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Access closure
11.1
Femoral access
11.1.1
Femoral access closure algorithm
The following algorithm ( Fig. 11.1 ) reflects the experience and current practice of the authors; other vascular closure devices can be incorporated in the algorithm depending on local availability and expertise. Use of vascular closure devices is favored for shortening the time to ambulation and potentially reducing the risk of complications, although the latter remains controversial .
11.1.2
Can the femoral sheath be safely removed?
In some patients the femoral sheath may need to remain in place, for example, in patients who are planned to have staged PCI within a few hours or patients who are likely to need a hemodynamic support device in the next few hours.
Conversely, the femoral sheath may need to be removed immediately, for example, if there is continued bleeding around the sheath (an alternative is to insert a larger sheath if the oozing is due to an arteriotomy size that is larger than the femoral sheath size).
If the femoral sheath needs to stay in place it is secured with sutures. If long sheaths were used they are usually replaced with short (10–13 cm) sheaths.
11.1.3
Able to use a vascular closure device?
Use of vascular closure devices improves patient’s comfort, speeds up ambulation, and may reduce access complications (although vascular closure devices may cause complications as well).
Femoral angiography is critical for determining the feasibility of vascular closure. Use of vascular closure devices requires:
-
Large femoral artery (>5 mm) without significant disease
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Access above the common femoral artery bifurcation.
The most commonly used vascular closure devices are the Angioseal (Terumo) and the Perclose (Abbott Vascular), and these are discussed in more detail later in this chapter. Use of the Perclose should be avoided in heavily calcified femoral arteries and use of Angioseal should be avoided in cases of high femoral artery puncture .
There are other vascular closure devices, such as the Starclose (Abbott Vascular), Mynx (Cardinal Health), Exoseal (Cordis), Vascade (Cardiva), and Celt (Vasorum) that can be used depending on local availability and expertise.
11.1.4
High-stick?
Use of the Angioseal ( Section 30.15.1.1 ) should be avoided when arterial stick is high (above the inguinal ligament) due to difficulty advancing the collagen plug all the way to the artery . Use of the Perclose ( Section 30.15.1.2 ) is preferred in such cases.
11.1.5
ACT<180 seconds?
Vascular closure devices can be used even when the ACT is high, although it may be best to not use them if the ACT is>300 seconds.
Removing the femoral sheath and holding manual pressure should be delayed until after ACT is <180 seconds to minimize the risk of bleeding.
Protamine ( Section 3.4 ) can be administered in some patients to reverse anticoagulation and allow for earlier sheath removal.
11.1.6
Manual compression
11.1.6.1
Goal
To achieve hemostasis without complications.
11.1.6.2
How?
- 1.
Patient should be on telemetry with noninvasive blood pressure monitoring.
- 2.
Personnel should be available to administer atropine or fluids if needed for a vasovagal reaction.
- 3.
Sterile gloves should be used.
- 4.
The operator’s hands are placed above the femoral puncture site.
- 5.
The sheath is removed while applying gentle pressure with small back bleed.
- 6.
Firm pressure is applied confirming hemostasis.
- 7.
Duration: approximately 2–3 minutes × the sheath size, i.e., 12–18 minutes for 6 French and 16–24 minutes for 8 French sheaths.
- 8.
The access site is checked for hematoma.
- 9.
Distal pulses are checked.
- 10.
A clear sterile dressing (such as Tegaderm) is applied over the puncture site.
11.1.6.3
Challenges
- 1.
Manual compression can be challenging in morbidly obese patients.
11.1.6.4
What can go wrong?
11.1.6.4.1
Bleeding ( Section 29.1.2 )
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Causes:
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Suboptimal placement of the operator hands (too low or to the side of the arterial entry point).
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Inadequate pressure.
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Anticoagulation.
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Hypertension.
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Obesity.
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Hematoma formation.
-
-
Prevention:
-
Optimal hand positioning.
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Application of firm pressure.
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ACT is checked prior to sheath removal to ensure patient is not anticoagulated.
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If patient is hypertensive, medications are given to lower blood pressure.
-
-
Treatment:
-
Reposition hands.
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Firm pressure.
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Endovascular intervention or emergency surgery may be needed if hemostasis cannot be achieved.
-
11.1.6.4.2
Lower extremity ischemia ( Section 29.1.1 )
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Causes:
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Iliac or femoral artery dissection.
