Peripheral arterial sheath removal program: A performance improvement initiative

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Vol. XXIV No. 4 PAGE 127JOURNAL OF VASCULAR NURSINGwww.jvascnurs.net

eripheral arterial sheath removal program:performance improvement initiative

irginia A. Capasso, PhD, APRN, BC, Cheryl Codner, RN, BSN, Gregory Nuzzo-Meuller, RN, BA, BSN, MDiv,rin M. Cox, RN, MSN, and Sharon Bouvier, RN, MS

The increasing number of endovascular procedures by both cardiologists and vascular surgeons strain availableresources, such as recovery space, creating delays in the throughput of patients. The use of alternative settings, personnel,and approaches to postprocedural care has been proposed to maximize the number of procedures that can be done withexisting procedure rooms. However, a key question remains about whether this can be done safely and achieve goodpatient outcomes. A performance improvement project was conducted to evaluate the safety and effectiveness of shiftingpostprocedural care and removal of intraarterial sheaths by the staff in the cardiac catheterization laboratory to speciallytrained acute care nurses on an inpatient vascular surgical unit. The purpose of this project was to develop a performanceimprovement project that included administrative, educational, and clinical components and to evaluate effects on key
patient outcomes, prospectively, over 15 months. (J Vasc Nurs 2006;24:127-132)
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EVIEW OF THE LITERATURE

Sheath removal has been studied extensively for more than5 years. By using the keyword “sheath removal,” queries of twoatabases, Medline (1966 to week 3 February 2006) and CINAHL1982 to week 3 February 2006), yielded 150 citations and 60itations, respectively. Of the 60 citations generated by CINAHL,8 were duplicative of Medline citations and 40 were consideredesearch.

Of the 117 citations that were reviewed from the two data-ases, 113 related to patients undergoing percutaneous coronarynterventional procedures and 4 pertained to patients undergoingeripheral arterial interventional procedures. The effects of nu-erous variables on patient outcomes were examined. Such

ariables included level of personnel removing the sheath,1-4

atheter size,5-7 catheter material,5 anticoagulation and antiplate-et therapy with unfractionated heparin, low-molecular weighteparin, or glycoprotein IIb IIa receptor inhibitors,8-10 manual andechanical methods of compression,11-15 and suture-mediated clo-

ure devices and vascular sealing devices.4,17-22 The outcomesncluded (1) complications of bleeding, hematoma formation

From the Munn Center for Nursing Research, Wound CareCenter, and Vascular Surgery, Massachusetts General Hospital,Boston, Massachusetts.

This program was honored with a Partners in Excellence Award,Massachusetts General Hospital, Boston, Mass (December,2003), and with the Best Poster Award by the Society forVascular Nursing, Albuquerque, NM (June, 2004).

Address reprint requests to Virginia A. Capasso, PhD, APRN,BC, Massachusetts General Hospital, 55 Fruit Street (FND 645),Boston, MA 02114 (E-mail: [email protected]).

1062-0303/2006/$32.00

Copyright © 2006 by the Society for Vascular Nursing, Inc.

ndoi:10.1016/j.jvn.2006.09.001

efore sheath removal and after sheath removal, pseudoaneu-ysm, vasovagal response, pain, major ischemic event, andeath;3,13,16 (2) time to sheath removal;19 (3) time to ambu-ation;7,9,15 and (4) time to discharge.4 These studies are dis-ussed next.

Early studies1,2 showed that physicians were responsible forheath removal in approximately 80% of the surveyed institu-ions, whereas nurses had primary responsibility for sheathemoval in 13% of surveyed institutions and shared responsibil-ty with physicians in 10% of institutions. Later studies revealhat sheath removal has become a routine responsibility of nursesroviding postprocedural care for patients after coronary inter-entional procedures, particularly on specialty cardiac units andn medical intensive care units.3,4 A retrospective chart review1

emonstrated that patient outcomes were better when femoralenous and arterial sheaths were removed by registered nursesather than by physicians (P � .01). Significant findings included

lower occurrence of bleeding (chi-square (P � .01) and aigher rate of premedication with analgesics and anxiolyticsefore sheath removal ((P � .01) when sheaths were removed byurses.

