13.3 Closure Devices, Pressure & Dressings

Closure Devices, Pressure & Dressings

ARRT CI Procedures Focus of Questions items 7 and 9 close the case: closure devices, manual and mechanical pressure, and dressings, plus the checks that prove the vessel is still alive. Getting in was 13.1. The table equipment was 13.2. This section is how you leave without a hematoma, an occluded radial, or a collagen plug in the SFA.

Quick Answer: Most femoral vascular closure devices (VCDs) require a common femoral artery (CFA) angiogram first. Manual compression teaching is about 3 minutes per French — a teaching rule of thumb, not an ARRT-published timer. Radial hemostasis is a TR-band-class device with patent hemostasis (and a reverse Barbeau) to avoid radial artery occlusion (RAO). Perclose-class is suture, Angio-Seal-class is a collagen plug, StarClose-class is a clip. Do not deploy a VCD for a puncture above the inguinal ligament, in the profunda or SFA, in a vessel that is too small, or through infection.

Manual compression

Femoral arterial. Hold pressure proximal to the skin nick if the puncture is higher than the incision — you are compressing the hole in the artery, not the hole in the skin. Teaching duration: about 3 minutes per French size of the sheath (a 6 Fr sheath → about 18 minutes of firm pressure) after anticoagulation has come down as the operator directs. Label that interval teaching, not a hidden ARRT cutoff and not a substitute for an activated clotting time (ACT) the physician wants first. Release gradually. If a hematoma blooms, go back on, mark the borders, and notify.

Femoral venous. Lower pressure, shorter hold, still real. A large venous sheath with residual anticoagulation can still make a hematoma that tracks into the thigh.

Radial. Manual hold is possible but most labs use a dedicated band (below). If you hold, compress the puncture, not the entire forearm, and do not blanch the fingers for half an hour.

Radial compression: TR band and patent hemostasis

A TR-band-class (or similar inflatable radial compression device) sits over the puncture with a defined air volume. The goal is patent hemostasis: enough pressure to stop bleeding, not enough to occlude the radial artery. RAO is common when the artery is clamped shut for the whole recovery.

Reverse Barbeau (ulnar compression test while the band is on): compress the ulnar artery and watch a pulse-oximeter waveform on the thumb or index finger. If the waveform disappears, the radial is occluded by the band — let air out until the tracing returns and the puncture stays dry. That is patent hemostasis in one maneuver. Recheck as you wean the band per protocol (often staged deflation over 30–120 minutes, lab-dependent).

An over-tight band plus anticoagulation is forearm hematoma and, if ignored, compartment syndrome (section 6.3). An under-tight band is a puddle. Neither is success. Distal radial / snuffbox punctures still need a device that covers the actual hole and a patent-hemostasis check, not a generic wrist band placed too proximal.

External mechanical compression (FemoStop-class)

A FemoStop-class device is an inflatable dome or arch that applies external pressure to the groin when staff cannot hold for 20 minutes, when the patient is restless, or as a bridge after a failed VCD. It is not an intra-arterial implant. Setup: position the dome over the arterial puncture (again, not merely over the skin nick), inflate to a pressure that stops bleeding, then wean. Trap: leaving it at systolic pressure for hours — limb ischemia, skin necrosis, and a hidden retroperitoneal bleed if the puncture was high. Check distal pulses with the device on. Wean as soon as hemostasis allows.

Permanent / active femoral VCDs

These leave hardware or a plug at the puncture. Must angiogram the CFA before deploying most femoral VCDs. Confirm:

• Entry in the CFA, not SFA, not profunda
• Anterior-wall stick
• Sheath not huge relative to the lumen
• No dense plaque, dissection, or infection at the site

Suture-mediated (Perclose-class). Needles pass a suture through the arterial wall; you cinch a knot over the hole. Indication: CFA of adequate size, including many large-bore cases (sometimes preclose before the big sheath goes in). Prep: flush, wire, deploy per instructions for use (IFU), cut the suture tails as directed. Trap: deploying into SFA/profunda or a high stick; pulling through a calcified wall that will not hold a knot.

