Influence Of Delaying Removal Of Arterial Sheath On Forearm Access Site Complications In Patient With High Bleeding Risk After Tansradial Coronary Intervention

Objective: Discussing influence of delaying removal of arterial sheath on forearm access site complications in patient with high bleeding risk after tansradial coronary intervention.Methods: Select consecutive patients who were diagnosed with coronary heart disease and performed transradial coronary intervention in the Second Hospital of Hebei Medical university from December 2013 to December 2014 with CRUSADE score higher than 31. Modified Allen’s test of all patients were normal. Exclusion criteria:(1) contraindication of heparin and iodinated contrast media;(2) severe hepato-renal failure;(3) cardiogenic shock, cardiac rupture and papillary muscle rupture after myocardial infarction;(4) severe heart valve disease;(5) malignant tumor or severe disease of other system;(6) deformity, trauma or operation history of forearm;(7) Raynaud’s disease;(8) patients need to maintain heparin after operation;(9) patients refuse operation. All patients were divided into immediate removal sheath group(IRS group) and delaying removal sheath group(DRS group) randomly and accepted routine drug treatment before operation. All patients were selected radial artery as access vascular and used 6F artery sheath, bolus-like injection 3000 U heparin and 200 ug nitroglycerin after inserting artery sheath. 4F angiographic catheter was used in coronary angiography. During Percutaneous coronary stenting(PCI), heparin doses was added to 100U/kg. With operation time exceeding every 1 hour, adding heparin 2000-3000 U. Activated coagulation time(ACT) needed to be maintained 250-300 s. The intervention instruments like guide catheter, guide wire, balloon, sent were decided by operators according to patients’ condition. Recording the frequency of puncture, total time of operation, ratio of PCI, type of guide catheters, quantity of stents. IRS group’s sheath were removed immediately after guiding pulling out. Access site were bandaged with pressure for 6 hours. DRS group’s sheath were removed 2 hours after guiding pulling out with bandaging for 4 hours. Recording access site complications, practicing forearm artery ultrasound on 3-day and 30-day after operation. Trace major adverse cardiac events(MACEs) in 30 days. Using logistic regression analysis to discuss independent risk factors of the patients who occurred access site hematoma. All statistic data were analyzed with SPSS 20.0 statistical software. P<0.05 were thought to be statistical significant.Results:1 82 cases were enrolled in this study and divided into IRS group with 40 cases and DRS group with 42 cases. There was no difference between two groups in characteristics like gender, age, systolic pressure, diastolic pressure, heart rate, BMI, diabetes, smoking history, drinking history, vascular disease history, myocardial infarction history, disease type, left ventricular ejection fraction(LVEF), red blood cell count(RBC), hemoglobin, hematokrit, platelet count, activated partical thromboplastin time(APTT), serum creatinine, medication use and radial artery diameter.(All P>0.05)2 There existed no statistically significant in frequency of puncture, operation time, ratio of PCI, type of guide catheter, quantity of stent between two groups.(All P>0.05)3 In terms of incidence of hematoma, DRS group was lower than IRS group(2 vs. 8, P=0.046). One patient occurred nerve injury in IRS group and no patient occurred in DRS group. There were not statistical significance between two groups(P>0.05). Forearm artery ultrasound was performed on 3-day after operation. There were not statistical significance in terms of radial artery stenosis, radial artery occlusion, pseudoaneurysm and arteriovenous fistula(All P>0.05). On 30-day after operation, patients’ s forearm artery ultrasound was examined again. 34 patients in IRS group and 35 patients in DRS group were followed. There were no statistical significance on the ratio of reexamination between two groups(P>0.05). There were not statistical significance in terms of radial artery stenosis, radial artery occlusion, pseudoaneurysm, and arteriovenous fistula between two groups(All P>0.05).4 Record MACEs in 30 days afters operation, no patient died in 30 days. In IRS group, 2(5.0%) patients occurred nonfetal myocardial infarction, 2(4.76%) patients occurred in DRS group. There were no statistical significance. 95 percentage of IRS group’s patients did not occur MACEs, and 95.24 percentage of DRS group’s patients did not occur MACEs, there was no difference.5 In this experiment, all patients were divided according to the incidence of hematoma. The hematoma group had 10 patients and no hematoma group had 72 patients. There were no difference in gender, BMI, usage percentage of 7F guide catheter between two groups(All P>0.05). The usage ratio of tirofiban, the frequency of puncture, the ratio of PCI and the operation time of nof hematoma group was higher than no hematoma group(60% vs. 9.72%, P=0.001; 3 vs. 1, P=0.000; 100% vs. 55.56%, P=0.005; 106.00±31.43 min vs. 40.90±22.33 min, P=0.000). The result of multi-factor logistic regression analysis showed: tirofiban usage(OR=27.537, 95%CI:1.020~743.43, P=0.049), more frequency of puncture(OR=5.554, 95%CI:1.154~26.730, P=0.032), longer operation time(OR=56.146, 95%CI:1.284~2454.397, P=0.037), these factors were independent risk factors of access site hematoma.Conclusion:1 Delaying removal of arterial sheath of patients with high bleeding risk after transradial coronary intervention diagnosis or therapy could prevent access site hematoma, without increasing incidence of radial artery stenosis, radial artery occlusion, nerve injury, pseudoaneurysm and arteriovenous fistula.2 Patients with high bleeding risk were more likely to have more puncture, longer operation time and develop access site hematoma in use of tirofiban during transradial coronary artery intervention diagnosis or therapy. It is suggested to delay removal arterial sheath to prevent access site hematoma.