Updated: May 19, 2019
Following vascular access of the radial artery, hemostasis can be achieved by using a vascular closure device or manual compression. A vascular closure device yields consistent performance from patient-to-patient when working to achieve hemostasis. Manual compression is performed without the need for additional medical equipment, yet it requires additional physician or recovery staff time to manually compress the artery until hemostasis is achieved. Radial access expert Dr. Aaron Fischman discusses the patent hemostasis concept, differences between the various closure devices, and how to determine time to hemostasis in your patients in episode 30 of the BackTable podcast.
The BackTable Brief
Radial access closure devices achieve radial artery hemostasis while maintaining vessel patency; following hemostasis, confirm patency by checking pulses or observing pulse oximeter waveforms during ulnar artery occlusion.
Various vessel closure devices are available and the most important consideration is choosing a device that allows for patent hemostasis; Dr. Fischman prefers the TR Band.
Duration of closure device use varies by protocol from 15 minutes to 120 minutes; consider the procedure and patient’s anticoagulation status when determining the optimal time to hemostasis.
Typically, 60 minutes of closure device use is sufficient to achieve hemostasis in most patients, says Dr. Fischman.
Photo credit: Dr. Keith Pereira
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Understanding the Patent Hemostasis Concept
Patent hemostasis is the concept of compressing the access vessel enough to cause hemostasis without completely obstructing the vessel lumen. The critical step during radial artery closure is to confirm vessel patency after hemostasis is maintained. Successful hemostasis is identified through a pulse check or using ulnar compression with subsequent identification of waveforms distally.
[Chris Beck] It's probably a good time to talk about what exactly you mean by patent hemostasis. I find that when people talk about radial access in their closures, I figured I would not have to reinvent the wheel when it came to the protocol for removing the TR Band, which is the only radial closure I've used. Surprisingly, there's some fair variation when it comes to how long people keep the TR Band and their deflation. Maybe it doesn't matter all that much, but let's talk a little bit about like what you mean by patent hemostasis exactly, and then specifically what that means in terms of your protocol for removing the TR Band.
[Aaron Fischman] Well, patent hemostasis is really the concept of putting on a band of some sort, but allowing the vessel to remain patent during the process. The critical step is when you put the band on, you fill it up with air, and then you deflate it until you get a blood flow in the vessel, and then you leave that up for a certain period of time. The way you document that is usually by using either blood return, or a pulse check, or using old ulnar compression and looking at the waveforms. There's lots of different ways to document that the vessel is open, but the critical thing is is to show to yourself that the vessel is open at the end of the process when putting the band on.
What is the best radial access closure device?
Various radial access closure devices available utilize patent hemostasis to finalize the vessel closure. Devices such as the Terumo TR Band utilize broad-based pressure to achieve hemostasis whereas others apply a pinpoint pressure to the access site. Dr. Fischman prefers using the TR Band, and states the hemostasis concept is the most important factor to consider when choosing a closure device.
[Chris Beck] Let me ask you this, one of our BackTable listeners was very interested in closure devices for radial access. I'll say that I've used the Terumo TR Band and it's been phenomenal. I'm sure there are some other ones out there. Maybe you're more familiar with them, and maybe there's some other cooler stuff out there that I don't know about. [Aaron Fischman] There are a lot, actually. The TR Band was the first one that I used, and the one that I use for the majority of my cases. It works great. One of the problems that I've come across, is that it was really designed for right radial because when you look through the window on the TR band, it's hard to actually see through it from the left radial side. That's really the biggest issue. Outside of that, it works phenomenal. There's definitely room for improvement in developing these devices. We can talk about that a little bit later. But since then, there's been several devices that have come to the market, and we use not infrequently. Merit has probably three or four different bands now. They have a band that also allows you to access the distal radial artery very easily, and then, it's a band that wraps around the thumb, which is very cool. There's also a band that creates a little bit more pinpoint pressure on the vessel as opposed to broad-base pressure, which is made by Forge Medical. There are a lot of different devices that can make the patent hemostasis process a little bit easier. We've demoed those and we’ve used those, and we’ve helped design those over the years. You'll probably see more of them in the coming years that are going to be able to do more than just press a little bit on the radial artery. The TR Band's great and that's our device of choice. It's okay to use other devices. I think the concept in general is that you use the patent hemostasis concept, and that's the most important thing. Whatever device you use, as long as you're doing that, I think will be fine.
How long do I keep the vascular closure device on for?
Duration of vascular device use depends on the patient and the procedure being performed. One hour is typically sufficient to achieve hemostasis in most patients, says Dr. Fischman. Some protocols recommend leaving the band on for up to two hours, however, these protocols are typically for heavily anticoagulated patients undergoing cardiac interventions. An hour wait time is sufficient for most IR procedures such as Y90 radioembolization.
[Aaron Fischman] … Then, how long you leave it on is really operator-dependent. We started out doing two hours, which is probably way too long, and then we went down to an hour and a half. We were very conservative at the beginning and now we do an hour with the band, and that's generally enough. Remember, in some people you may have to keep it on a little bit longer, but I typically say about an hour is my standard, but there are people that do even 30 minutes. There are actually protocols that start taking air down at 15 minutes depending on what device they're using. That's probably a little bit too soon, but you have to think about what your goal is. Is your goal to get the band off in 30 minutes? If the patient is going to be in your recovery room for an hour or two hours, you probably don't need to take the band off that soon. The key is to remember that you want to make sure that the vessel is patent and the vessel is not occluded at the end of the case.
[Chris Beck] How long you keep it on is not too big of a deal if you're talking about a patient who's going to be in your recovery longer than two hours. There are sometimes, if you’re talking Y90 treatment, where I feel like the patient is hanging around just to get the band off. You touched on 60 minutes and that really cuts down on the onus on the recovery people. If you can get that patient out an hour earlier than you would, and you don't really derive any benefit for keeping TR Band on longer, I think that's good to hear.
[Aaron Fischman] An hour is a good amount of time, absolutely. Ultimately, you have to think about what the case is. If somebody is coming in for a Y90, yeah, it makes sense to get it off sooner. We've looked at this. We've looked at Y90 and patient discharge times - it's clearly a lot better when you compare it to femoral access. There's no question about that.
[Chris Beck] Drawing comparison, I mentioned earlier that we split time with some of the cardiologists, and originally, I was just going to use the cardiologist protocol. Their protocol actually keeps it on for, I think, 120 minutes and then they start the deflation process. It’s a different patient population though, certainly the majority of their patients are coagulated for treatments.
[Aaron Fischman] The cardiologists obviously do things a little bit differently. These patients are very heavily anti-coagulated. The time may be different compared to what we're doing.
---------- Podcast Participants:
Dr. Aaron Fischman is a practicing interventional radiologist at Mount Sinai Hospital New York.
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite this podcast:
BackTable, LLC (Producer). (2018, June 27). Ep 30 – Transradial Access: Basic to Advanced [Audio podcast]. Retrieved from http://www.backtable.com/podcasts
The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.