started to do a little bit more with Perclose just because the aneurysms started to become more, we started to do more aneurysms.

We were still doing cutdowns when I finished my training, so that was pretty much the standard way to do aneurysm surgery back then. I would say throughout my career using Angio-Seal, using the Boomerang device, we used other sources, things like Mynx. I've used a couple generations of Mynx , Perclose, Starclose, so used a little bit of almost everything that's been on the market. I started using CELT as soon as it came out in January of 2018, so I've been using it for five years now. Yes, so that's my background.

[Dr. Aaron Fritts]
Yes, and for the audience, we are going to be talking a lot about CELT since I think it's probably the newest thing on the market now. I was using Angio-Seal throughout residency and fellowship, so that's what I was most comfortable with. It's funny you mentioned the Boomerang. I haven't heard that since fellowship, and that was 10 years ago. I think we used it for like one or two cases with like an 8 French opening. That's why we pulled that. I remember it being, like, not convenient, right, or cumbersome.

[Dr. Syed Hussain]
It was a cumbersome device. Just like you, I used it maybe once or twice, and then after that, I think we just abandoned it and went back to manual compression. Closer devices were frowned upon back then just because there were so many complications, and being a vascular surgeon, taking out the Angio-Seals, it was always the Friday night special at two in the morning, so in those cases, seldom went well just because patients always ended up with some type of nerve issue afterwards just from all the scarring and damage to the arteries. Not that it happens frequently, but when it does happen, it was always a big deal.

Listen to the Full Podcast

New Innovations in Closure Devices with Dr. Omar Saleh and Dr. Syed Hussain on the BackTable VI Podcast)
Ep 384 New Innovations in Closure Devices with Dr. Omar Saleh and Dr. Syed Hussain
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When to Use Closure Devices

Endovascular closure devices like the CELT are predominantly used after gaining femoral artery access in cases such as PAD interventions, Y-90, UFE, and carotid artery stenting. The CELT device has become the preferred option for Drs. Hussain and Saleh, significantly reducing the need for radial access outside of specific diagnostic and AV-fistula cases. Amongst these interventionalists, groin access remains favored for most arterial interventions, reserving radial access for cases with difficult anatomy or specific procedural needs.

[Dr. Aaron Fritts]
Yes. Assuming you guys are both using these devices for PAD cases, Syed, would that be predominantly what you're using them for?

[Dr. Syed Hussain]
Yes. We do a little bit of everything. We don't do any coronary interventions. Essentially, for my practice, it's all PAD interventions. We do some embolizations, some uterine fibroids. We do carotid artery stenting. This is our go-to device now.

[Dr. Aaron Fritts]
Got it. Are you ever going radial first for anything?

[Dr. Syed Hussain]
It's a little unusual. Besides doing fistulograms, which is sometimes a maybe I'll do a radial, but usually I access the fistula directly, I'll use a radial approach. I'll sometimes do a radial approach if I have to do a diagnostic that I know for sure is going to be diagnostic. I'll tell you, honestly, ever since I've started using the CELT device, the utility of doing radial has essentially vanished for our practice.

[Dr. Aaron Fritts]
Interesting. Omar, what about you? What are you using closure devices for most? I'm sure it's more than PAD, but anything else?

[Dr. Omar Saleh]
Yes, mostly PAD. I do a lot of fibroid embolizations. We're starting to do a lot of genicular artery embolizations. Yes for mostly PAD and embolizations using closure devices.

[Dr. Aaron Fritts]
Okay. Are you doing much radial in your practice?

[Dr. Omar Saleh]
I do a lot of radial, but we're a pretty Ellipsys-heavy practice. We're creating a lot of Ellipsys endo-AV fistulas. For those, we bring them back in a month and we go radial to mature to help like angioplasty, the radial artery and then anastomosis. Sometimes we do the endo AVF fistulas through radial approach. It just makes it a lot easier. That's pretty much the only reason I do a lot of radial work is through that, but not much for PAD or for UFEs, not really. I know a lot of guys are doing radial for prostates and UFEs. I just feel I guess old school in the sense that I like groin to go to even do fibroids but occasionally if they have difficult anatomy or something, I'd probably have to bring them back and go radial or if needed, but not, that's not my go-to.

