“You Can’t Keep a Good Man (or Woman) Down”

There has been an impressive decrease in the incidence of vascular complications following cardiac catheterization in recent years;¹ however, excess bleeding from the access site, hematoma, arteriovenous fistula and arterial pseudoaneurysm formation continue to lengthen patients’ hospital stay and affect morbidity. After diagnostic left heart catheterization from the femoral artery, hemostasis has traditionally been achieved through manual compression with the fingertips over the arterial pulse. Many operators act on anecdotal evidence when determining the duration of patient bed rest following arterial sheath removal. Some support the notion that 3 minutes of manual pressure per catheter French size is sufficient for hemostasis while 1 hour of bed rest per French size is necessary to maintain hemostasis; however, statements such as these are largely untested. Advances in the use of arterial closure devices have helped reduce the duration of patient bed rest following sheath removal;^2–5 however these devices contribute to increased health care costs and it remains unclear whether closure devices actually reduce complication rates.⁶ Protocols for duration of manual compression and bed rest following sheath removal vary widely across centers. In truth, there is a lack of sufficient data with which to construct universal guidelines seeking to minimize vascular complications and patient discomfort while improving efficiency in the catheterization lab and potentially reducing costs. The study by Gall et al. published in this issue of the Journal of Invasive Cardiology⁷ demonstrates a low incidence of vascular complications in patients undergoing diagnostic left heart catheterization who receive mechanical compression for 30 minutes over the femoral artery after sheath removal followed by only 60 minutes of seated bed rest. The authors report a 0.1% incidence of minor bleeding following this protocol and a 0.2% rate of femoral artery pseudoaneurysm formation. A total of 987/1,000 (98.7%) of patients treated via this protocol were successfully discharged home the day of the procedure and there were no cases of complications following discharge. Although there was no control group in this study, these results compare favorably to the existing literature in which patients have adhered to longer bedrest protocols of 2–6 hours and have experienced complications at a rate of 1.6%–19%.^8–11 While inadequate compression of the femoral artery has been linked to postcatheterization complications,¹ the results of this study in which the Femostop® was used for mechanical compression can likely be generalized to cases in which manual compression is utilized, as the two methods have previously been demonstrated to be equal in efficacy.¹² The authors report in this study that complications (notably hematoma formation) were more common in obese patients (11/13 patients with complications had BMI > 25) and in women (2.6% vs. 0.6%). While increased vascular complications have previously been reported in women,^13–16 an increased risk has not previously been described for obese patients. Nursing shortages, decreasing insurance reimbursement, and increased cost of new catheter and device technology are issues in the catheterization laboratory and trends toward early ambulation protocols reflect the growing importance of efficiency in the catheterization laboratory as a means to improve patient satisfaction and throughput. Furthermore, a protocol such as the one described by Gall et al. utilizing only 30 minutes of supine bedrest followed by 60 minutes of seated bedrest might significantly reduce patient discomfort following catheterization procedures, particularly in patients with back or neck pain or volume overload and orthopnea. In our attempts to maximize efficiency and patient turnover in the catheterization laboratory, it is vital to remember that patient safety is the most important factor to consider when making decisions regarding early ambulation and early hospital discharge. Protocols outlining shortened durations of bedrest must be carefully scrutinized before being put to widespread use. Previously, 2.5 hour bedrest protocols have been demonstrated to be safe in small studies.8,9 The study by Gall et al. demonstrates the safety of an early ambulation protocol requiring only 30 minutes of supine bedrest followed by 60 minutes of seated bed rest. At our institution, the use of smaller diameter (4 and 5 French) arterial sheaths during uncomplicated diagnostic cardiac catheterization has increased, and one can postulate that the duration of bedrest may be further reduced in this setting without compromising patient safety. Further study is needed to evaluate ideal strategies in patients undergoing coronary interventional procedures, as anticoagulant and antiplatelet agent administration, longer duration of procedures, and generally larger diameter arterial sheaths during these procedures significantly increase the incidence of vascular complications.^17,18 Future randomized trials will need to clarify the ideal roles of closure devices and manual pressure in managing arterial access sites. Further investigation of complication rates in women and obese patients might justify the use of modified protocols for these patient groups to ensure safety. Potentially, a strategy of manual pressure and early ambulation may prove to be an extremely safe and cost-efficient method to handle patients undergoing diagnostic femoral arterial catheterization.

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