The ECO-PLUG Technique: Ultrasound-Guided Optimization of Haemostasis After Percutaneous Femoral Access - a Pictorial Technical Note

Purpose: To describe the ECO-PLUG technique, a standardised ultrasound-guided workflow for percutaneous femoral access and plug-based closure, and to report its feasibility and clinical performance in patients undergoing peripheral artery revascularization procedures. Technique: The ECO-PLUG protocol incorporates continuous ultrasound guidance throughout all procedural phases: femoral access, closure device deployment, and post-procedural haemostasis verification. Five predefined checkpoints (C1-C5) structure the workflow from pre-access mapping to early and delayed ultrasound follow-up. Key elements include in-plane puncture, ultrasound-guided plug deployment with a modified retract manoeuvre, and systematic colour-Doppler assessment at 0 and 3 to 5 minutes after closure. Results: A total of 200 elective endovascular procedures using 6F/8F femoral access were analysed. Anatomical complexity was common, including moderate-to-severe anterior wall calcification (55%), arterial depth >35 mm (24%), and bifurcation variants (22%). Immediate haemostasis was achieved in 98% of cases, while 2% required prolonged compression or manual conversion. Access-related complications occurred in 4% of patients, including pseudoaneurysms (1.5%) and haematomas. No arterial occlusions or surgical conversions were observed. Conclusions: The ECO-PLUG protocol demonstrates acceptable haemostasis efficacy and a favourable access-site safety profile across anatomically complex settings, supporting its potential as a structured image-guided closure strategy. Prospective comparative studies are needed to validate these preliminary findings.Clinical ImpactThe ECO-PLUG protocol introduces the first formally structured, checkpoint-based ultrasound workflow integrating continuous imaging guidance across all phases of percutaneous femoral closure, from pre-access mapping through plug deployment and hemostasis verification. Unlike conventional approaches, where ultrasound use is typically limited to arterial puncture alone, ECO-PLUG extends real-time sonographic control to anchor positioning and collagen release, reducing operator dependency in anatomically complex cases. With 98% immediate hemostasis and no arterial occlusions or surgical conversions across 200 consecutive procedures, including patients with heavy calcification, deep vessels, and bifurcation variants, this protocol offers clinicians a reproducible, teachable standard applicable across varying experience levels.