“Control of the Puncture Site Following Sheath Removal

Originally, standard groin management required the effect of heparin to wear off or be reversed by protamine to an ACT <160 seconds before the arterial catheter and sheath were removed and manual pressure applied, except in the case of bivalirudin as mentioned above. Manual pressure method is best applied using three fingers of the left hand that are positioned sequentially up the femoral artery beginning at the skin puncture. With the fingers in this position, there should be no ongoing bleeding into the soft tissues or through the skin puncture, and it should be possible to apply sufficient pressure to obliterate the pedal pulses and then release just enough pressure to allow them to barely return. Pressure is then gradually reduced over the next 10 to 15 minutes, at the end of which time pressure is removed completely. The venous sheath is usually removed 5 minutes after compression of the arterial puncture has begun, with gentle pressure applied over the venous puncture using the right hand. To avoid tying up the catheterization laboratory during this period, patients were usually taken to a special holding room in the catheterization laboratory or back to their hospital beds before the sheaths were removed. If such relocation is to be performed prior to sheath removal, it is important that the sheaths are secured in place (suture, or at least tape) to prevent them being pulled out during transport.

When procedures are performed using larger arterial sheaths or with thrombolytic agents or IIb/IIIa receptor blockers, more prolonged (30- to 45-min) compression is typically required. To avoid fatigue of the operator or other laboratory personnel performing compression, occasionally a mechanical device (Compressar [Applied Vascular Dynamics, Portland, OR], The Clamp Ease device [Pressure Products Inc., Rancho Palos Verdes, California] or FemoStop [Radi Medical, Wilmington, MA]) can be used to apply similar local pressure. These devices can be equally or even more effective in prolonged holds,22 but are uncomfortable for the patients and human supervision is required while in place; hence manual compression is preferred for removal of smaller (6F) sheaths or in patients with peripheral vascular disease or prior peripheral grafting surgery where occlusive compression or flow restriction might cause arterial occlusion. In every case, however, it should be emphasized that a trained person must be in attendance throughout the compression to ensure that the device is providing adequate control of puncture site bleeding and is not compromising distal perfusion.”

From Grossman and Baim’s Cardiac Catheterization, Angiography, and Intervention; editor, Mauro Moscucci, MD, MBA, professor of medicine, chairman, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida. — Eighth edition. Copyright 2014 (new edition will be coming out in 2020). Main page for book > Table of Contents > Section II – Basic Techniques > 6 – Percutaneous Approach, Including Transseptal and Apical Puncture > CATHETERIZATION VIA THE FEMORAL ARTERY AND VEIN > Control of the Puncture Site Following Sheath Removal
Link to book: https://tinyurl.com/y2hqn6wf