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Hemostasis: Manual Compression and Closure Device

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0:01

So let's talk about the methods for

0:02

achieving hemostasis and closure

0:04

of the arteriotomy post procedure.

0:07

So let's get back to the case of Ms.

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G, our 56-year-old patient with a past

0:11

medical history of type 2 diabetes,

0:13

hypertension, and hyperlipidemia.

0:14

A little bit of a sort of vasculopathic

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sort of comorbidities on this patient who is

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sort of being prepped for treatment of severe

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left renal artery stenosis.

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So, she has her scheduled operation today.

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Here's her imaging, which we've reviewed before.

0:31

So let's talk about hemostasis and closure.

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So both the renal artery stent and the

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tunneled dialysis catheter, which we're

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being consulted for, were completed

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without intraoperative complications.

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So how do we achieve the arterial

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hemostasis in our patient?

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So manual compression versus a closure device.

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It's a nice decision tree to start with.

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So when it comes to manual compression,

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it's very important to note that there

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are three fingers that really are active.

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You have your middle finger that

1:00

should really be on your arteriotomy.

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You have your index finger that

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should be just superior to it.

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And then you have the ring finger

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that should be inferior to it.

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And what you often are doing is making sure that

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you are identifying the arteriotomy so

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that it's very clear that the arteriotomy is

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in view and your finger is not obscuring it.

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So you want to apply what we call non-luminal

1:22

obliterating compression of the artery.

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So what are the benefits and

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drawbacks of manual compression?

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Well, some benefits are the following.

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So, I would say that you have a particularly

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high rate of success, and a low rate of major

1:36

access site complications. So when we're

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thinking about manual compression.

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So, no implanted devices left behind.

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You know, it's something that you

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are very, very, very, very, very certain

1:51

that you've achieved hemostasis.

1:53

You know that if you hold pressure for 20

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minutes on an access arteriotomy

2:00

that is 5 to 8 French in caliber,

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you know that you are probably highly

2:08

successful in achieving that hemostasis.

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Now some of the drawbacks include the following.

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It is very reproducible.

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20 minutes is 20 minutes is

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20 minutes is 20 minutes.

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And that is particularly effective.

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But some people may say, you know what, actually

2:22

I want to be able to get on with my day.

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You know, I want to move to the next patient.

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I want to get some throughput.

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If you have an outpatient lab,

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you may say, well, time is money.

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You know, not to put it in those terms,

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but if you're actually thinking about it in

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those terms, maybe the time spent 20 minutes

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for 5 patients or 8 patients, that adds

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up to some time that they're just

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lying on the table waiting for hemostasis.

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Some patients actually may have issues being

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in that recumbent position for an extended

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period of time, which six hours would be the

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time that they would need to be recumbent; you

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know, typically four hours flat, but

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after four hours, raising

2:57

the head of bed to about 30 or 45 degrees.

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But for some people, they may not

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actually be able to lie flat for four hours.

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And in terms of anticoagulation, you know,

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if you need to restart anticoagulation

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in this setting, this may result in

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a prolonged manual compression time.

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So you want to consider these

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things as you appraise manual compression.

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So let's think about it a little bit more.

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So when we think about closure devices,

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this is sort of the nexus here.

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So closure devices in the

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setting of anticoagulation.

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Manual conversion, the setting

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of manual, manual conversion.

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So let's think about some benefits and drawbacks.

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That may be the first one that comes to mind.

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So let's talk about the benefits

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and some of the drawbacks.

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So, one of the major reasons why closure

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devices are used is because they are a good

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tool to push expeditious throughput as

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it relates to patients being moved

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into the IR suite and out of the IR suite.

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So people see this as sort of maximizing

3:54

resource utilization, as opposed to

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the settings where manual compression is used.

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Some drawbacks include the fact that,

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if you fail to deploy,

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you're going to end up using a device that

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was expensive, didn't do its job, and

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you still have to hold pressure, okay?

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Or, in some situations, there may be

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embolization of the little sort of components,

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whether that's a little metal plate.

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Whether that is a little collagen plug,

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or that little plug or plate may result

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in thrombosis or occlusion of the vessel,

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or may serve as an impetus for infection.

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So, some people say, you know what, the

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beauty of these devices is that they

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can decrease bleeding complications,

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time to discharge, and overall cost.

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Because of that alone, I will use it.

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Others may say, nope, I'm not

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going to do any such thing.

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I'm going to hold pressure because

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it's durable and it's reliable.

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So, what are some indications that

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favor the use of a closure device?

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Well, you may say an arterial

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intervention that's greater than 7

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French, that's particularly challenging.

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You know, if I feel like if I use minor

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compression alone, it may rebleed.

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And I may say, good on you.

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If you say this patient's critically

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ill, you know, they have sort of

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therapeutic levels of anticoagulation.

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This was sort of a trauma patient or a sudden

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patient that wasn't able to sort of be optimized

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from the standpoint of anticoagulation.

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And then we say, you know what?

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I just don't feel safe pulling

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out and holding pressure.

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This may be like a 45-minute or an hour hold.

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Not trying to do that.

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Let's go ahead and use a closure device.

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Good on you.

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An obese patient, large pannus, holding pressure.

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It's like, you know, maybe

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doing like a barbell curl.

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You're just like, I want to get this done for 20

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minutes, but I feel like I can't get this done.

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So let's do ourselves a solid and maybe

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use a closure device and do the patient

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a solid and sort of minimize the time

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that they're going to be recumbent.

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And also sort of achieve hemostasis.

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The patient sort of can't tolerate

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the bedrest as we talked about before.

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Again, good enough reasons

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to use a closure device.

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So, what are some relative contraindications

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to using a closure device?

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Well, you know, if you've got a small vessel

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size, usually there's some settings

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where 4 millimeters is the instruction

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to use for deploying a closure device.

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So anything 3 millimeters or

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less, don't even consider it.

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If you have a large arteriotomy, you may say,

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oh, okay, this is actually a situation where

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you say, if I use a large closure device and

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a large arteriotomy, this may not be enough.

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I may actually have to use manual compression.

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I may have to actually use both.

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Or you may say, you know what, actually,

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3 millimeters is sort of the caliber

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where this shouldn't be deployed.

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4 millimeters is kind of our cutoff.

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But if this patient has atherosclerotic disease,

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if I measure the vessel where I actually

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got access, you know, it's four millimeters

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sort of in the native vessel, but with this

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calcification, it's a little chunky monkey here,

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you know, now it's actually two millimeters.

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So definitely don't want to use it there because

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the functional diameter is actually less because

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of the concomitant atherosclerotic disease.

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And, you know, if there's a need for repeated

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access and, like, you know, you come

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in and you perform a, you know, closure device

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closure, you know, for your sort of maybe pre

6:54

Y90 radiomobilization planning next week again,

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and, you know, treatment again for a TACE in

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the future, and, you know, before you know it,

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you have five accesses in the course of the year,

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and you've all used a bunch of closure devices

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in order to achieve hemostasis in all of them.

7:09

I would say maybe you may consider hemostasis

7:12

via manual compression this time around.

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If the patient has an allergy to

7:16

a device component, then also,

7:18

manual compression may be your safest option.

Report

Faculty

Mikhail CSS Higgins, MD, MPH

Director, Radiology Medical Student Clerkships; Director, ESIR

Boston University Medical Center

Tags

Vascular Imaging

Vascular

Ultrasound

Interventional

Iatrogenic

Fluoroscopy

Angiography

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