Interactive Transcript
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So let's talk about the methods for
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achieving hemostasis and closure
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of the arteriotomy post procedure.
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So let's get back to the case of Ms.
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G, our 56-year-old patient with a past
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medical history of type 2 diabetes,
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hypertension, and hyperlipidemia.
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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.
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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
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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
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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
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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
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that you've achieved hemostasis.
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You know that if you hold pressure for 20
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minutes on an access arteriotomy
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that is 5 to 8 French in caliber,
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you know that you are probably highly
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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
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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
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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
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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
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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.
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I would say maybe you may consider hemostasis
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via manual compression this time around.
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If the patient has an allergy to
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a device component, then also,
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manual compression may be your safest option.
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