Deploying the CELT Closure Device

The CELT endovascular closure device is deployed through an 11-centimeter sheath, with techniques varying slightly between retrograde and antegrade access. For retrograde deployment, fluoroscopic imaging is used to precisely locate the deployment site. After completing the intervention, the sheath is switched back to a smaller size, and the CELT is deployed under fluoroscopy. The patient is then asked to bend their knee to confirm proper deployment.

Antegrade deployment involves a shallower angle of access, often at the level of the lesser trochanter, with ultrasound guidance to ensure accurate placement of the device's first disc. This method prevents dragging against the arterial wall, particularly in calcified arteries. According to the interventionists, the described approach results in reliable and reproducible outcomes, with immediate confirmation of device efficacy and no need for further blood pressure monitoring.

[Dr. Aaron Fritts]
Yes. It's time to start jumping into the CELT. Omar, can you walk through how you place the Celt?

[Dr. Omar Saleh]
Sure. It goes through an 11 centimeter sheath. Say you do your angiogram. I've done CELT antegrade access and retrograde. From retrograde, what I do is when I do the angiogram, I always do an image store of the fluoro of where my needle is entering, so I know exactly where the CELT is going to be deployed, so I have an idea how far to bring it back when I deploy it. Then, if you do an intervention through like a long destination sheath after you're done, you just switch it out back for like a 6 French or 7 French, 11 centimeter sheath and then you just place the CELT and under fluoro you can deploy it. Then as soon as I deploy it, I have the patient bend their knee and you can just see it under fluoro that, okay, it works, you're done. They're ready to go. It's super reproducible, super reliable.

For antegrade, I do it a little differently. I stick a little lower. I like to use a more shallow angle. Sometimes it's hard for me to place a CELT device if the angle is steep, when you're trying to do an antegrade access. What I'll do is I'll try to stick to a more shallow angle and sometimes I'll end up accessing at the area of the lesser trochanter where I can. Then the reason for that is I want to be able to see under ultrasound exactly where my CELT is being deployed and I deploy it under ultrasound.

I really want to release the first disc where you can really see it so it doesn't drag on the wall of the artery or anything like that. Then as soon as that thing, you can deploy it under ultrasound and you're good to go. You're done. That's how I've been doing the two ways of CELT deployment. Man, when that thing goes, it's like, Steph Curry shoots a three and just turns around. He doesn't even look to see. It's money. That's what I do. I don't even look. I leave. I'm done. I see him in recovery. You don't have to worry about blood pressure or anything.

[Dr. Aaron Fritts]
That's cool. Syed, is your technique different from Omar's in any way?

[Dr. Syed Hussain]
It's fairly similar. I access all my arteries under ultrasound just like Omar does and I'm sure most of the interventionists out there do. After the procedure is done, you switch out to a five, six or seven or eight with short sheath, whichever sheath you decided to use. I'll put the device in. I will typically under flouro, pull the device back. What I'll do is with an ultrasound machine, I'll have a an idea where I access the artery. I look at the ultrasound while I'm doing flouros. I can see, okay, this is where I need to be to be out of the artery.

I'll deploy the disc, pull it back and again, just like Omar, I tend to try to minimize how early I deploy that first disc so I don't drag it across the artery, especially if it's calcified or full of plaque, et cetera. Once I pull it back against the anterior common femoral artery wall, I'll usually have my cap lab technologist who's scrubbed in with me, she'll come around to the top of me and she'll actually push the skin down so it's going to put pressure on either side of it and push it down so there's maximum contact between the anterior wall and the device and minimal subcutaneous tissue to deal with.

