This document discusses manual compression versus arterial puncture closing devices following femoral cardiac catheterization. It identifies coronary artery disease and cardiac catheterization as major health issues. The authors recommend a protocol where arterial puncture closing devices are used for hemostasis in non-high risk patients, while developing a high-risk checklist. They suggest alternative approaches to further study differences between manual compression and arterial puncture closing devices.

1. Manual Compression vs.
Arterial Puncture Closing
Devices Following Femoral
Cardiac Catheterization
Rachel Wilkinson Stephanie Ford
Brenna Johnson Michelle Giddens

2. Discussion
• Identify the problem
• Review of literature
• Recommended
Protocol/Procedure/Intervention
• Suggestions for further study

3. Identifying the Problem
• Coronary Artery Disease is the leading cause of death in
the United States (Centers for Disease Control And
Prevention, 2004).
• Cardiac catheterization is one of the most common
procedures in the United States (Harper, 2007).
– 1.5 million will receive a cardiac catheterization this
year
– In 2%-10% of cases, vascular complications will occur
• Oklahoma is ranked 8th in the nation for being one of the
―fattest‖ states.
– 65.1% of Oklahoma’s population falls in to the
category of obese or overweight (Calorielab,2008).

4. PICO Question
• Which arterial closure method is
safer, more effective, and causes less
vascular complications following cardiac
catheterization in adults—the use of
manual compression or the use of arterial
puncture closing devices (APCDs)?

5. Identifying the Problem Continued
PICO
• Population: Adult patients18 and older receiving
femoral cardiac catheterization including all
genders and ethnicities
• Intervention: Arterial puncture closure devices
(APCDs) to achieve hemostasis
• Comparison: Manual pressure to achieve
hemostasis
• Outcome: Decrease vascular complications

6. Review of Literature
• Arterial puncture closing devices compared with
standard manual compression after cardiac
catheterization: systematic review and meta-analysis
(Koreny et al., 2004).
– Systematic review and meta-analysis consisting of 30
randomized controlled trials
– Measured risk of acquiring
hematomas, bleeding, developing an arteriovenous
fistula, and pseudoaneurysm when using APCDs
– Manual compression was determined to be the best
way to prevent complications following cardiac
catheterization

7. Review of Literature Continued
• A propensity analysis of the risk of vascular
complications after cardiac catheterization procedures
with the use of vascular closure devices
(Nipun, Matheny, & Sepke, 2006).
– Single study comparing manual compression to the use
of APCDs and the complications associated with each
after cardiac catheterization
– The results revealed that there was a 58% reduction in
the risk of vascular complication when APCDs were
used after diagnostic cardiac catheterization as opposed
to using manual compression

8. Review of Literature Continued
• Vascular complications associated with arteriotomy
closure devices in patients undergoing percutaneous
coronary procedures: A meta-analysis (Nikolsky et
al., 2004).
– Systematic review and meta-analysis consisting of 30
studies including 37,066 patients comparing the
vascular complications that result from either manual
compression or the use of APCDs after cardiac
catheterization
– This study concluded that there was no significant
difference in vascular complications when an APCD
was used compared to manual compression after
femoral cardiac catheterization

9. Review of Literature Continued
• Vascular complications with newer generations of
angioseal vascular closure devices (Applegate et al.,
2006).
– A single study that compared newer generations of a
particular type of APCD called Angioseal to manual
compression and older generations of Angioseals after
cardiac catheterization
– The results in this study concluded that the older and
newer generations of Angioseal proved to have similar
or lower vascular complications than that of manual
compression

10. Review of Literature Continued
• Risk of local adverse events following cardiac
catheterization by hemostasis
device use and gender (Tarvis, et al., 2004).
– Single study that compared complications following the use
of two types of hemostasis devices (sutures and collagen
plugs) to manual compression
• Complication rates were assessed by gender
– Complications were less common in patients who used
suture devices or collagen plugs following diagnostic
cardiac catheterization than those who used manual
compression
– Complications were more frequent in females than in males
due to smaller vessel size and/or hormonal differences

11. Review of Literature Continued
• Risk of Local Adverse Events following Cardiac
Catheterization by Hemostasis Device Use -- Phase II
(Tavris et al., 2005).
– Single study that assessed the risks of vascular
complications by the type of APCD used compared to
manual compression
– The results of this article revealed that vascular
complications were similar between most APCDs and
manual compression after cardiac catheterization
– Women were at twice the risk for any vascular
complication compared to men

12. Review of Literature Continued
• Predictors of Vascular Complications Post Diagnostic
Cardiac Catheterization and Percutaneous Coronary
Interventions (Dumont, C. J., Keeling, A.
W., Bourguignon, C., Sarembock, I. J., &
Turner, M.,2006).
– This article was a retrospective, descriptive and
correlational study
– The population studied consisted of 11,110 patients whose
records were retrieved from the Clinical Automated Office
Solutions database
– Results of this study found that vascular complications
occurred more often in patients whose age was greater than
70 years, being female, having hypertension, and renal
failure