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Femoral artery thrombosis.
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Thrombus or plaque embolization.
-
-
Prevention:
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Use meticulous technique while obtaining access ( Chapter 4 : Access).
-
-
Treatment:
-
Emergency angiography followed by endovascular or surgical intervention.
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11.1.6.4.3
Hypotension ( Section 28.1 )
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Causes:
-
Bleeding.
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Cardiac causes (tamponade, ischemia, arrhythmias, valvular regurgitation, and left- or right-ventricular failure).
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Vasovagal reaction or anaphylactic reaction.
-
-
Prevention:
-
Optimal access technique.
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Normal saline administration prior to removing the sheath.
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Local anesthetic administration prior to sheath insertion to minimize the risk for pain-induced vasovagal reactions.
-
-
Treatment:
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Bleeding: resuscitation with normal saline and blood transfusion if needed, followed by endovascular or surgical intervention, depending on type of bleeding.
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Cardiac failure: treat the underlying cardiac cause: for example pericardiocentesis in case of tamponade, vasopressors, inotropes, and hemodynamic support devices in case of heart failure.
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Vasovagal reaction: normal saline administration—atropine may be used in case of bradycardia.
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11.1.7
Angioseal VIP
The Angioseal VIP device is described in Section 30.15.1.1 .
11.1.7.1
Step 1. Prepare the device for use
11.1.7.1.1
How?
- 1.
Open the Angioseal sterile package.
- 2.
Remove the dilator and the sheath from the package. Insert the dilator into the sheath, ensuring that the two pieces snap together securely ( Fig. 11.2 ). There is a reference indicator on the dilator that should align with the indicator on the sheath.
11.1.7.2
Step 2. Advancement of a 0.035 in. guidewire and removal of the femoral sheath
11.1.7.2.1
How?
- 1.
Advance a 0.035 in. guidewire through the femoral sheath. The wire provided with the Angioseal device is adequate for sheaths up to 25 cm in length. Longer sheaths will require a longer 0.035 in. wire. A 0.038 in. guidewire can be used for the 8 French but not the 6 French Angioseal.
- 2.
Perform fluoroscopy to confirm that the guidewire is in the aorta.
- 3.
Remove the femoral sheath leaving the 0.035 in. guidewire in place.
11.1.7.3
Step 3. Insertion of the Angioseal sheath
11.1.7.3.1
How?
- 1.
Advance the Angioseal sheath/dilator assembly into the vessel until flow of blood is observed through the drip hole ( Fig. 11.3 ).
- 2.
Slowly withdraw the Angioseal sheath/dilator assembly until blood flow from the drip hole stops ( Fig. 11.4 ). This suggests that the blood inlet holes of the insertion sheath have just exited the artery.
- 3.
Readvance the Angioseal sheath/dilator assembly until blood begins to flow from the drip hole of the dilator.
11.1.7.4
Step 4. Removal of the guidewire and dilator
11.1.7.4.1
How?
- 1.
Fix the tip of the Angioseal sheath in place using the operator’s left hand. There should be no movement of the sheath.
- 2.
Flex the dilator tip upward to separate it from the sheath.
- 3.
Remove the dilator and guidewire (ensuring that the sheath does not move, Fig. 11.5 ).
11.1.7.5
Step 5. Insertion of the Angioseal device
11.1.7.5.1
How?
- 1.
Hold the Angioseal device close to its tip.
- 2.
Ensure that Angioseal device reference indicator is facing up.
- 3.
Insert the Angioseal device tip through the hemostatic valve of the Angioseal sheath.
- 4.
Advance the Angioseal device until it is completely inserted into the Angioseal sheath and the devices snap together ( Fig. 11.6 ).
11.1.7.6
Step 6. Deployment of the anchor
11.1.7.6.1
Goal
Deploy the anchor inside the artery ( Fig. 11.7 ).
11.1.7.6.2
How?
- 1.
The Angioseal sheath cap continues to be held firmly during this maneuver. There should be no movement of the sheath during anchor deployment.
- 2.
Slowly pull back the Angioseal device until resistance is felt. The resistance is due to the Angioseal anchor catching the distal tip of the sheath.
- 3.
The Angioseal device sleeve colored band should be completely visible ( Fig. 11.8 ).
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