I don't know if you guys can picture what I'm talking about. You basically have them push pressure down so it's literally right up against the anterior wall and then I'll deploy the device and I don't check it with an ultrasound, I just check it under flouro to make sure it's not moving and then I assume it's deployed because like Omar said, you deploy it and then it's like mic drop and you walk away. I literally do the same thing for antegrade access and for all my other types of accesses like popliteal or mid-SFA or whatever. I'll access the artery and I'll do it the same way every time. There's not a lot of variation for that perspective.

Pros & Cons of the CELT Closure Device

The CELT device offers distinct advantages over other closure technologies. Its precise placement under ultrasound guidance and minimal scarring make it a favorable option for procedures requiring re-access. Despite initial concerns about multiple deployments, intravascular ultrasound (IVUS) exams in Dr. Hussian’s practice suggest that CELT integrates well with the arterial wall, exhibiting minimal intimal hyperplasia. Moreover, CELT enables rapid patient ambulation and discharge, significantly enhancing patient experience and throughput, particularly in office-based lab settings.

Nevertheless, some challenges are associated with the CELT device. Managing large bore access sites can be complex, and plaque dislodgement during deployment is a potential issue as well. However, these complications are generally manageable with careful technique, as Drs. Saleh and Hussain explain.

[Dr. Aaron Fritts]
It is pretty neat to be able to place it under ultrasound. Those are the demos that I've watched, just watching that plate come up under ultrasound. I don't know if you saw this, Omar, but recently Duke Duncan posted some comments about the CELT I guess he had just gotten a demo for it and he was sourcing some questions from the audience or asking for feedback, and there was a bunch of questions on there. I thought it'd be actually great to pull some questions from the audience because I think one of the most common questions is like, and I want to get y'all's thoughts on leaving a metal implant behind, which is essentially what it is, right? A small plate. Omar, can you speak to that? Have you seen any negative consequence of that or?

[Dr. Omar Saleh]
Yes, I think that is probably one drawback of CELT like where you have to avoid that. It's changed my practice a little bit. If I know I'm using CELT you don't want to keep bringing patients back if you don't need to. You want to do maximize their angiogram, right? You want to hit, two levels, DCB, whatever you need to do so they don't have to come back. It makes you more conscious. Okay, you don't want to keep bringing them back, but the thing is you can stick the CELT you can deploy the CELT right next to the previous deployment or you can go a little lower. You can use areas that are not being conventionally used for previous access.

What I try to do is I want to leave a little space for anybody else, say if the patient needs something else done by another doctor that they can just go above my CELT and do it and close. I've had that. We have some patients that I've shared with my local vascular surgeons who are not using CELT and they'll just tell me, yes, I went above your CELT and I use Mynx or whatever, because these are like patients with really calcified arteries or things like that, or they're using some other type of device.

I can see that being a problem. If you end up putting like six CELTs in one. I saw one that a angiogram where someone has six CELTs there, and they're doing fine, like on IVUS, everything's okay, it's endothelialized. That is one drawback. I would like to say also that, if you, if you do six Angio-Seals on that groin, it's going to be hard to access, you're going to be struggling putting in like a sheath, huh?

[Dr. Aaron Fritts]
Yes, way worse. I think with the Angio-Seals, given those foot plates.

[Dr. Omar Saleh]
Right. Even with CELT, with CELT at least the groin, when you bring them back, it's nice and soft. You can easily access, whereas Angio-Seal, sometimes it's very hard to even put like a sheet in or you have to use like some other techniques, like a stiff glide and stiff, 0.018 systems and upsize. With that, you're also battling. You may end up holding pressure on those. It becomes a hostile groin later on anyway. That's just a, just a couple of my thoughts on that subject.

[Dr. Aaron Fritts]
Syed, Does it impact the ability to do future large and small bore procedures for you, because you do open surgeries as well, what have you seen?

[Dr. Syed Hussain]
Just to tell you, number one, what Omar said is 150% correct. I think I do the exact same thing he does. The CELT actually guides me for my next CELT placement. I'm able to say, okay, I'm going to put them right next to it or right above it or right below it. I try to keep my CELTs lined up in the same area if at all possible. It does give other practitioners the opportunity to access above or below if they need to. Again, same findings on the IVUS exams I've done with patients with four or five CELTs, I have not seen any significant intimal hyperplasia that causes significant narrowing in the artery. It's well endothelialized on the anterior wall.

