Best Practices for Early Ambulation and Same-Day Discharge

Suture-Based Techniques Versus Manual Compression for Femoral Venous Hemostasis After Electrophysiology Procedures

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Interview by Jodie Elrod

EP LAB DIGEST. 2024;24(11):ONLINE ONLY.

In this interview, EP Lab Digest speaks with Mark Mills, MBChB (Hons), MSc, MRCP, Clinical Research Fellow in Electrophysiology (EP) at Liverpool Heart and Chest Hospital in the United Kingdom, about his research¹ on suture-based techniques versus manual compression for femoral venous hemostasis after EP procedures, including clinical impact, best practices for early ambulation and same-day discharge, and future directions.

Can you discuss the key differences in complication rates between manual compression and suture-based techniques for femoral venous hemostasis, particularly in patients receiving periprocedural anticoagulation?

First, thank you for inviting me to discuss this important topic. While hemostasis is not as trendy as the latest advances in ablation technologies, vascular complications remain the most common complications after EP procedures, and thus deserve our close attention as clinicians and scientists. Even though the introduction of ultrasound-guided access has led to a reduction in vascular complications, these continue to occur, and can lead to patient discomfort, delayed ambulation or discharge, and sometimes life-threatening emergencies. At my institution in the United Kingdom, we are working on a range of projects to improve vascular access site management.

In our recent manuscript in the Journal of Cardiovascular Electrophysiology,¹ we set out to examine the impact of hemostasis methods on clinical outcomes in an all-comer cohort of patients undergoing EP procedures. Through a retrospective review of clinical notes, we compared the outcomes of 1089 patients receiving either manual compression, a figure-of-8 suture secured with a hand-tied knot, and a figure-of-8 suture secured with a 3-way stopcock. At our center, we perform the full range of EP procedures, but our most common procedures include atrial fibrillation (52%), atrial flutter (11%), and atrioventricular nodal re‐entrant tachycardia (10%) ablation. We defined access site complications as major if they delayed discharge, required intervention or blood transfusion, or resulted in death; or as minor if bleeding or hematoma developed after initial hemostasis requiring additional compression.

Our main finding was that, in patients receiving periprocedural anticoagulation (79% of those studied), the figure-of-8 suture secured with a 3-way stopcock was associated with fewer bleeding complications than manual compression or the hand-tied figure-of-8 suture. The majority of complications were minor only (ie, rebleeding after initial hemostasis requiring manual compression). On the other hand, in patients not receiving periprocedural anticoagulation, complications did not differ between hemostasis methods. Admittedly, the cohort of patients not receiving periprocedural anticoagulation was relatively small, and underpowering may have contributed towards these neutral results in this group. 

How do the findings of this study impact current clinical practices in achieving femoral venous hemostasis during EP procedures, and what recommendations would you suggest for practitioners based on this evidence?

I am aware of many EP colleagues across international centers who continue to use either manual compression or a hand-tied figure-of-8 suture for venous haemostasis after EP procedures. I hope that the results of our study can convince these colleagues that a figure-of-8 suture secured with a 3-way stopcock is preferable over these other options. 

Indeed, in my experience, a hand-tied figure-of-8 suture is more likely to snap while tying the knot, and does not offer the possibility to further tighten the suture in the event of loosening or re-bleeding. Further, the hand-tied suture is more difficult to perform as a single operator, as the suture cannot be tightened with one hand while removing the sheaths. Although we did not formally assess it in our study, I suspect that the figure-of-8 suture leads to faster turnaround times in the catheterization laboratory compared with manual compression, which frequently takes 10-15 minutes at the end of the procedure. And finally, patients seem to prefer the suture to the more uncomfortable manual compression!

For those not familiar with the figure-of-8 suture with 3-way stopcock technique, we have included a step-by-step figure and video to accompany our article. This technique is cheap, easy to learn, and ultimately extremely elegant! And—unlike expensive vascular closure devices—it uses equipment that is already on the procedural table. Unfortunately, as the suture and stopcock are not money-makers for industry, we as cardiologists must advocate for their use! 

What best practices can be derived from this study to facilitate early ambulation and same-day discharge for patients after EP procedures, particularly with respect to the choice of hemostasis technique?

In our center, it is standard practice for patients to remain on bed rest for 4 hours after initial hemostasis. Same-day discharge is usually reserved for those whose procedures finish before 2 PM to avoid late night discharges. The results of our study suggest that a figure-of-8 secured with a 3-way stopcock is the optimal hemostasis method in reducing bleeding complications after the EP procedure; therefore, increasing the probability of early ambulation and same-day discharge.

When teaching the figure-of-8 suture technique, I always stress the importance of considering the depth of the femoral vein and artery, which can be appreciated at the start of the procedure when inserting the sheaths under ultrasound guidance. In cases where the vessels are very superficial, care is required to ensure they are not punctured with the suture. 

Critically, venous hemostasis is just one component of optimal vascular access management, and other practices not explicitly studied in the present study remain crucial, specifically, the use of ultrasound-guided vascular access, ensuring the fewest number of sheaths are placed to adequately perform the procedure, the reversal of heparinization with protamine, and institutional standardization of bed rest and anticoagulation protocols.

Given the limitations identified in the study, what future research directions would you recommend to further explore the effectiveness of suture-based techniques versus manual compression, particularly in diverse patient populations and different procedural settings?

It is important to acknowledge that our study was observational and retrospective, and therefore, prone to bias and confounding. We attempted to account for this through multivariable logistic regression, but ultimately only a randomized, controlled trial can truly assess the difference between these hemostasis methods. Large studies comparing manual compression, suture-mediated closure, and vascular closure devices would be welcomed, particularly focusing on the cost-effectiveness of each method.

As a single-center study, I encourage EPs across the world to implement, audit, and publish their experience of the figure-of-8 suture secured with a 3-way stopcock to assess the efficacy and safety of this technique in a range of settings.

At our center, we are currently conducting the HARNESS (Hemostasis AfteR veNous accESS in atrial fibrillation ablation) randomized, controlled trial, which is assessing the impact of different hemostasis methods and bed rest durations on postprocedural care. We hope to publish the results of this in the next year.

Reference

1.              Mills MT, Calvert P, Snowdon R, et al. Suture-based techniques versus manual compression for femoral venous haemostasis after electrophysiology procedures. J Cardiovasc Electrophysiol.2024 Sep 4.doi:10.1111/jce.16417