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Principles of vascular closure and haemostasis


Despite being a great opportunity to talk to your patients, obtaining haemostasis after a diagnostic or therapeutic angiogram is tedious. Hence, the art of staunching the flow is often neglected or delegated to the most junior member of staff in the vicinity. This approach risks haematoma or haemorrhage; make sure you give as much importance to haemostasis as you do to arterial access ( Fig. 37.1 ). In reality, haematoma is a much more common complication of arterial procedures than any other.

Fig. 37.1
Fatal haematoma following SFA angioplasty through a 4Fr sheath.
The patient was resuscitated following cardiorespiratory arrest and had the artery repaired but succumbed to a CVA. (A) Coronal reformat showing massive haematoma in the left thigh (white arrowheads) with active bleeding (black arrowhead). (B) The point of extravasation is seen anterior to the femoral head. (C) Coronal oblique reformat clearly demonstrating active bleeding from the CFA.

Stopping the bleeding is usually straightforward unless:

  • The patient is severely hypertensive

  • The patient is obese

  • The patient is excessively anticoagulated or has a bleeding diathesis

  • You did not puncture the artery in the correct place

  • You made a bigger hole than normal, i.e. >7Fr

  • Or, as is often the case, a full house of the above.

Tip

If you are anticipating problems, call for help before you remove the sheath. Consider using an arterial closure device. If necessary, leave the sheath in situ, keep the patient heparinized and have it removed surgically. Less than 1% of patients should require transfusion or emergency surgery.

Manual haemostasis: how to prevent haemorrhage and haematoma

If you have only recently given 5000 units of heparin, stop and have a cup of tea before taking out the sheath. When both you and the patient are ready, and have emptied your bladders (do not omit this key step!), you can start.

Remember that the skin entry point is not directly above the arterial puncture site! In antegrade punctures, the skin entry point is above; in retrograde punctures, it will be lower.

Alarm

In ‘well-padded’ patients, the relationship between the skin entry point and arterial puncture site is complex. Skin entry may be considerably higher if there is a beach ball-shaped abdomen or may be lower if you had to retract a large fold of skin to puncture. Make sure that you can feel the pulse before you pull the sheath.

Key steps in haemostasis

  • 1.

    Empty all bladders.

  • 2.

    Attach blood pressure and pulse monitoring and make a baseline recording.

  • 3.

    Place a finger to either side of the catheter proximal and distal to the hole in the artery. You should be able to feel the pulse. Press firmly down until the pulse reduces; if increasing the pressure abolishes the pulse, you are in control.

  • 4.

    Look at a clock and check the time.

  • 5.

    Remove the sheath and continue pressing, feeling the pulse. Watch the puncture site or the patient will develop a haematoma.

  • 6.

    After 5 min according to the clock, slowly reduce the pressure and check the puncture site.

  • 7.

    If the bleeding has stopped, get someone else who understands the principles of haemostasis to press for a further 5 min, just to be on the safe side.

  • 8.

    When the bleeding has completely stopped, the puncture site will remain dry. Place a swab over it, place the patient's hand on the pulse and check that they can feel it. Instruct them to keep pressing until they get back to the ward and to remember to press if they cough, sneeze, etc.

  • 9.

    Document in the case notes or operation sheet the access site and the required observations.

Special circumstances

Children

Most cases will be performed under general anaesthetic. This is great during the procedure but can be problematic for haemostasis. The good news is that most children are thin and the pulse is easy to feel and hence compress for haemostasis. The bad news is that they wake up very quickly and are guaranteed to flex their limbs as soon as they regain consciousness and certainly when the anaesthetist manipulates their airway. It is best to have achieved haemostasis before this! It is always courteous to warn the anaesthetist that the procedure is drawing to a close so that they do not give another dose of muscle relaxant.

Tip

Mention haemostasis in the pre-procedure safety check and politely request the anaesthetist to hold-off waking the patient until you have removed the sheath. Even a couple of extra minutes helps.

Bedrest post-angiography

There is no scientific formula and precious little evidence to tell us what the optimum period of rest is before mobilizing. For uncomplicated 3/4Fr punctures, it is probably reasonable to sit up after 30 min and get out of bed after about 1 h. For larger punctures, a period of 4 h bedrest is probably prudent. Make sure that you advise patients to rest as much as possible for the remainder of the day. Day-case and outpatients should be given clear instructions to rest up and only to exercise the remote control. They and their carer should be shown how to press on the puncture site and told how to contact help if bleeding starts again after discharge.

Troubleshooting

Bleeding has not stopped when you check after 5 min

  • Still pulsatile bleeding? Press for at least another 10 min before you check again.

  • Gentle ooze? Press for another 5 min before checking.

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