Immediate Ambulation: Closing in on the True Outpatient Catheterization

Crocker et al., in this issue of the Journal, have demonstrated a close to 90% success rate with immediate (See Crocker et al. on pages 728–732 repeatedly raised by skeptics of vascular device closure: why expose the patient to potential additional risk and the hospital to additional cost if the management algorithm is not substantially changed by these devices? The skeptics will point out that these patients were kept in the recovery area for 4 hours, so the primary differences are presumably that the patient was sitting, could go the restroom, and could transfer themselves from the table instead of being moved by the cath lab staff. Four-hour discharges are not novel in this population even with manual compression, especially when even smaller sheaths are used; so what is the clinician to do with the findings of this study? First, there is a growing body of literature suggesting that neither the risk1 nor the cost2 is greater when vascular closure devices are used. Second, the algorithm was quite conservative, and patients could potentially have been discharged earlier. However, sedation during the procedure, the delayed effects of contrast and the stress of the catheterization are other reasons one should not discharge these patients without at least a few hours of observation. Third, a patient sitting in the recovery room requires fewer resources: no manual compression, less nursing and orderly time, and availability of the bed for other patients. Fourth, patients as a rule remember only the discomfort of the sheath pull and of prolonged bed rest; thus, the “misery index” of cardiac catheterization can be reduced. Some other issues need to be raised. First, practitioners of the radial approach will point out that there is ample experience of early ambulation with that technique. However, when performed by experienced operators, femoral access followed by closure device use can lead to similar low complication rates3 and as shown by this study, immediate ambulation as well. Second, five minutes of light holding after device deployment could mask a partially effective closure with temporary hemostasis and lead to significant bleeding when the patient ambulates. Finally, patients with venous sheaths were excluded from early ambulation in this study. We have ample experience with device closure in femoral veins and in the setting of severe back problems or other indications for early ambulation, venous sheath closure is an off-label option.4 The low complication rates described by Crocker et al. are likely in part related to their compulsive performance of femoral angiography at the end of the catheterization. A significant number of operators continue to avoid doing this, despite its clear benefits and few drawbacks. Besides the exclusions from early ambulation based on the findings from these angiograms, we recommend several others: vessel size

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