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Arteriotomy management protocol

There is a slight difference in the management of femoral arteriotomies because of the size of the vessel as well as its potential for percutaneous closure. Along these lines, if the patient has a femoral sheath in place at the moment of the discovery of the acute neurologic changes, 2 options are available: (1) percutaneous closure, and (2) suturing the sheath with delayed removal. If the former path is chosen, we favor the use of closure devices to secure the arterial wall. Following closure, however, care of the arteriotomy site should be quite similar to that of a patient with a recently removed sheath due to the possibility of leakage following thrombolytic treatment. Patients who have radial or brachial arteriotomies should always have their sheath removed because of the thrombotic complications associated with smaller arteries. Following removal of any arteriotomy sheath, pressure dressings must be available to control any thrombolytic-related bleeding. Femoral arteriotomies are best handled using a combination of femoral artery compression device with Doppler monitoring of distal pulses. The device should be inflated to a pressure sufficient to contain the bleeding, while producing minimal effect on the distal Doppler signal. Radial arteriotomies can be handled similarly by using the radial artery compression device; in most of these cases, Doppler monitoring is unnecessary due to the collateral circulation to the hand. Finally, the most threaded arteriotomies involve the brachial artery, which is an unforgiving vessel. No specific devices for bleeding control are available for this site; we recommend using a standard blood pressure cuff position proximal to the arteriotomy site and always in conjunction with Doppler monitoring of the distal circulation. (Contributed by Dr. Jose Biller.)