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Arterial sheath removal after percutaneous coronary intervention: resident versus specialized nurse
(Portuguese PDF version)

José Del Carmen Solano,¹ George Cesar Ximenes Meireles,² Luciano Mauricio de Abreu,³ Antonio Artur da Cruz Forte,³ Marcos Kiyoshi Sumita,³ Jorge Hideki Hayashi³

1. Resident, Catheterization Lab and Interventional Cardiology, Hospital Stella Maris, Guarulhos, SP, Brazil.
2. PhD in Cardiology, Instituto do Coração, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil.
3. Assistant physicians, Catheterization Lab and Interventional Cardiology, Hospital Stella Maris, Guarulhos, SP, Brazil.

* This study was presented at XXVII Congresso da Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista and XI Congresso da Sociedad Latinoamericana de Cardiologia Intervencionista.

Correspondence:
George Cesar Ximenes Meireles
Hospital Stella Maris, Guarulhos, SP.
Rua Maria Cândida Pereira, 770, Itabegica
CEP 07041-020 - Guarulhos, SP - Brazil
Tel.: +55 (11) 6421.2833
Fax: +55 (11) 6424.3218
E-mail: george@tre-sp.gov.br

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ABSTRACT

Objective: To compare the results of sheath removal by the catheterization lab specialist nurse and by the interventional cardiology resident in patients submitted to a percutaneous coronary intervention.

Methods: Prospective study with 100 patients submitted to percutaneous coronary intervention, from September to October 2004, who were divided into two groups: Group A (GA) - nurse (n = 48) and Group B (GB) - resident (n = 52). Small hematoma was defined as a palpable swelling at the access site measuring less than 2 cm; mild hematoma, from 2 to 6 cm in diameter; and large hematoma when it was larger than 6 cm in diameter. The heparin dose was 100 IU/kg. The sheaths were removed after activated coagulation time control (ACT < 180 seconds) and a 15-minute manual compression was used.

Results: Patients' age was 59.54 ± 11.1 (GA) and 61.7 ± 10.4 (GB) years with a predominance of male patients (GA = 75% and GB = 58%). 7F sheaths were used. Manual compression time was 19.4 ± 3.1 min for GA and 19.6 ± 3.1 min for GB (P = 0.76). There were eight hematomas in GA (seven small and one mild) and nine hematomas in GB (seven small and two mild), P = nonsignificant. The hematomas were clinically treated, with no complications.

Conclusion: Arterial sheath removal, after percutaneous coronary interventions, can be made by the catheterization lab specialist nurse or interventional cardiology resident safely and without major complications.

Key-words: Percutaneous transluminal coronary angioplasty, nursing, training.

J Vasc Bras. 2006;5(1):42-6

Article submitted November 25, 2005, accepted March 20, 2006.

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The handling of the puncture site and the arterial sheath removal after percutaneous coronary interventions are a major concern, since they are related to the hemorrhagic and vascular complications, causing an increase in the morbidity rate and hospital costs.

With the use of the current ASA antiplatelet regimen, associated with ticlopidine or clopidogrel after stent placement, major local hemorrhagic complications may occur in approximately 2.5% of patients.^1,2 It has been estimated that major complications of the arterial access site increased the hospitalization time in approximately 2 days, adding US$ 2,000.00 to the total cost of the procedure.^3,4

The arterial and venous sheath removal by residents is a common practice in our country. In some institutions, it is done by the catheterization lab specialized nurse, but any survey has been performed in the institutions, neither studies about the results of such procedures.

To investigate the safety of arterial sheath removal after percutaneous coronary interventions by the resident or nurse, the study RIPRE (arterial sheath removal after percutaneous coronary interventions: resident versus nurse) was developed.

METHODS

It is a prospective register of arterial sheath removal by the catheterization lab specialized nurse versus resident in interventional cardiology, in patients submitted to percutaneous coronary interventions. The patients were included from September to October 2004. The present study was evaluated and approved by the ethics committee of our institution (protocol 06/04, approved in August, 2004).

Inclusion criteria were: being eligible for percutaneous or surgical myocardial revascularization; patients with diagnosis of stable or unstable angina and acute myocardial infarction. Exclusion criteria were: vascular complications during the percutaneous coronary intervention; presence of hematoma after the puncture of the femoral artery; peripheral arterial vascular disease; hemorrhagic diseases (purpura, coagulopathies, etc.); continuous use of anticoagulants; fibrinolytic therapy over the past 48 hours; morbid obesity (body mass index higher than 40).

Complications were defined as follows: major bleeding, such as intracranial bleeding, or reduction in the hemoglobin concentration higher than or equal to 5 g/dl, or hematocrit decrease higher than or equal to 15%; minor bleeding, such as reduction in the hemoglobin concentration higher than 3 g/dl and lower than 5 g/dl, or hematocrit decrease higher than 10% and lower than 15%;⁵ peripheral vascular complication, such as lower limb ischemia related to the arterial puncture, pseudoaneurysm, arteriovenous fistula or repair surgery for vascular injury;^5,6 small hematoma, with swelling at the access site measuring less than 2 cm; moderate hematoma, from 2 to 6 cm in diameter; and large hematoma, larger than 6 cm in diameter.⁷

We used the 7F sheath and the guiding catheter with the same diameter as the 7F using the femoral access.

The patients were medicated with aspirin 200 mg a day and clopidogrel 300 mg on the day previous to the procedure. The intravenous heparin dose of 100 IU/kg was applied before the implantation. After hospital discharge, clopidogrel 75 mg was administered for 30 days and the aspirin indefinitely.