Catheter size has been identified as an important determinantf postprocedural complications. Reduction of catheter size from.15F to 6.15F, in combination with more flexible catheters andremounted stents, resulted in significant reduction in postpro-edural complications among patients undergoing renal arterynterventional procedures for renal artery stenoses.5 Use of 5Fatheters in patients undergoing percutaneous coronary interven-ion has been associated with successful immediate postproce-ural sheath removal and early discharge (ie, 8-12 hours after thend of the procedure), even after treatment with aspirin andhienopyridines for 72 hours before percutaneous coronary in-ervention and intravenous unfractionated heparin 70 IU/kg afterrterial puncture.6 Use of 4F catheters and 4F sheaths in patientsndergoing transfemoral diagnostic angiography permitted safembulation 3 hours after sheath removal without clinically sig-
ificant groin complications.7

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PAGE 128 DECEMBER 2006JOURNAL OF VASCULAR NURSINGwww.jvascnurs.net

Current scientific evidence suggests that time to hemostasisfter sheath removal is shorter with manual compression thanith mechanical-assisted compression devices. Manual com-ression achieved hemostasis 2 to 10 minutes faster than me-hanical compression, with an average compression time be-ween 14 and 22 minutes.11-15

The evidence related to vascular complications associatedith manual compression versus mechanical compression is

quivocal. In a three-group design, Lehmann and associates3

emonstrated that bleeding was lower among patients whonderwent manual compression (3%) and clamp compression4%) than among those who underwent pneumatic compression16%), with a statistically significant difference between manualompression and pneumatic compression (P � .0001). Meanematoma size also trended upward from the manual compres-ion group (3.9 cm2) to the clamp compression group (7.8 cm2)o the pneumatic compression group (19.8 cm2), also with atatistically significant difference between manual compressionnd pneumatic compression (P � .036). Similar results wereoted by Benson and associates,16 who found that patients whonderwent manual compression after sheath removal had feweromplications than patients treated with the Compressor oremstop mechanical compression devices (P � .04). Con-ersely, Pracyk and colleagues13 found that ecchymosis, oozing,nd hematomas occurred at equal frequencies in two cohorts ofatients who were treated with manual compression and me-hanical clamp compression, respectively. However, mechanicallamp compression reduced the number of ultrasound-definedemoral vascular complications (femoral artery thrombosis,chogenic hematoma, pseudoaneurysm, or arteriovenous fistula)y 63% by 24 hours after sheath removal compared with manualompression.

Numerous studies have compared time with hemostasis usinglosure devices (implantable collagen plug, percutaneous sutureevice) and mechanical-assisted compression devices or manualompression. Closure devices have been shown to be superior toechanical-assisted compression devices4,7,17-19 and manual

ompression18 in reducing time to hemostasis. Time to hemo-tasis was 50% to 66% shorter when a closure device was usedather than manual compression.20 Closure devices decreaseime to hemostasis when anticoagulants and antiplatelet agentsre administered after the procedure. Additional advantages oflosure devices include less patient discomfort, earlier ambula-ion, and discharge. The risks of infection and reactive narrowing

TABLE I

CRITERIA FOR POSTPROCEDURAL ADMISSION

● Following diagnostic angiogram only or diagnostic angiodisease

● Hemodynamically stable without expanding hematoma, bof acute peripheral arterial occlusion

● No glycoprotein IIb IIa receptor inhibitors● No Compressar C-clamp (Medicla Inc. Porland, OR) or

devices

fter deployment of the device, especially in women with smaller t

iameter vessels, heighten concern about the use of vessellosure devices.21 Predictors of complications associated withlosure devices include reduced hematocrit levels, presence of aleeding disorder, and previous use of a closure device in theessel, of which the latter is the strongest predictor variable.22

In summary, the research literature is replete with studiesbout the effect of various independent variables on the out-omes of patients undergoing arterial sheath removal, the clearajority of which relate to coronary diagnostic and interven-

ional procedures. Studies have demonstrated the safety of sheathemoval by nurses, most of whom practice in specialty cardiac orritical care units. In most studies, manual compression isssociated with a shorter time to hemostasis (14-22 minutes) andlower rate of complications than mechanical-assisted compli-

ations. Closure devices achieve more rapid hemostasis thanechanical compression devices, especially in the setting of

nticoagulation and antiplatelet therapy after the procedure.owever, risks of reactive narrowing and limb-threatening in-

ection heighten concern about their use as the exclusive methodf achieving hemostasis. To date, no studies have described theutcomes of patients with peripheral arterial disease who un-ergo sheath removal by vascular acute care nurses after diag-ostic or interventional peripheral arterial procedures.

