♦ Preoperative
Operative Planning
- Anticipate need and timing of repeat arterial access (e.g., to monitor or treat cerebral vasospasm)
- If access at same location of previous Angio-Seal (Kensey Nash, Exton, PA) use is necessary within 90 days, reentry should be performed 1 cm proximal to the previous puncture site
- Repeat puncture after use of suture-mediated closure device considered acceptable
- If access at same location of previous Angio-Seal (Kensey Nash, Exton, PA) use is necessary within 90 days, reentry should be performed 1 cm proximal to the previous puncture site
- Reverse anticoagulation if appropriate
- Review angiogram of femoral artery
- Best performed with 45-degree ipsilateral oblique angle to display bifurcation of CFA
- Look at caliber of vessel (closure devices not recommended in arteries smaller than 5 mm diameter)
- Verify that puncture site is in CFA segment, not proximal (external iliac) or distal (SFA)
- Superficial epigastric artery marks location of the inguinal ligament, which demarcates external iliac from CFA
- If puncture site is in external iliac, consider placing sheath in contralateral femoral artery before deploying closure device, thus preserving vascular access to repair iliac artery in case device fails (iliac artery cannot be compressed against femoral head, unlike CFA).
- Superficial epigastric artery marks location of the inguinal ligament, which demarcates external iliac from CFA
- Look for atherosclerotic plaque, stenosis, etc.
- Best performed with 45-degree ipsilateral oblique angle to display bifurcation of CFA
- Consider sheath size (see equipment list)
Equipment
- Many devices currently available. The first three anchor a collagen or thrombin plug to the vessel wall; the last three use mechanical fixation (nitinol clip or suture) to seal puncture site
- Angio-Seal: available in 6 French (F) and 8F size
- On-Site (Maquet, Inc.): compatible with 5 to 6F sheaths
- Duett (Vascular Solutions, Minneapolis, MN): compatible with 5 Fr to 9 Fr sheaths
- Perclose: compatible with 5 to 8F sheaths
- StarClose (Abbott): compatible with 5 to 6F sheaths
- ProStar XL (Abbott): compatible with 6.5 to 10F sheaths
- Mynx (AccessClosure, Mountain View, CA): available in 5F and 6/7F size
- Angio-Seal: available in 6 French (F) and 8F size
♦ Intraoperative
- Consider use of systemic antibiotic (if sheath has been in place for more than 8 hours)
- Reapply local anesthetic (1% bupivacaine for long duration, buffered with bicarbonate to reduce discomfort)
- Deploy device of choice (see previous list of equipment)
- Apply manual pressure until bleeding controlled (duration variable)
- Clean site, apply topical antibiotic, and clear dressing
♦ Postoperative
- Order groin checks (inspect for bleeding, hematoma) and distal pulse checks every 15 minutes for first hour, then possibly every hour for up to 4 hours
- Instruct patient to avoid strenuous exercise or soaking in bath for 1 week
- Instruct patient to monitor for pain, enlarging mass, bleeding, redness, discharge, fever, etc.
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