Size of sheath (Fr)
Duration of manual compression (min)
4–5
15
6–7
20–25
7–10
30
Gradually decrease the applied pressure (every 5 min or so) while maintaining hemostasis.
Following 15–20 min, when the pressure has been completely relieved, the puncture site should not be bleeding. If visible bleeding or soft tissue swelling is noted after releasing pressure, reapply occlusive pressure for another 5 min, then check again.
Compression Devices
Femostop®
Ensure BP is under control.
Patient should be in supine position.
We prefer applying manual compression for 15–20 min prior to the application of Femostop, but a shorter duration is acceptable if the ACT is low (<150).
Place the Femostop belt under the patient’s hips, in line with the puncture site.
Ensure that Femostop is properly positioned over the arteriotomy site.
To achieve this, the see-through inner circle of the Femostop dome should be positioned 1 cm superior and 1 cm medial to the actual puncture site and over the femoral artery.
Fully compress sidearm levers on compression arch to allow belt to be threaded. Adjust the belt to a snug fit. The arch should be level and sit squarely across groin area.
Inflate the Femostop to 20–30 mmHg above the patient’s systolic pressure. If this does not result in hemostasis, inflate to higher pressures until distal pulses are occluded. If the Femostop is positioned properly, the distal pulses will attenuate with device inflation.
The properly positioned device will push straight downward upon the artery and not be tilted, or at an angle other than 90° to the underlying artery.
Maintain distal pulse occlusion for 5–7 min and then readjust the manometer pressure until good pedal pulse and good color of extremities are achieved.
Once hemostasis occurs, reduce manometer pressure to half the number and observe the site for 2–3 min. Additionally, continue to check the pressure applied, as the device may have a tendency to deflate spontaneously.
Continue to progressively decrease the applied pressure over the course of several hours, until the device can be discontinued entirely.
Usually, a Femostop is maintained for 6–12 h in anticoagulated patients.
While the Femostop is applied, continue neurochecks, vital signs, O2 sats; pedal pulses, limb color, sensation of warmth; puncture site for bleeding, hematoma on a flowchart. The following frequency of observations may be considered:
Every 15 min for 1 h.
Every 30 min for 2 h.
Every hour until Femostop is discontinued.
Instruct the patient to inform the nurse immediately of any obvious bleeding, sensation of wetness, burning or tearing at the puncture site.
After the Femostop is removed. Continue monitoring for signs of vascular complications, e.g., tenderness; groin mass, pulsatility; bruit, signs of leg ischemia.
The following frequency of monitoring may be considered:
Every 15 min for 1 h.
Every 30 min for 2 h.
Every hour for 4 h.
Percutaneous Closure Devices
Angioseal (St. Jude Medical, Minnetonka, MN)
This is our device of choice for closure due to its simplicity of use and reliability. Additionally, unlike most other percutaneous devices, it does not cause attenuation of vessel lumen.
Available in 6 Fr and 8 Fr sizes.
Angioseal device consists of 3 components: (i) arteriotomy locator, (ii) insertion sheath, and (iii) carrier tube (Fig. 3.1). The arteriotomy locator is advanced into the insertion sheath until it locks in place. The single unit so formed is then advanced over the wire into the artery, after the sheath used for procedure is removed over the wire, leaving the wire in place. The arteriotomy locator and the wire are withdrawn concurrently, leaving the insertion sheath in the artery. The carrier tube is advanced into the insertion sheath for completion of the closure. The details are as follows:
Fig. 3.1
Components of Angioseal. The J wire (arrow) is introduced into the vessel through the access sheath, and the sheath is then removed, taking care that wire remains within the vessel. The arteriotomy locator (with * on either end) has been inserted into the 6 Fr sheath (thick arrow), ready to be advanced over the wire into the artery. Once in the artery, the locator is removed and the sheath left in place. The carrier tube (curved arrow) is then inserted into the sheath, until it snaps in place
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Perform femoral angiography to ensure the arteriotomy is proximal to femoral bifurcation and that vessel diameter ≥4 mm.
Remove any catheter traversing the femoral sheath.
Cut the suture securing the sheath to the skin (if an anchoring suture was used).
Continue to maintain sterile field.
Remove the Angioseal device contents from the foil package. Pull the foil apart completely, before removing the Angioseal device to ensure none of the contents get kinked.
Insert the arteriotomy locator into the insertion sheath, until the two pieces snap securely in place (Fig. 3.2).
Fig. 3.2
Diagrammatic representation of Angioseal a The arteriotomy locator is about to be inserted into the insertion sheath. The arrows on the sheath and arteriotomy locator are appropriately facing the same side. The same is demonstrated in the photograph b where the arteriotomy locator is being inserted into sheath. The markings on the sheath indicate that it is 6 Fr in size. The arteriotomy locator has been completely inserted and snapped into position in the sheath c (Figure 3.2a courtesy St. Jude Medical, Minnetonka, MN. Angioseal™ is a trademark of St. Jude Medical, Inc. or its related companies. Reprinted with permission from St. Jude Medical™, © 2012. All rights reserved)
When inserted correctly, the arrow mark on the arteriotomy locator is aligned with a similar mark on the insertion sheath.
Insert the J wire provided in the Angioseal kit, or longer exchange wire as required for longer access sheaths, into the femoral sheath and advance it into the artery.
Remove the femoral sheath over the J wire and discard it. Ensure that the J wire maintains its position so that arterial access is not lost.
Thread the arteriotomy locator-insertion sheath unit onto the J wire. Advance it over the wire into the artery, until blood is noted to pulsate out of the drip hole located at the outer (proximal) aspect of the arteriotomy locator (Fig. 3.3).
Fig. 3.3
When the sheath is at least 1.5 cm within the artery, blood is seen to spurt out of the drip hole at the proximal aspect of the arteriotomy locator (Figure courtesy St. Jude Medical, Minnetonka, MN. Angioseal™ is a trademark of St. Jude Medical, Inc. or its related companies. Reprinted with permission from St. Jude Medical™, © 2012. All rights reserved)Related posts:
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