ERFORMANCE IMPROVEMENT PROGRAM

The Sheath Removal Performance Improvement Programad four components. These components included administra-ive, educational, clinical, and evaluation.

The administrative component of the program, an essentialrst step, included development and approval of policies, nursingare guidelines, and procedures. The policies delineated (1) admis-ion criteria for postprocedural patients (Table I), (2) Nursingractice Committee credentialing of vascular nurses to removerterial sheaths and draw blood from arterial sheaths, (3) com-lications that require physician referral (Table II), and (4)taffing and scheduling of sheath removal nurses. Initially, oneheath removal nurse was scheduled only on Tuesday and Thurs-ay, from 7:00 A.M. to 3:00 P.M., when the vascular surgeons hadlocks of time available for procedures in the cardiac catheter-zation laboratory. When construction of the endovascular suiten the operating room was completed, a sheath removal nurseas scheduled from Monday to Friday to meet the expandedeed. In addition, sheath removal nurse coverage was extended

INPATIENT VASCULAR SURGERY UNIT

plus interventional procedure for peripheral arterial

ing, hemorrhage, hypotension, bradycardia, or evidence

Stop (USCI, Norwalk, CT) mechanical compression

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o 7:00 A.M to 7:00 P.M. to address the needs of early and late

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ases. However, because sheath removal during the early morn-ng hours was rare, the sheath removal nurses’ schedule washifted to 11 A.M to 11 P.M.

The educational component included a self-learning packetnd a supervised clinical practicum. The self-learning packetontained the procedure for sheath removal, guideline for ad-inistration of atropine, and journal articles related to assessing

eripheral arterial perfusion, sheath removal, reducing bleedingfter percutaneous femoral access, and pseudoaneurysm. Theheath removal competency was established through a super-ised clinical practicum. Initially, the vascular nurses went to theardiac catheterization laboratory, where experienced nursesemonstrated and then supervised the procedure for sheathemoval. The vascular nurses demonstrated competency by suc-essfully removing five arterial sheaths and achieving hemosta-is through manual compression. Later, when there was a cadref sheath removal nurses on the inpatient unit, the supervisedlinical practicum was divided between the cardiac catheteriza-ion laboratory and the vascular unit, allowing the trainee toemove sheaths under the same conditions as they independentlyould remove sheaths in the future.

Nursing care guidelines delineated the responsibilities of theascular nurse assigned to the care of the patient post-angiogramnd the sheath removal nurse, frequency of monitoring physical,oninvasive and laboratory parameters, and priorities of care inhe event of complications. Guidelines were also established for“Sheath Removal Cart” and Resource Manual.

The unit nurse assigned to the care of the patient post-ngiogram maintained overall responsibility for the patient, in-luding initial assessment and serial monitoring of the vitaligns, oxygen saturation, peripheral pulses, presence of bleedingr hematoma at catheterization site, and results of partial throm-oplastin time after discontinuance of intravenous heparin. How-ver, once criteria for sheath removal were met (Table III), theheath removal nurse removed the sheath and continuouslyxerted manual pressure at the catheterization site for an averagef 20 minutes before visually inspecting the catheterization sitend palpating the surrounding tissues. The manual compressionay be interrupted in less than 20 minutes if bleeding or

ematoma formation is suspected. Similarly, if bleeding per-isted or an expanding hematoma was detected after sheathemoval, the sheath removal nurse resumed manual compres-ion. The nurse initially directed management of an evolvingedside emergency, such as vigorous bleeding or rapid expan-ion of a hematoma, for which there were guidelines includingmmediate consultation with a vascular surgeon or residenthysician. Further, the sheath removal nurse was in the bestosition to identify a complication and initiate treatment, such as

TABLE II

CRITERIA FOR SHEATH REMOVAL

� Partial thromboplastin time � 60� Blood pressure within normal limits for patient� Adequate control of pain, anxiety, and restless leg

syndrome, if indicated

edation for agitation or atropine for a vasovagal response. O

The parameters that were monitored frequently includedlood pressure, heart rate, respiratory rate, oxygen saturation,ondition of catheterization site, and peripheral pulses. Beforend after sheath removal, the monitoring frequency was every 15inutes for 1 hour, every 30 minutes for 2 hours, and every hour

or 4 hours. Use of a multifunction noninvasive bedside monitorermitted monitoring at preset intervals and printing of a hardopy for inclusion in the patient record.