13. Review of Literature: Manual Compression
Pros Cons
• Easy to learn • Painful
• Safe and Effective • Prolonged mean time to
• No requirement for special achieve hemostasis (15-20
equipment minutes)
• Prolonged time to
ambulation (4-6 hours)
• Vascular complications
• Nurse arm and hand fatigue
• Longer hospital stay

14. Review of Literature: APCDs
Pros Cons
• Shorten the mean time to • Costly ($190-$200)
achieve hemostasis (1.46- • May take up to 20 cases for
8.2 minutes) a physician to become
• Shorten the mean time to proficient
ambulation (2.2-4.5 hours) • Many nurses have a
• Increases patient comfort knowledge deficit in regards
• Decrease hospital stay to APCDs
• Safe and Effective • Vascular complications
• Decreases cost to patients

15. Recommendation
• Our Recommendation:
– Nurses to become advocates for APCD
use in non-high-risk patients
– Multidisciplinary approach to develop a
high-risk checklist

16. Recommendations Continued
• Our recommendations are based on Kurt
Lewin’s Change Theory (Yoder-
Wise, 2007):
– Unfreezing
– Experiencing the change
– Refreezing

17. Recommendations Continued
• Unfreezing
– Awareness
• Formal Channels
– High-risk checklist
– In-services
• Informal Channels
– Talking with floor nurses/physicians

18. Recommendations Continued
• Experiencing the change
– Incorporating the use of APCDs
• Praise nursing staff
• Encouraging doctors

19. Recommendations Continued
• Refreezing
– Evaluation
• Formal Channels
• Informal Channels
– Acceptance
• Determined by surveys given to
patients, nurses, and doctors

20. Suggestions
• Alternative approach to studying the
problem
– Chart trends comparing APCDs to
manual compression

21. Suggestions Continued
• Research Questions:
– In APCDs, are the efficacy rates the same for
using a suture device compared to a collagen
plug?
– Is standard manual compression better than
mechanical compression devices such as
Femostop and C-clamps?

22. Any Questions?

23. References
• Applegate, R.J., Sacrinty, M., Kutcher, M.A., Sanjay, G.K.,
Talal, B.T., Renato, S.M., William, L.C. (2006). Vascular
complication with newer generations of angioseal vascular
closure devices. Journal of Interventional Cardiology, 19(1),
67-74.
• Calorielab. (2008). Mississippi is the fattest state for 3rd straight
year, Colorado still leanest, D.C. loses weight. Retrieved March
24, 2009, from http://calorielab.com/news/2008/07/02/fattest-
states-2008/

24. References Continued
• Centers For Disease Control And Prevention. (2004). Division for
Heart Disease and Stroke Prevention. Retrieved March 28,
2009, from Department of Health and Human Services
Web site: http://www.cdc.gov/dhdsp/state_program/ok.htm
• Dumont, C. J., Keeling, A. W., Bourguignon, C., Sarembock, I.
J., & Turner, M. (2006). Predictors of vascular
complications post diagnositc cardiac catheterization and
percutaneous coronary interventions. Dimensions of Critical
Care Nursing, 25(3),137-142.
• Harper, J. P. (2007). Post-diagnostic cardiac catheterization.
Journal For Nurses in Staff Development , 23(6), 271-276.

25. References Continued
• Koreny, M., Riedmuller, E., Nikfardjam, M., Siostrzonek, P.,
Mullner, M. (2004). Arterial puncture closing devices
compared with standard manual compression after cardiac
catheterization: Systematic review and meta-analysis.
American Medical Association, 291(3), 350-357.
• Nikolsky, E., Roxana, M., Amir, H., Aymong, E.D., Mintz, G.S.,
Lasic, Z., Negoita, M., Fahy, M., Krieger, S., Moussa, I.,
Moses, J.W., Stone, G.W., Leon, M.B., Pocock, S.J., Dangas,
G. (2004). Vascular complications associated with
arteriotomy closure devices in patients undergoing
percutaneous coronary procedures: A meta-analysis. Journal of
the American College of Cardiology, 44(6), 1200-1209.

26. References Continued
• Nipun, A., Matheny, M.E., Sepke, C. (2006). A propensity
analysis of the risk of vascular complications after cardiac
catheterization procedures with the use of vascular closure
devices. American Heart Journal, 153(4), 606-611.
• Tavris, D. R., Dey, S., Albrecht-Gallauresi, B., Brindis, R.G.,
Shaw, R., Weintraub, W., Mitchel, K. (2005). Risk of local
adverse events following cardiac catheterization by hemostasis
device use: Phase II. The Journal of Invasive
Cardiology, 17(12), 644-650.
• Tarvis, D. R., Gallauresi, B. A., Rich, S. E., Shaw, R. E.,
Weintraub, W. S., Brindis, R. G., et al. (2004). Risk of local
adverse events following cardiac catheterization by hemostasis
device use and gender. The Journal of Invasive
Cardiology , 16 (9), 459-464.

27. References Continued
• Yoder-Wise, P. S. (2007). Leading and managing in nursing
(4th ed.). St. Louis: Mosby