Collagen plug (Angio-Seal-class). An intra-arterial anchor plus a collagen plug on the outside of the hole, sandwiching the wall. Indication: CFA with room for the anchor. Trap: the anchor in a small SFA can occlude the limb. The collagen is not for infected groins. Patients should be told a mass may be felt at the site for days; a pulsatile expanding mass is not the plug — that is a pseudoaneurysm until proven otherwise.

Nitinol clip (StarClose-class). An extravascular clip cinches the adventitia. Indication: CFA per IFU. Trap: same CFA-only rule; a clip will not fix a retroperitoneal high stick.

All three are active / permanent-class closers. They fail when the angiogram was skipped. They also fail when anticoagulation is still extreme and the operator expected the device to replace a hold; a VCD reduces time to hemostasis — it does not erase ACT, dual antiplatelet therapy, or a high stick.

Nonpermanent methods: pads, patches, surgical glue

Hemostatic pads and patches (chitosan, kaolin, and similar) go on the skin or in a shallow tract. They are adjuncts to compression, not substitutes for a high femoral puncture or an 18 Fr hole.

Surgical glue / topical sealants (cyanoacrylate-class or other topical adhesives, per lab IFU) may seal a dry skin nick or a superficial tract. They do not replace CFA angiography rules and they do not close a retroperitoneal hole.

These methods are appropriate when a VCD is contraindicated, the stick is venous, or the operator wants extra surface help after a short manual hold. Do not inventory them in your head as equal to Perclose-class suture in a 7 Fr CFA.

Contraindications to femoral VCDs

Do not fire a CFA-designed device if:

• Puncture is above the inguinal ligament (no bone; retroperitoneal bleed — hold pressure, do not plug)
• Puncture is in the profunda or SFA
• Vessel is too small for the IFU (sheath-to-artery mismatch)
• Infection or a grossly contaminated groin
• Severe CFA plaque, dissection, or a posterior-wall stick the angiogram just showed

Manual compression or a carefully positioned FemoStop-class device is the safer answer. A closure device does not un-do a high stick.

Dressings and post-access checks

After hemostasis:

• Clean blood so you can see the site later.
• Apply a sterile dressing (transparent for groins so hematoma is visible; radial bands have their own cover).
• Write time, site, pulses, and device on the dressing or in the record.
• Check distal pulses or Doppler (dorsalis pedis / posterior tibial after femoral; ulnar and capillary refill after radial) before the patient leaves the lab, and compare to baseline from 3.1.
• Teach the hold: leg straight after femoral; wrist still after radial; what pain, numbness, or a growing bruise must trigger a call.

A quiet dressing is not proof of hemostasis (retroperitoneal bleed — 6.3). A numb hand with a rock-hard forearm is not the band doing its job. Recheck after the first ambulation or the first band wean — that is when delayed oozing declares itself.

Method / access site / key requirement

Scenario and exam traps

Elective 6 Fr femoral PCI. Ipsilateral oblique sheath angiogram shows entry below the bifurcation in the SFA. Do not deploy Perclose-class, Angio-Seal-class, or StarClose-class hardware. Hold manual pressure (teaching ~18 minutes for 6 Fr, adjusted for ACT) or use a carefully placed external compressor. Same day, right-radial PCI: the TR band is tight, the puncture is dry, and reverse Barbeau (ulnar compressed) kills the oximeter waveform. Let air out until the waveform returns and the site stays dry — that is how you avoid RAO.

Traps: treating 3 minutes per French as a law that overrides bleeding. Deploying a collagen plug because the lab always closes after a high stick. Leaving a TR band occlusive because dry equals success. Skipping pulse checks because the dressing looks perfect. Using surgical glue as the plan for an 8 Fr CFA.