Early Mobilization Following Percutaneous
Coronary Intervention

There are a number of reasons why early mobilization following coronary intervention is desirable. Patient comfort is obviously one reason, but limitations on health care resources increasingly drive this issue. A number of strategies have been entertained in the pursuit of facilitating early mobilization and discharge. How arterial access is achieved is an obvious place to start this discussion. At one time, brachial arteriotomy was advocated as a means of achieving early and reliable hemostasis. Percutaneous radial access more readily facilitates these goals and is currently in more direct competition with the alternative of femoral access.1–5 Whatever the arterial access site, a smaller puncture is desirable. A progressive reduction in sheath size has been possible due to continuing technological advances in angioplasty equipment. Procedures which once required large diameter catheters are now accomplished routinely through 6 French (Fr) sheaths. This trend continues, with reports demonstrating the feasibility of even smaller interventional systems (4 and 5 Fr), although these still remain cumbersome.2,3,6 Anticoagulation is a modifiable variable. Intensity can be reduced by administering lower doses of heparin or avoiding glycoprotein inhibition.2,3,7 However, the safety of this approach remains to be demonstrated. Another approach is to reduce the time allowed for anticoagulant effect to dissipate prior to femoral sheath removal. A common practice is to wait some number of hours following administration of heparin prior to sheath removal. Sheath dwell times following coronary intervention of 3 to 10 hours are commonly reported, varying with institutional heparinization protocols.8,9 With low dose heparin protocols early, or even immediate, sheath removal may be possible.2–5, 10–12 A rational, although unproven approach is to monitor activated clotting time and allow sheath removal once this has fallen to some predetermined level.7 The past decade has seen the development and popularity of a number of arterial closure devices.13 Vasoseal, Angioseal, Perclose and Duett have been shown to reduce time to hemostasis and to mobilization.14,15 The trade-off may be an increase in vascular complications and certainly in disposable cost as compared to traditional approaches.16,17 A final approach is simply to challenge the need for long periods of immobilization. Most programs maintain strict bedrest for 6 to 8 hours following coronary intervention, followed by manual compression.6,18,19 The feasibility of very early mobilization following low dose heparinization has been demonstrated.2,3 In this issue of the Journal of Invasive Cardiology, Vlasic et al. demonstrate that mobilization as See Vlasic et al. on pages 788–792 early as 2 hours following full dose heparinization and femoral puncture site hemostasis can be accomplished safely in selected patients.7 Clearly, there are many approaches to facilitating early hemostasis and mobilization, it behooves the clinician to be aware of them.

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