I think as far as the Angio-Seal, the Mynx devices, multiple Perclose devices used on these groins, those groins do turn into hostile groins, and they are very difficult to reaccess. Even though you don't have a scar on the groin, you've got an artery that's completely scarred off on the inside. Again, I can't agree with them more on his explanation for that. I think that's really understated as well, because this idea of leaving something behind has become such a big deal.

What people don't realize is that even though you've got multiple CELTs in the groin, the amount of scarring that you get is so minimal compared to what you see with Mynx or with Angio-Seal, or with Perclose devices placed in there multiple different times. Especially if you've got-- My personal experience with Mynx has been a lot of pseudo aneurysms. You've got people with pseudo aneurysms that have been injected, and now you've got these multiple hematomas that are sitting in there that have to be treated.

As far as opening these patients up, I'll tell you, opening up the groin on somebody with multiple Angio-Seals, or Mynxs or Percloses, it's like a bomb went off in the groin. When you get in there, everything is stuck together. The nerve-- You can't tell the nerve, you can't tell the artery or the vein is stuck together. It requires a lot of meticulous dissection. Groin exposure takes like 10, 12 minutes. Can take up to an hour just to try and dissect everything off. I've done the exposures for CELT devices where I've done eventual fem pops on patients or fem distal bypasses. I'll be honest with you, there is inflammation there too, but it's very localized to where you deployed that CELT. It is very easy to get above and below to get control of the artery. You have very minimal dissection to do with the CELT deployment.

The nice thing is when you open these arteries up, you can see the actual CELT device on the artery and how it's literally embedded in the arterial wall. It's really quite amazing to open it and to see that it's on the interior wall. It's much easier.

[Dr. Aaron Fritts]
Interesting. Another question from the audience was how many is too many CELTs? Have you seen that they're-- What's the most you've seen and was it problematic, I guess?

[Dr. Syed Hussain]
I'd say, uh, I've not been overly impressed with number. I don't have a number to tell you, honestly. I've seen some patients who I've done four or five on, I've seen some patients who come from all over the place who've got 10 or 12 that are distributed all over the artery. That's the interesting thing about CELT is you'll see punctures in the mid SFA, you'll see punctures in the proximal SFA, you'll see functions in the external iliac artery. They're distributed everywhere.

The issue that a lot of vascular surgeons and some cardiologists have complained about is large bore access, 12-French, 18-French sheaths, 20-French sheaths, things like that. Honestly, I have not found that to be an issue. I do AAA and thoracic aneurysms, and I'll tell you, typically you'll be able to find a spot on the artery where you can access and do your percutaneous intervention.

The bigger problem becomes where you're doing branched endograft. Multiple branched endograft, the mesenteric, the renals. You're doing thoracic endograft, you're trying to put in complex endograft up in the branch vessels of the thoracic aorta. You need multiple access sites. If at the end of the day, if that's an issue, then the easiest thing to do is just cut down and expose the artery and you're able to do that too. There may be some limitations for that perspective, but ultimately in some, nothing that can't be overcome.

[Dr. Aaron Fritts]
Omar, any concerns regarding plaque? I know you talked about it when you're watching it under ultrasound, but one question from the audience was concerns regarding plaque dislodgement while retracting the device to the vessel wall?

[Dr. Omar Saleh]
Yes, it hasn't been an issue for me because I really-- I'll deploy the first disc, even if I'm under fluoro. I always save where I'm entering, so I'll deploy very close to the arteriotomy. From there, I haven't had any issues. If there's any resistance, I put the CELT device very parallel to the artery, and then usually if I feel any resistance, I can watch under fluoro and ultrasound to make sure I don't hit any plaque or anything like that. Antegrade SFA is much easier. I can see-- I don't deploy it until I can see it and then I can see exactly-- Go against the wall and do the second marker.