The Sheath Removal Cart was created for ease of access toquipment and supplies needed during the process of sheathemoval. Resources stocked on the cart included phlebotomyquipment, intravenous solutions, and intravenous boluses oftropine.

The evaluation component of the program included sheathurses’ evaluation of the educational materials and process,heath nurses’ experience during the sheath removal process, andutcomes of the patients undergoing sheath removal by speciallyrained nurses on the inpatient vascular unit. Changes notedreviously in relation to the clinical component of the trainingrogram and in the scheduling of sheath nurses reflect feedbackrom the sheath removal nurse team. Patient outcomes during therst 14 months of the program are described next.

ETHODOLOGY

A secondary analysis of the data set from the Sheath Re-oval Performance Improvement Project was conducted to eval-

ate the safety and effectiveness of peripheral arterial sheathemoval by specially trained acute care nurses on the inpatientascular surgical unit.

ubjects

A convenience sample consisted of 160 patients who under-ent diagnostic angiography, diagnostic angiography plus an-ioplasty, or diagnostic angiography plus angioplasty and stentlacement followed by periprocedural care and intraarterialheath removal by specially trained vascular surgical nurses inhe acute care setting during the 15-month period between

TABLE III

CRITERIA FOR PHYSICIAN REFERRAL

● Unchecked expansion of hematoma● Uncontrolled bleeding from catheterization site● Sustained vasovagal response● Pseudoaneurysm formation● Acute peripheral arterial occlusion● Severe, uncontrolled pain● Cardiac or respiratory arrest● Other

- Patient’s body habitus exceeds sheath nurse’scapacity to exert adequate pressure to achievehemostasis

- No sheath nurse available to remove sheath

ctober 1, 2002, and December 31, 2003.

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nclusion criteria

1. Patients whose sheaths were removed only by speciallytrained vascular surgical nurses who practice in the acutecare setting.

2. Patients who returned to the inpatient unit with indwell-ing intraarterial sheaths.

xclusion criteria

1. Continuous infusion of unfractionated heparin.2. Postprocedural administration of low-molecular-weight

heparin or IIb/IIIa glycoprotein inhibitors.3. Insertion of collagen or suture-mediated closure devices.4. Use of mechanical-assisted compression devices.

nstruments and measures

Data were collected using a tool adapted from the “Sheathata Sheet” developed by colleagues on the hospital’s cardiol-gy interventional unit. The form includes the date of therocedure, patient gender, age, procedure, anatomic location ofheath, size of sheath, time and value of last activated clottingime drawn in cardiac catheterization laboratory, time and valuef partial thromboplastin time drawn before sheath removal, timeheath removal began, time arterial compression discontinued,omplications before sheath removal, complications after sheathemoval, and code for nurse who removed the sheath. Age wasecorded for all patients less than 90 years of age; in accordanceith Health Insurance Portability and Accountability Act regu-

ations, categoric data were collected for all patients 90 years ofge or older. Procedures were grouped into three categories:1) only diagnostic angiography, (2) diagnostic angiography plusngioplasty, and (3) diagnostic angiography plus angioplastylus stent placement. For the sheath insertion site, four optionsere identified: right femoral artery, left femoral artery, rightrachial artery, and left brachial artery. Categoric options for theize of the sheath ranged from 5F to 8F. Complications includedarly and late hematoma formation, hemorrhage, and vasovagalesponse.

ata collection procedures

Data were recorded prospectively on the “Sheath Data Sheet”y the sheath removal nurses. Interrater reliability among theheath removal nurses was not determined. The data collectionheets were stored in the unit’s Operations Coordinator’s officentil data analysis began.

rotection of human subjects

An application for the “Secondary Use of an Existing Dataet” was submitted and approved by the hospital’s Humanesearch Committee.

ata analysis

A database was created in the Statistical Package for theocial Sciences for Windows (v. 13.0) by the nurse scientist andne of the sheath removal nurses, who then entered the data from
he Sheath Data Sheets. Although five patients had bilateral c
emoral sheaths, data related to removal of only one sheath fromach subject were included in the analysis. After frequenciesere run on each variable, the data were cleaned and erroneousata were corrected. Descriptive statistics were calculated on allariables. The low number of complications that occurred afterheath removal precluded any secondary analysis of the data.

