Letter from the Editor

Push, Pull, Click, Stitch: Managing Femoral Punctures

Morton Kern, MD, Clinical Editor, Pacific Cardiovascular Associates, Inc., Costa Mesa, California;Adjunct Clinical Professor, Keck School of Medicine,University of Southern California, Los Angeles, California
Morton Kern, MD, Clinical Editor, Pacific Cardiovascular Associates, Inc., Costa Mesa, California;Adjunct Clinical Professor, Keck School of Medicine,University of Southern California, Los Angeles, California
As it is also the most common vascular access for cardiac cath, it is also most common source of morbidity (very rarely mortality) and complications such as hematomas, pseudoaneurysms and retroperitoneal bleeding. Rarely is the site the source of significant vessel occlusion, emboli or limb ischemia. Every lab has experienced at least one patient (and probably more) with common and rare complications related to managing the femoral puncture site. Because a complication of the puncture site can cause patient problems, prolong the hospital stay (with increased costs) with the possibility of needing blood transfusions or surgery, successful control of the femoral puncture has real advantages to both the patient and hospital. The management of femoral punctures actually starts with the operator’s initial puncture technique. The lab should assist in access management by accurate pulse assessment and draping. Because access is a blind puncture without seeing the true location of the artery, the localization by body landmarks such as the iliac crest, inguinal crease and symphasis pubis is helpful (see femoral anatomy, Figure 1). It is also helpful to mark the skin entry site with a clamp, using a quick fluroscopic view of the femoral head to see proximity to the common femoral artery path. Of course, the arterial anatomy will vary among individuals. Despite an accurate skin approach, the bifurcation of the superficial and profunda femoral arteries may be high or low. Remember, low femoral punctures have higher risk of pseudoaneurysms. High punctures have higher rates of retroperitoneal bleeding. Punctures in the bifurcation itself may not seal due to the angulation of the junction of the 2 vessels. Calcified vessels may also bleed despite excellent access technique. Management of the femoral puncture site following the procedure has evolved from manual compression to the widespread use of vascular closure devices. For diagnostic studies without anticoagulation, manual compression is still a highly effective method. However in some patients with high punctures, a closure device may be preferred for better security of hemostasis. For interventional procedures in anticoagulated patients, a vascular closure device is often preferred. Limitations that preclude the use of most vascular closures devices include 1) atherosclerotic disease; 2) small vessel (Push: Manual compression (and compression aids) is the easiest and cheapest hemostasis method, and is highly effective. When properly performed, compression produces excellent results, especially with small (Pull: This group of closure devices was linked because of the need to pull something up from inside the artery to secure hemostasis. The original VasoSeal device uses a marker guide which is pulled back to set the depth of the collagen delivery sheath. (Note: the new On-Site closure device employs a temporary retractable disc which both locates the arteriotomy and provides over the wire delivery of the collagen plug for placement above the arteriotomy.) A collagen plug is delivered on the surface of the vessel and the 10 Fr delivery sheath then removed. Hemostasis is achieved after brief, complementary manual compression. The major advantage is no material is placed in the artery. The disadvantage is the large tract required to deliver the collagen, which may not get all the way to the artery and like other devices, has difficulty in puncture tracts associated with scar tissue. The Duett device uses a balloon in the artery pulled back to tamponade the puncture from the inside, while extruding a collagen thrombin mix on the surface of the vessel through the retracted sheath to produce hemostasis. Although highly effective, accidental collagen injection into the vessel has been reported. The Boomerang is a temporary hemostasis device using a spring tension wire with an expandable foot pad which is pulled back into the artery wall at the puncture site and permits the large puncture hole to shrink to a small 18g diameter. The foot pad is maintained against the arterial wall by spring tension and after 15 minutes is removed with brief manual compression. This device has the advantage of leaving no material behind, but has the slight disadvantage of potential late bleeding in the anticoagulated patient. Click: This group is described by the click of delivering a metal clip on the surface of the vessel to pinch the puncture site to produce hemostasis. No material is left in the vessel. Delivery with a large diameter device may leave a large tract with post-delivery oozing. Initial experiences are highly favorable. Stitch: Intravascular suture delivery systems are also widely available and highly effective. Some patients have noted discomfort with the stitch delivery and operators have commented on suture failure with early models. Rare cases of late vascular compromise have been reported. Bottom Line Femoral artery management remains a critical and integral part of the cath procedure. Many patients remember their cath lab experience by how the femoral artery was managed. Use of a femoral closure device must balance cost, patient comfort and safety, and nurse/technologist labor and lab turnover. Closure device selection is prioritized by closure security, lowest device failure rate, lowest complication rates and highest patient comfort.