[Dr. Aaron Fritts]
Got it. Somebody sent over from the audience a journal, I guess this is an abstract from JVS talking about the safety and efficacy of the CELT from 2022. What was most interesting about it was the median time to hemostasis, to ambulation and to discharge was all under 31 minutes. They only report no major complications to minor complications, which were minor soft tissue bleeding from the access site. Can you guys speak to the time to ambulation and discharge at all? That seems unbelievable, honestly. You'd never do that with any other closure device. Syed, can you talk a little bit about that, because that seems to be one of the biggest benefits?

[Dr. Syed Hussain]
I think in our OBL we would routinely-- Typically when I do an angiogram, I won't give a ton of sedation. I'll give maybe 50 of fentanyl, maybe a milligram of versed, and we'll do our case that way. By the time you're done with the case, the the sedation is essentially worn off. We'll put the CELT in and more times than not, we'll actually have the patients get off the table and walk back to the recovery room.

Then we'll check their groin and that'll tell you everything you need to know. There's no hematoma. Like I said, we give them a little snack and then 20 minutes later they get discharged. Some of the patients who are a little bit more groggy, we basically do the light test like Omar talked about. We'll sit them up in their gurney, we roll them back and then our protocol has always been 30 minutes of bedrest, get them up, walk them in the hallway, and then discharge them after that.

It's worked out great. I try to do that in my hospital now where I'm employed and that's always a shocking thing. The staff is like, "No, we can't do that." It freaks everybody out when they see the patient walking back from the cath lab and they're just like, "Wait a second. The patient's got to be in the chair and they might fall, et cetera. It is a little bit more challenging to do it in the hospital just because of the rules, but it does get the staff-- The look on the staff is always interesting to watch. Watching the patient walk back from the cath lab.

[Dr. Aaron Fritts]
I bet that's pretty impressive to your cardiology colleagues. Are In vitro cardiologists starting to use the CELT at your hospital?

[Dr. Syed Hussain]
That's been a little bit challenging. The arguments that I get back from them is, they don't like leaving a piece of metal behind. That's been their only complaint at this point. I don't know if it's more because they don't want to use it because the vascular surgeon's using it. It's hard to say.

[Dr. Aaron Fritts]
Omar, what about you? What's been your experience with getting patients ambulating afterwards?

[Dr. Omar Saleh]
Oh, it's been amazing. I've had some recent patients that had severe back pain. They can't lie flat on the table and they just we can sit them up right away. That's been great. My mother-in-law had a geniculate artery embolization done, and they did CELT. I actually did it on her. She had the CELT placed and she walked immediately to the bathroom. She didn't want to use a bed pan.

She's the happiest person. From the geniculate artery embo, thank you BackTable for that podcast episode that got me started on that procedure. Also the CELT it's been awesome. She walked immediately and then went home. Fibroid embolizations, they're always in pain. The have that cramping where they can bend their knees and walk to the bathroom. It's been a huge change in our OBL practice or even hospital practice now since using the CELT.

Podcast Contributors

Dr. Omar Saleh discusses New Innovations in Closure Devices on the BackTable 384 Podcast

Dr. Omar Saleh

Dr. Omar Saleh is a practicing interventional radiologist with the California Vascular Center.

Dr. Syed Hussain discusses New Innovations in Closure Devices on the BackTable 384 Podcast

Dr. Syed Hussain

Dr. Syed Hussain is the chairman of vascular and endovascular surgery at Christie Clinic Vein and Vascular Center in Illinois.

Dr. Aaron Fritts discusses New Innovations in Closure Devices on the BackTable 384 Podcast

Dr. Aaron Fritts

Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.

Cite This Podcast

BackTable, LLC (Producer). (2023, November 13). Ep. 384 – New Innovations in Closure Devices [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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New Innovations in Closure Devices with Dr. Omar Saleh and Dr. Syed Hussain on the BackTable VI Podcast)
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