Читать книгу Interventional Cardiology - Группа авторов - Страница 54

Manual compression has been the standard for sheath removal for decades. Classically, after diagnostic catheterizations the technique involves sheath removal after normalization of the activated clotting time (ACT) to <160–180 seconds and direct digital pressures with fingers positioned over the arterial puncture site and one to two fingerbreadths more proximally. The manual pressure should be applied with enough force to allow for a faint palpable distal pulse. Pressure is held for 10–15 minutes, during which hemostasis should be achieved, after which the patient is kept under bed rest for 4–6 hours.

The use of larger arterial sheaths, more intensive anticoagulation, and antiplatelet regimes associated with coronary and cardiac interventions have led to the need for more prolonged direct pressure to achieve hemostasis and more prolonged bed rest prior to ambulation. A variety of mechanical manual compression aids, such as the Femostop (Radi Medical System, Sweden) and CompressAR C‐clamp (Advanced Vascular Dynamics, Portland, OR), have been developed to relieve the requirement for staff to physically apply prolonged direct digital pressure. A number of studies have compared such devices with direct manual pressure, with most studies finding lower vascular complications with mechanical compression devices [17–19] although a small study (90 subjects) found better results with direct manual pressure [20].

Clamp devices provide compression without the need to have someone using direct manual pressure. While clamps may be less demanding on personnel, they do not obviate the need for careful supervision of the compression process. If clamps are applied with too much pressure or left in place for too long, they can result in arterial or venous thrombosis. If applied without adequate pressure, bleeding can result. The Femostop (RADI Medical) uses an inflatable bubble to apply pressure to the puncture site. This is our preferred device for compression in fully anticoagulated patients with failed suture closure or large caliber arterial or venous sheaths. The bubble is clear, so the puncture site can be observed directly. The pressure is regulated with a blood pressure cuff bulb. Near systolic pressure (usually 10 mm less than systolic blood pressure) can be applied for 15–30 minutes, and then the pressure can be decreased 10–15 mmHg every 10–20 minutes.

Even with interventional procedures, there have been some remarkable experiences with ambulation as early as 2 hours after simple manual compression. With the use of bivalirudin, in a study of 100 patients, after a mean manual compression time of 13 minutes, patients were able to ambulate at a mean duration of 2 hours and 23 minutes after sheath removal [21]. Even using heparin, there are various studies suggesting ability to ambulate after 2 hours. Using a regime of a standard heparin dose of 5000 IU and 6 Fr guiding catheters, two studies involving 359 and 907 patients were able to have sheaths removed immediately, with a mean compression time of around 10 minutes and successful early ambulation within 2 hours with no significant excess in puncture site complications [22, 23]. A study with more aggressive anticoagulation (ACT to 300 seconds) and subsequent sheath removal when ACT is less than 150 seconds showed no difference in Site complications between patients ambulating at 2 hours compared to 4 or 6 hours. In this latter study, there are also similar results in a subgroup of patients who received GP IIb/IIIa inhibitors [24]. Thus, manual compression is clearly an acceptable form of puncture site management in all patients.