The sheaths were removed after activated coagulation time control (less than 180 seconds), followed by a 15-minute manual compression. After this period, the presence of local bleeding was evaluated and, if necessary, the compression was prolonged, with assessments every 5 minutes until complete hemostasis.

After the procedure of arterial sheath removal, an assistant physician verified the presence of hematoma and/or local bleeding, and the pulses of the lower limb from which the sheath was removed were assessed, as well as the perfusion and differences in temperature. The patients remained lying on bed for a minimum period of 6 hours, with the limb in horizontal rest.

A blood count and a coagulogram were obtained before the stent implantation and a blood count and activated coagulation time 4 hours after the procedure.

In case there were no complications, hospital discharge was scheduled for 24 to 48 hours after the stent implantation.

The quantitative variables were presented as averages and standard deviations. The absolute and relative frequencies related to the qualitative variables were calculated. The Student's t test was used for the statistical analysis of continuous variables, and Fisher's exact test for frequency comparison.

The data were collected in individual forms for each patient, with the information on demographic data, risk factors and risks related to the procedure.

RESULTS

From September to October 2004, 100 consecutive patients were included, and then divided into two groups: Group A (GA) - nurse (n = 48) and Group B (GB) - resident (n = 52). One patient was excluded due to the presence of hematoma after the puncture. Patients' age was 59.54 ± 11.1 (GA) and 61.7 ± 10.4 (GB) years with a predominance of male patients (GA = 75% and GB = 58%). The patients' basal characteristic did not present statistically significant differences (Table 1).

Table 1 - Basal characteristics of the 100 patients

Basal characteristics	GA (%) (n = 48)	GB (%) (n = 52)
Gender (male/female)	75/25	58/42
Age (years)	59.54 ± 11.1	61.7 ± 10.4
Current/past smoking habit*	4.2/52.1	7.7/51.9
Family history of coronary disease	2	7.7
Previous percutaneous coronary intervention	30.8	31.25
Previous femoral puncture	39.6	32.73
Systemic hypertension (≥ 140/90 mmHg)	90.4	85.4
Diabetes mellitus (≥ 126 mg/dl)	25	40.4
Hypercholesterolemia (≥ 200 mg/dl)	70.2	67.3
Previous myocardial infarction (> 180 days)	20.8	28.9
Previous percutaneous coronary intervention	31.2	30.8
Acute coronary syndrome	45.8	32.7
Stable angina	54.2	67.3

* Past = quitted smoking for more than 1 month and less than 1 year.
GA = group receiving care by nurses; GB = group receiving care by residents.
P = nonsignificant for all variables.

 

All patients received ASA 200 mg and clopidogrel 300 mg on the day before the procedure. The approaches used were the right femoral arteries (GA = 68.75% and GB = 76.9%) and left femoral arteries (GA = 31.25% and GB = 23.1%). 7F sheaths were used. The coronary stent implantation was performed in 100% of GA patients and 98.1% of GB patients, and the procedure was successful in 100% of GA interventions and 98.1% in GB interventions.

With regard to the time of sheath removal, compression time and formation of hematoma, there were no statistically significant differences between both groups. The hematomas were clinically treated, and progressed with no complications (Table 2).

Table 2 - Results

Variables	GA (n = 48)	GB (n = 52)	P
Sheath removal time (min)	268.2 ± 28.4	269.54 ± 54.4	0.87
Manual compression time (min)	19.4 ± 3.1	19.6 ± 3.3	0.75
Formation of hematoma	8	9
Small hematoma	7	7
Moderate hematoma	1	2	1.0

GA = group receiving care by nurses; GB = group receiving care by residents.

DISCUSSION

This is the first study comparing the safety of arterial sheath removal by the specialized nurse or by the resident in interventional cardiology, after percutaneous coronary interventions in the daily practice of an interventional cardiology unit.

In Brazil, the arterial sheath removal after diagnostic and therapeutic percutaneous coronary procedures can be performed by nurses, once they had been submitted to a specialization course on intensive care nursing or catheterization lab, since the procedure is complex and may present serious risks to the patient.⁸

The advantage of nurse training for arterial sheath removal is that a higher number of professionals who work in the interventional cardiology team will be able to perform this procedure, thus reducing the work overload of its members.

The arterial and venous sheath removal by the nurse after percutaneous coronary interventions is a growing practice in Canada, USA and England.^9-13 In Canada, this participation is present in approximately 1/4 of the institutions,10 and the satisfaction level of nurses concerning this change in practice was obtained in 46% of interviewees.¹⁴

Juran et al.,⁹ in a prospective multi-centered study with 4,000 patients submitted to percutaneous coronary interventions, showed a significant correlation between the interventions done by the nurse and the occurrence of moderate to intense bleeding at the arterial access site, without major consequences. The most significant factors in the reduction of complications at the arterial access site were the shorter time needed to remove the arterial sheath, the type of mechanism used to obtain hemostasis, the professional allocation and the method used in the removal.

When we compared the techniques of manual and mechanical compression to remove the femoral arterial sheath by the nurse, there was no difference in relation to the bleeding; however, there was an increase in hematomas in the manual compression group.¹⁵

In October 2001 a training program for early arterial sheath removal after percutaneous coronary interventions was implemented by the nurses of the cardiology unit at Massachusetts General Hospital. As a result, 106 sheaths were removed in November 2001; of these, 58% were done by nurses, in which there was the formation of hematoma in nine patients (8.5%), a comparable rate when the procedures were performed by doctors.¹⁶

In conclusion, the arterial sheath removal by the catheterization lab specialized nurse or resident in interventional cardiology proved to be a safe procedure, without major complications. It is important to highlight the importance of a specialized training for these professionals in order to obtain good results.

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