Access Site Hemostasis

Abstract

The majority of arterial access procedures use the femoral route, with its attendant risks and lengthy periods of immobility. The traditional method for closure is manual compression, either with pressure through the operator’s hands or with an external compression device. Multiple vascular closure devices (VCDs) have been developed over the years with the idea of speeding the process of hemostasis and potentially reducing the incidence of vascular complications, which can include hematoma, pseudoaneurysm, AV fistula, retroperitoneal hematoma, need for surgical repair, and infection. VCDs have been successful on multiple fronts, most notably in shortening the time needed to achieve hemostasis and the time to ambulation, and thus can significantly impact patient comfort. The ability to close the access site at the end of a procedure means not only that the patient spends a shorter period of time laying supine, but also that fewer human resources need to be expended in caring for patients with arterial sheaths, in manually pulling those sheaths, and in subsequent recovery. The data on complications of these devices when compared with manual compression is mixed and is difficult to interpret. For the most part, VCDs seem to have a comparable safety profile to manual compression, with some notable exceptions (e.g., the Vasoseal device, which appeared in some studies to have an increased rate of complications and has since been removed from the market). This is based on registry data, small studies, and meta-analyses, all of which have significant flaws. At least one large registry, as well as data from the ACUITY trial, has suggested that VCDs actually lower the risk of bleeding. In the end, the decision to use or not use VCDs must be made by each operator based on their own experience and institutional resources, and on the needs and vascular anatomy of each particular patient.