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.

0:09

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

0:17

sort of comorbidities on this patient who is

0:20

sort of being prepped for treatment of severe

0:23

left renal artery stenosis.

0:25

So, she has her scheduled operation today.

0:29

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

0:31

So let's talk about hemostasis and closure.

0:34

So both the renal artery stent and the

0:36

tunneled dialysis catheter, which we're

0:38

being consulted for, were completed

0:40

without intraoperative complications.

0:42

So how do we achieve the arterial

0:44

hemostasis in our patient?

0:46

So manual compression versus a closure device.

0:49

It's a nice decision tree to start with.

0:52

So when it comes to manual compression,

0:54

it's very important to note that there

0:56

are three fingers that really are active.

0:58

You have your middle finger that

1:00

should really be on your arteriotomy.

1:02

You have your index finger that

1:03

should be just superior to it.

1:05

And then you have the ring finger

1:07

that should be inferior to it.

1:09

And what you often are doing is making sure that

1:11

you are identifying the arteriotomy so

1:15

that it's very clear that the arteriotomy is

1:17

in view and your finger is not obscuring it.

1:19

So you want to apply what we call non-luminal

1:22

obliterating compression of the artery.

1:25

So what are the benefits and

1:26

drawbacks of manual compression?

1:27

Well, some benefits are the following.

1:30

So, I would say that you have a particularly

1:33

high rate of success, and a low rate of major

1:36

access site complications. So when we're

1:39

thinking about manual compression.

1:43

So, no implanted devices left behind.

1:46

You know, it's something that you

1:48

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

1:56

minutes on an access arteriotomy

2:00

that is 5 to 8 French in caliber,

2:05

you know that you are probably highly

2:08

successful in achieving that hemostasis.

2:11

Now some of the drawbacks include the following.

2:14

It is very reproducible.

2:15

20 minutes is 20 minutes is

2:17

20 minutes is 20 minutes.

2:18

And that is particularly effective.

2:20

But some people may say, you know what, actually

2:22

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

2:25

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

2:27

I want to get some throughput.

2:28

If you have an outpatient lab,

2:29

you may say, well, time is money.

2:31

You know, not to put it in those terms,

2:33

but if you're actually thinking about it in

2:34

those terms, maybe the time spent 20 minutes

2:38

for 5 patients or 8 patients, that adds

2:41

up to some time that they're just

2:42

lying on the table waiting for hemostasis.

2:44

Some patients actually may have issues being

2:46

in that recumbent position for an extended

2:48

period of time, which six hours would be the

2:50

time that they would need to be recumbent; you

2:52

know, typically four hours flat, but

2:55

after four hours, raising

2:57

the head of bed to about 30 or 45 degrees.

2:59

But for some people, they may not

3:01

actually be able to lie flat for four hours.

3:03

And in terms of anticoagulation, you know,

3:05

if you need to restart anticoagulation

3:08

in this setting, this may result in

3:10

a prolonged manual compression time.

3:12

So you want to consider these

3:14

things as you appraise manual compression.

3:17

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

3:19

So when we think about closure devices,

3:21

this is sort of the nexus here.

3:23

So closure devices in the

3:25

setting of anticoagulation.

3:27

Manual conversion, the setting

3:28

of manual, manual conversion.

3:29

So let's think about some benefits and drawbacks.

3:31

That may be the first one that comes to mind.

3:33

So let's talk about the benefits

3:35

and some of the drawbacks.

3:36

So, one of the major reasons why closure

3:38

devices are used is because they are a good

3:41

tool to push expeditious throughput as

3:46

it relates to patients being moved

3:49

into the IR suite and out of the IR suite.

3:52

So people see this as sort of maximizing

3:54

resource utilization, as opposed to

3:57

the settings where manual compression is used.

4:00

Some drawbacks include the fact that,

4:01

if you fail to deploy,

4:05

you're going to end up using a device that

4:08

was expensive, didn't do its job, and

4:10

you still have to hold pressure, okay?

4:12

Or, in some situations, there may be

4:14

embolization of the little sort of components,

4:17

whether that's a little metal plate.

4:19

Whether that is a little collagen plug,

4:22

or that little plug or plate may result

4:25

in thrombosis or occlusion of the vessel,

4:27

or may serve as an impetus for infection.

4:30

So, some people say, you know what, the

4:32

beauty of these devices is that they

4:34

can decrease bleeding complications,

4:36

time to discharge, and overall cost.

4:38

Because of that alone, I will use it.

4:40

Others may say, nope, I'm not

4:42

going to do any such thing.

4:43

I'm going to hold pressure because

4:44

it's durable and it's reliable.

4:46

So, what are some indications that

4:47

favor the use of a closure device?

4:49

Well, you may say an arterial

4:50

intervention that's greater than 7

4:51

French, that's particularly challenging.

4:54

You know, if I feel like if I use minor

4:55

compression alone, it may rebleed.

4:57

And I may say, good on you.

4:59

If you say this patient's critically

5:00

ill, you know, they have sort of

5:02

therapeutic levels of anticoagulation.

5:03

This was sort of a trauma patient or a sudden

5:05

patient that wasn't able to sort of be optimized

5:08

from the standpoint of anticoagulation.

5:09

And then we say, you know what?

5:11

I just don't feel safe pulling

5:12

out and holding pressure.

5:13

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

5:15

Not trying to do that.

5:17

Let's go ahead and use a closure device.

5:19

Good on you.

5:20

An obese patient, large pannus, holding pressure.

5:24

It's like, you know, maybe

5:25

doing like a barbell curl.

5:26

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

5:28

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

5:30

So let's do ourselves a solid and maybe

5:32

use a closure device and do the patient

5:34

a solid and sort of minimize the time

5:37

that they're going to be recumbent.

5:38

And also sort of achieve hemostasis.

5:41

The patient sort of can't tolerate

5:42

the bedrest as we talked about before.

5:44

Again, good enough reasons

5:47

to use a closure device.

5:50

So, what are some relative contraindications

5:52

to using a closure device?

5:53

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

5:55

size, usually there's some settings

5:57

where 4 millimeters is the instruction

6:00

to use for deploying a closure device.

6:02

So anything 3 millimeters or

6:03

less, don't even consider it.

6:05

If you have a large arteriotomy, you may say,

6:08

oh, okay, this is actually a situation where

6:11

you say, if I use a large closure device and

6:14

a large arteriotomy, this may not be enough.

6:15

I may actually have to use manual compression.

6:17

I may have to actually use both.

6:19

Or you may say, you know what, actually,

6:20

3 millimeters is sort of the caliber

6:23

where this shouldn't be deployed.

6:25

4 millimeters is kind of our cutoff.

6:27

But if this patient has atherosclerotic disease,

6:30

if I measure the vessel where I actually

6:32

got access, you know, it's four millimeters

6:34

sort of in the native vessel, but with this

6:36

calcification, it's a little chunky monkey here,

6:38

you know, now it's actually two millimeters.

6:39

So definitely don't want to use it there because

6:41

the functional diameter is actually less because

6:43

of the concomitant atherosclerotic disease.

6:46

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

6:47

access and, like, you know, you come

6:50

in and you perform a, you know, closure device

6:52

closure, you know, for your sort of maybe pre

6:54

Y90 radiomobilization planning next week again,

6:57

and, you know, treatment again for a TACE in

6:59

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

7:01

you have five accesses in the course of the year,

7:04

and you've all used a bunch of closure devices

7:06

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.

7:15

If the patient has an allergy to

7:16

a device component, then also,

7:18

manual compression may be your safest option.