18.1 Arterial & Venous Hemostasis

Hemostasis as a Core RCIS Competency

Post-procedural hemostasis is Domain E Task 1 on the CCI RCIS Detailed Test Outline. After diagnostic or interventional catheterization, the RCIS participates in sheath removal, compression or closure device deployment, distal perfusion monitoring, and documentation of the hemostasis method. Hemostasis is not a passive waiting period — it is active surveillance for rebleeding, hematoma expansion, limb ischemia, and closure-device failure while balancing the competing goals of achieving hemostasis and preserving vessel patency.

Every hemostasis plan begins with three questions answered before sheath pull: Is anticoagulation adequate for hemostasis? Is the patient hemodynamically stable? Which site-specific technique does institutional protocol require? The RCIS communicates these answers to the operator and nursing team before proceeding.

Pre–Sheath Removal Assessment

Anticoagulation Status

Most cath lab cases involve unfractionated heparin with ACT (activated clotting time) monitoring. Typical sheath-removal thresholds:

If ACT remains elevated, options include waiting, protamine reversal (heparin-specific, per physician order with allergy assessment), or continued sheath dwell with immobilization. The RCIS does not independently order reversal agents — scope is measure, report, and assist.

Hemodynamic Stability

Sheath removal during active hypotension, ongoing bleeding, or unstable arrhythmia increases risk. Confirm stable blood pressure, no active groin or wrist bleed, and adequate distal perfusion before proceeding. For femoral large-bore cases (TAVR, Impella, ECMO), the team may remove sheaths in the lab with surgical backup available.

Distal Perfusion Baseline

Before arterial sheath pull, document baseline distal perfusion: radial access — pulse oximetry plethysmography on the thumb, capillary refill, hand temperature; femoral access — dorsalis pedis and posterior tibial pulses (Doppler if non-palpable), foot color and temperature. Post-hemostasis monitoring compares against this baseline every 15 minutes (or per protocol) for the first hour.

Transradial Arterial Hemostasis

Transradial patent hemostasis is the standard of care for radial sheath removal. Unlike complete radial compression (which occludes antegrade flow and increases radial artery occlusion [RAO] rates of 5–10%), patent hemostasis maintains forward flow through the radial artery while achieving surface hemostasis at the puncture site.

Patent Hemostasis Technique

1. Connect a hemostatic wrist device (TR Band, Vasc Band, or equivalent) to a pulse oximetry probe on the thumb.
2. Remove the sheath while applying minimal surface pressure.
3. Inflate the device just enough to achieve hemostasis — confirmed by absence of bleeding AND visible plethysmography waveform on the thumb oximeter.
4. If the waveform disappears, slightly deflate until flow returns; if bleeding persists, incrementally inflate.
5. Gradual deflation per device protocol (typically over 1–2 hours) with waveform monitoring throughout.

RAO is usually asymptomatic but eliminates future radial access in that artery. Risk factors include small artery diameter, multiple punctures, inadequate procedural anticoagulation, and prolonged complete compression. Patent hemostasis, 6–7 Fr or smaller sheaths, and adequate heparinization during the case reduce RAO incidence.

Manual Radial Compression

When a patent hemostasis device is unavailable, direct manual pressure at the puncture site for 10–20 minutes followed by a pressure dressing is acceptable. Avoid complete radial artery compression across the wrist — use point pressure over the arteriotomy only.

Transfemoral Arterial Hemostasis

Femoral hemostasis strategy depends on sheath size, anticoagulation, and operator preference.

Manual Compression

Manual compression remains the reference standard. For a 5–6 Fr sheath, typical compression duration is 15–20 minutes of firm, direct pressure over the common femoral artery puncture site (not the vein, not the surrounding tissue). Larger sheaths require longer compression (20–30+ minutes for 8 Fr, proportionally longer for large-bore). The RCIS or trained team member applies pressure with two hands stacked or a mechanical compression assist device (FemoStop, Clo-Sur, etc.) while monitoring the patient.

Critical technique points:

• Pressure is applied 1–2 cm above the skin entry (the arteriotomy lies cephalad to the skin nick).
• The leg remains straight and immobilized.
• After initial hold, apply a sandbag or pressure device and monitor for hematoma, bruit, and distal pulse loss.

Closure Devices

Suture-mediated closure (Perclose ProGlide, Prostar) deploys stitches across the arteriotomy. Collagen plug devices (Angio-Seal) create an anchor inside and outside the artery. Sealant/gel devices (Mynx, Mynx Control) deliver an extravascular sealant. Nitinol clip devices (StarClose, Catalyst) clip the arteriotomy.

Closure devices allow earlier ambulation and shorter manual compression but carry device-specific complications: infection, delayed bleeding after early ambulation, leg ischemia from suture entrapment, and failure requiring surgical repair. The RCIS documents device type, size, and deployment success in the procedural record.

Brachial and Other Arterial Sites

Brachial artery hemostasis requires firm, directed pressure for 15–20 minutes without compressing the median nerve (located medial to the brachial artery). Monitor hand perfusion (capillary refill, thumb pulse oximetry) because brachial collateral circulation is limited compared with the radial-ulnar arch.

Ulnar artery access (rare) follows radial patent hemostasis principles with monitoring on the fifth digit plethysmography.

Venous Hemostasis

Venous sheath removal (IJ, femoral vein, antecubital vein) requires less compression force than arterial sites because venous pressure is lower. Apply direct pressure for 5–10 minutes until hemostasis is achieved, then a pressure dressing. Avoid excessive compression that creates venous stasis or thrombosis.

For IJ sheath removal, have the patient perform a Valsalva maneuver during removal (reduces air embolism risk), apply pressure at the puncture site, and observe for neck hematoma, airway compromise, or voice changes suggesting expanding hematoma.

Troubleshooting Failed Hemostasis

Documentation Requirements

Document in the procedural record:

• Sheath size and removal time
• ACT or coagulation status at removal
• Hemostasis method (manual, device type, patent hemostasis band)
• Distal perfusion check before and after
• Complications or re-bleeding events

Exam Focus Points

High-yield RCIS scenarios include patent hemostasis with plethysmography waveform monitoring, ACT thresholds before sheath pull, femoral compression duration by sheath size, closure device bed-rest restrictions, and differentiating over-compression (flat plethysmography) from adequate patent hemostasis. Wrong answers often suggest complete radial artery occlusion is acceptable, venous and arterial hemostasis require identical pressure duration, or sheath removal proceeds despite ACT >250 without reversal plan.