Closure Devices

Manual Compression

Manual compression (MC) has been the gold standard for achieving hemostasis after arterial access for more than 50 years. Manual compression has a high success rate and a low complication rate. Hemostasis can usually be achieved within about 15–25 minutes, although the exact time can vary based on arteriotomy size, health of the vessel, and patient coagulation. Hematoma is the most common complication, although most are minor, requiring only conservative therapy. The major complication rate is approximately 2%, and includes pseudoaneurysm, retroperitoneal hemorrhage, and vessel thrombosis.

Although MC appears straightforward, there are a few steps that can help direct the operator in an optimal technique for holding pressure (described for common femoral artery access).

• • 1.

    Using the left hand for right femoral access, three fingers are placed over the femoral pulse proximal to the access site, and one finger distal to the access site.

  • 2.

    While applying firm pressure with the left hand, the right hand is used to remove the sheath from between the fingers of the left hand. The right hand can then be repositioned over the left hand to improve holding pressure and reduce fatigue.

  • 3.

    Occlusive pressure should be held for no more than 2–3 minutes, and then pressure slightly lessened for the remainder of the time used to hold pressure to allow for distal blood flow.

  • 4.

    The fingers should be straight to prevent the artery rolling out from under the fingers. This takes significantly more force than holding pressure with the fingertips. Pressure should be maintained firm enough to prevent any hematoma formation, which is detected as firmness around the compression site.

  • 5.

    After hemostasis is achieved, the distal pulses should be reexamined and compared with the baseline exam.

The drawbacks to MC are that it can be time consuming, it can be physically challenging to hold adequate pressure to achieve hemostasis in very large patients, it may not work in fully anticoagulated or uncooperative patients, and it may be difficult to avoid vessel thrombosis in small arteries. It also requires postprocedure bed rest for 4–6 hours. This last reason has been a particularly important motivator in the development of vascular closure devices (VCDs), partly because the bed rest requirement can be quite difficult for certain patient populations (e.g., patients with orthopnea or musculoskeletal pain), sometimes even precluding them from a potential procedure if they cannot lie flat. Perhaps even more relevant is that in an ever-evolving cost-conscientious health system, decreasing the time to ambulation and expediting discharge times is increasingly desired.