Cath Lab Digest - October 2007 - (Page 32)

32 HEMOSTASIS OCTOBER 2007 Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System Bernadette Longo, PhD, Associate Professor, Department of Writing Studies and Director of Graduate Studies, doctoral program in Rhetoric and Scientific and Technical Communication, University of Minnesota, Twin Cities, Minnesota Vascular Access Management Continuum of Care F or patients requiring percutaneous vascular access procedures, the event is seldom limited to a single occurrence. Frequently, after the procedural catheter is removed and the arteriotomy “closed,” the event is considered over and done — that is, until the next time. Cath lab nurses and technologists know that arterial access is sometimes difficult to obtain on their “repeat” patients, oftentimes due to scarring from earlier percutaneous access. Recovery and site healing from previous procedures, with or without complications, can compromise future arterial access, whether hemostasis is achieved using manual compression or vascular closure devices. The site closure decisions made during today’s procedure can have longterm implications for the patient’s future access. Protecting the artery for future access should be one of the most important considerations, especially for those patients who will undergo multiple percutaneous access procedures during their lifetimes. Therefore, it is essential that today’s clinician chooses a method of closure that supports a continuum of care, going beyond the end of the first procedure to include site management and healing in all subsequent procedures. Manual compression remains the gold standard of post-procedure care for many cath labs because it leaves nothing behind in the artery when the patient is discharged. However, as a result of the increased volume of percutaneous access procedures and the use of larger sheaths, vascular closure devices (VCD) were developed as an alternative to manual compression, using active fixation and closing the arteriotomy when the patient leaves the procedure table. Regardless of the product type, VCDs always leave something behind, whether it is a suture, or staple, or clip, or collagen plug. These retained materials induce an inflammatory response, leading to scarring, infection or other complications such as vessel thrombosis. Additionally, catastrophic failure requiring surgical removal or repair is a known risk of VCD use.1 Focusing on a Broader Continuum of Care Hoffer and Bloch summarize arterial access site closure as “problematic… unglamorous, time-consuming, and potentially lethal.”2 Successful arterial closure defined only as “time to hemostasis” misrepresents what is most relevant to patients and cath lab staff: timely hemostasis, ambulation, discharge, increased throughput and vascular healing without complications. Adopting the long-term perspective of vascular access management, cath lab staff and physicians consider the cumulative effects of vascular access and closure, particularly as it relates to scarring due to repeated femoral access as shown in Figure A, and the potential for complications, including critical limb ischemia.3-5 Gregory Mishkel, MD, stated, “Once you close the vessel and achieve hemostasis, you can’t just wipe your hands clean and leave. We really need to rethink this idea of vascular closure as the endpoint because subsequent events may have serious implications for the future care of our patients.” Mishkel is the co-director of the cardiac catheterization laboratory at the Prairie Heart Institute in Springfield, Illinois. As the largest cath lab in the state and considered one of the premier facilities in the U.S., Prairie Heart has extensive experience in cutting-edge vascular access management and successful recovery. Mishkel went on to state, “Considering the full continuum of care — from procedure access to closure through recovery, discharge, and possible reaccess — better reflects the realities of the patient’s and the physician’s experience.” Nilesh Goswami, MD, an interventional cardiologist at Prairie Heart, described the concept of vascular access management this way: “PCI is not primarily an acute event for us. We look at it from a 360degree view of the world, with everyone involved from the arterial puncture to discharge, to the 30-day follow-up and beyond. We’re making decisions about the patient’s care all along the way to minimize adverse events. It’s important to us that when the patient is discharged, the access site has achieved hemostasis without significant patient discomfort and in a timely fashion. To reduce risks of complications such as infection and vascular injury and to allow for future access, it is important that there’s nothing left behind in that artery.” Achieving Hemostasis Using Manual Compression For more than half a century, Disclosures: Bernadette Longo, PhD, is a medical writer who received a fee from Cardiva Medical for her work on this article. Drs. Mishkel and Goswami have served as speakers and consultants for the company, but as of this writing have no financial interest in the company. Kelley Weakley, Sheryl Friedrich, Sherry Day and Roger A. Pierjok have nothing to disclose. manual compression has changed little and remains the gold standard for achieving arterial hemostasis. Since the 1980’s, however, the enormous growth in percutaneous vascular access procedures and use of anticoagulants has increased the demand for better closure techniques to manage bleeding, minimize bedrest, increase patient throughput, and reduce staff repetitive stress injuries associated with compression. Wide variations exist in the published literature regarding the rates of “major” and “minor” complications for femoral access sites managed with manual compression, ranging from lows of 0.4% to as high as 27%.6-8 It should be noted that complications are likely to be underreported since most institutions only record complications if they require surgical repair or blood transfusion. Even in the absence of reportable complications, manual compression often results in patient discomfort during recovery due to hand pressure and immobilization. Kelley Weakley, nursing technician at the Prairie Heart Cath Lab, commented, “With manual compression, we have to exert a lot of pressure on that tender groin area for at least 20 minutes and even then may use the C-clamp for 10 more minutes. That’s an uncomfortable procedure for patients.” Manual compression traditionally is taught through an apprenticeship approach, with senior staff members teaching new staff members. Training inaccuracies and inconsistencies can lead to patient complications as well as staff injuries with long-term negative consequences. Maintaining pressure on the arteriotomy site for long periods of time can result in repetitive stress injuries

Table of Contents Feed for the Digital Edition of Cath Lab Digest - October 2007

Saints Medical Center Fibromuscular Dysplasia in Children and Adolescents Cerebral Vascular Accident Following a Pulmonary Embolism: Search for the Hidden Patent Foramen Ovale Contents Clinical Editor’s Corner Meetings Calendar CEU Education Center Radiation Tracking in the Cardiac Catheterization Lab Letter to the Editor Carotid Stenting: An update Release from Stent-jail: Beneficial Snow-Plowing? Patient Management Guidelines Searching for a Cardiovascular Position? Tips for Creating a ‘Stand-Out’ Resume Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System The Ten-Minute Interview with… Angie Bowles, RN, CCRN CMS Issues Final FY 2008 IPPS Rule ACVP• Membership Page Experience with a New Workhorse Guidewire Ask the Clinical Instructor: Q&A for Those New to Cath Lab A Glimpse of the Future of Clinical Education: Boston Scientific’s SimSuite Bus Visits Carnegie Institute 2007 Educational Fair Held at the Washington Hospital Center Research Update: Original Contribution Abstracts from The Journal of Invasive Cardiology What Do You Think? A Virtual Cath Lab Viewer (VCL): The Development of an Online 3D C-arm Simulator and Coronary Anatomy Viewer Clinical & Industry News Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization

Cath Lab Digest - October 2007

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