ESULTS

The Peripheral Arterial Sheath Removal Program wasaunched on October 1, 2002. Over the next 15 months, 160ubjects underwent sheath removal by a specially trained staffurse on the inpatient vascular surgical unit. During the firstuarter of the new program, sheaths were removed from approx-mately 80 patients by nurses on the vascular unit. During eachf the subsequent four quarters of the program, sheaths wereemoved from an average of 25 to 30 patients.

Of the total sample of 160 subjects, 60% were male and 40%ere female. Subjects ranged in age from 35 to more than 90ears with a mean age of 72 years (standard deviation � 11.1).he size of the arterial sheath ranged from 5F to 8F, althoughizes 5F (47%) and 6F (42%) accounted for almost 90% of theatheters used in patients in the study. The arterial sheath waslaced in one of the femoral arteries in 83% of cases. Alterna-ively, it was placed in one of the brachial arteries in 17% ofases. In order of decreasing frequency, 53% of subjects under-ent diagnostic angiogram plus angioplasty, 27% underwentnly diagnostic angiogram, and 20% underwent diagnostic an-iogram plus angioplasty and stent placement.

After removal of the sheath, only manual compression waspplied to achieve hemostasis. Compression times ranged from0 to 80 minutes. The average compression time was 24 minutes.

Before sheath removal, 12% of the subjects sustained peri-heath hematomas. Complications after sheath removal includedasovagal response requiring intravenous administration of aolus of atropine (3%), bleeding without the formation of aematoma (3%), and new hematoma after sheath removal (1%).

ISCUSSION

A Performance Improvement Project was undertaken to eval-ate the safety and effectiveness of shifting postprocedural carefter peripheral arterial interventional procedures from the car-iac catheterization laboratory to the inpatient vascular surgicalnit under the aegis of specially trained acute care nurses. Afterhe initial 3-month period, an average of 25 to 30 postinterven-ional patients per quarter recovered in the inpatient vascularnit. The majority of subjects were elderly men who underwentiagnostic angiogram plus angioplasty through a sheath placedn one of the femoral arteries. The average duration of manualompression to achieve hemostasis was 24 minutes, which wasomparable to the time to hemostasis of 20 minutes20 and 27.5inutes14 reported in other recent studies. The rate of peri-sheath

ematomas present before sheath removal (12%) was approxi-ately 50% less than the 19% reported by Chlan and associ-

tes,14 a difference that may be attributable to the administration,efore sheath removal, of eptifibatide (38%) and clopidogrel3%) to patients in the latter sample who had undergone percu-aneous coronary intervention procedures. Overall, the rate of
omplications after sheath removal was low.

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The program demonstrated that postprocedural recovery andrterial sheath removal could be safely shifted from staff in theardiac catheterization laboratory to specially trained acute careurses on the inpatient vascular surgical unit, thereby preventing

backlog of cases in the cardiac catheterization laboratoryonsequent to a lack of available recovery bays. The programas continued and actually expanded in response to a need torovide postprocedural care to patients who were studied in thendovascular suite in the operating room. Recovery in thenpatient unit helped to avoid another potential backlog ofatients in the operating room resulting from recovery of post-rocedural patients in the postanesthesia care unit. The programay serve as a model of care for busy cardiovascular centersith a cadre of experienced specialty nurses and limited avail-

bility of outpatient recovery bays.The program evaluation should be repeated during one quar-

er of each year to serially monitor patient outcomes. Thevaluation may identify further opportunities for performancemprovement. In addition, the program offers numerous oppor-unities for qualitative research, for example, related to thexperience of the nurse and patient involved in the removal ofrterial sheaths.

cknowledgmentshe authors thank all members of the Sheath Removal Nurseeam and program consultants who made the program a successnd this report of the outcomes possible. Sheath Removal Team:atricia Buradagunta, RN, BSN, Diane S. Carter, RN, BS,ennifer Chase, RN, BSN, Cheryl Codner, RN, BSN, Kristineote, RN, BSN, Rebecca Johnson, MSN, APRN, BC, HeathercDonald Nelson, RN, BSN, Christine McKinnon, RN, BSN,

atricia Murphy, RN, Gregory Nuzzo-Meuller, RN, BA,SN, MDiv, Jennifer O’Neil, RN, BSN, and Susan Wood, MSN,PRN, BC. Consultants: Susan Cronin Jenkins, RN, BS, for-erly Nurse Manager, Cardiac Catheterization laboratory; Sio-

an Haldeman, RN, MS, CNS, Cardiac Access Unit; Colleenonzalez, RN, MSN, formerly CNS, Cardiac Access Unit;llen K. Mahoney, RN, DNS, Senior Nurse Scientist, Knightursing Center; Jacqueline Somerville, RN, MS, Associatehief Nurse; and Richard Cambria, MD, Chief, Division ofascular Surgery.

EFERENCES

1. Peet GI, McGrath MA, Brunt JH, et al. Clinical rounds.Femoral arterial sheath removal after PTCA: a cross-Canadasurvey. Can J Cardiovasc Nurs 1995;6:13-19.

2. Rubin S, Wiens L, Fingler I, et al. Evaluating a change inpractice: femoral sheath removal by registered nurses. CanJ Card Nurs 1996;7:19-27.

3. Lehmann KG, Heath-Lange SJ, Ferris ST. Randomizedcomparison of hemostasis techniques after invasive car-diovascular procedures. Am Heart J 1999;138:1118-25.

4. Rickli H, Unterweger M, Sutch G, et al. Comparison ofcosts and safety of a suture-mediated closure device withconventional manual compression after coronary arteryinterventions. Catheter Cardiovasc Interv 2002;57:297-
302.
5. Zeller T, Frank U, Muller C, et al. Technological advancesin the design of catheters and devices used in renal arteryinterventions: impact on complications. J Endovasc Ther2003;10:1006-14.

6. Lasevitch R, Melchior R, Gomes V, et al. Early dischargeusing five French guiding catheter for transfemoral coronarystenting. Am J Cardiol 2005;96:766-8.

7. Dowling K, Todd D, Siskin G, et al. Early ambulation afterdiagnostic angiography using 4 Fr. catheters and sheaths: afeasibility study. J Endovasc Ther 2002;9:618-21.

8. Choussat R, Montalescot G, Collet JP, et al. A unique,low dose intravenous enoxaparin in elective percuta-neous coronary intervention. J Am Coll Cardiol 2002;40:1943-50.

9. Allie DE, Lirtzman MD, Wyatt CH, et al. Bivalirudin as afoundation anticoagulant in peripheral vascular disease: asafe and feasible alternative for renal and iliac interventions.J Invasive Cardiol 2003;15:334-42.

0. Allie DE, Hall P, Shammas NW, et al. The AngiomaxPeripheral Procedure Registry of Vascular Events Trial(APPROVE): in-hospital and 30-day results. J Interv Car-diol 2004;16:651-6.

1. Simon A, Bumgarner B, Clark K, et al. Manual versusmechanical compression for femoral artery hemostasisafter cardiac catheterization. Am J Crit Care 1998;4:308-13.

2. Bogart DB, Bogart MA, Miller JT, et al. Femoral arterycatheterization complications: a study of 503 consecutivepatients. Cathet Cardiovasc Diagn 1995;34:8-13.

3. Pracyk JB, Wall TC, Longabaugh JP, et al. A randomizedtrial of vascular hemostasis techniques to reduce femoralvascular complications after coronary intervention. Am JCardiol 1998;81:970-6.

4. Chlan LL, Sabo J, Savik K. Effects of three groin compres-sion methods on patient discomfort, distress, and vascularcomplications following a percutaneous coronary interven-tion procedure. Nurs Res 2005;54:391-8.

5. Jones T, McCutcheon H. A randomized controlled trialcomparing the use of manual versus mechanical compres-sion to obtain haemostasis following coronary angiography.Intensive Crit Care Nurs 2003;19:11-20.

6. Benson LM, Wunderly D, Perry B, et al. Determining bestpractice: comparison of three methods of femoral sheathremoval after cardiac interventional procedures. Heart Lung2005;34:115-21.

7. Chevalier B, Lancelin B, Koning R, et al. Effect of a closuredevice on complication rates in high-local-risk patients:results of a randomized multicenter trial. Catheter Cardio-vasc Interv 2003;58:285-91.

8. Wetter DR, Rickli H, von Smekal A, et al. Early sheathremoval after coronary artery interventions with use of asuture-mediated closure-device: clinical outcome and resultsof Doppler US evaluation. J Vasc Interv Radiol 2000;11:1033-7.

9. Baim DS, Knopf WD, Hinohara T, et al. Suture-mediatedclosure of the femoral access site after cardiac catheter-
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Documents

Peripheral arterial sheath removal program: A performance improvement initiative