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Abstract

Background:

Nursing care in interventional cardiology is vital during perioperative stages, especially with coronary angiography. Radial artery access is now preferred, requiring proper haemostasis to prevent complications. Standardised protocols are needed for effective and economical haemostasis methods. This review aims to map the literature on haemostasis of the radial artery after coronary angiography, an area not previously reviewed.

Methods:

Following the Joanna Briggs Institute methodology for scoping reviews, two reviewers independently selected studies based on eligibility criteria. Data were extracted using a specially developed tool, with disagreements resolved through discussion or a third reviewer. Data synthesis is presented in tabular form and narrative summary. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews guidelines were followed. Searches were conducted in PubMed, CINAHL Complete, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus, Opengrey, DART-Europe e-theses portal and six key interventional cardiology reference sites.

Results:

From 43 manuscripts, four haemostasis methods for the radial artery after coronary angiography were identified: manual compression (n = 5), compression bandages (n = 16), compression devices (n = 30) and haemostatic patches (n = 7). Nearly 70% (n = 30) of references focused on compression devices. Nine techniques were used to evaluate haemostasis methods, with visual inspection (34 references) and Doppler ultrasound (17 references) being the most common. Only nine haemostasis methods lacked an associated protocol.

Conclusion:

This scoping review identifies four primary haemostasis methods post coronary angiography: manual compression, compression bandages, compression devices and haemostatic patches, with compression devices being the most frequently discussed. The variability in evaluation techniques, predominantly visual inspection and ultrasound, underscores the need for standardised guidelines. The absence of protocols for some methods further highlights the necessity for uniform standards to improve consistency and reliability in clinical practice. Standardising these methods and protocols is essential to enhance patient outcomes and advance the field.

Keywords

Bleeding compression bandages coronary angiography haemostasis radial artery

Introduction

Nursing care is provided in a wide range of contexts. In the field of interventional cardiology, although predominantly medical care, nursing care is relevant throughout the perioperative stages of procedures. It is expected from these qualified and experienced nurses to work within the multidisciplinary team in a competent manner, ‘displaying an awareness of current developments in research and knowledge relating to perioperative nursing care’.¹

Coronary angiography is used to examine the vascular system of the heart muscle after injection of a contrast medium under X-ray guidance. As a diagnostic or interventional procedure, it has become an invaluable tool in assessing and treating many ailments of the heart, resulting in it being a common procedure.^2,3

Vascular access is needed to reach the coronary arteries, and while in its inception, the brachial and femoral approaches were preferred, the radial artery is now the recommended routine access for this procedure, elective or urgent.^2,4 According to the Atlas survey developed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), ‘transradial access was used in >50% of cases in all countries except Egypt, Turkey, Germany, and Denmark’,⁵ being has high as 90% in the Netherlands.⁵ Recent data published in the United States of America attest to a steady rise in radial access between 2011 and 2018, with results consistent with those found by their European counterparts – 50% of cases.⁶ Considering that not all coronary angiographies result in percutaneous coronary interventions (PCI), there may be a significant portion of radial access not shown in these data, where haemostasis methods are also applied. The proper closure of the radial artery is just as crucial as a good puncture, presently with many methods to choose from.⁷ The industry provides a range of different devices, but before that (and sometimes even now, due to economic restrictions), nurses recurred to use manual compression and compression bandages made with accessible materials (folded gauze and adhesive, for example). Moreover, while bleeding is an issue to consider, there is also the potential danger of radial artery obstruction (RAO).³ These are not the only possible complications associated with radial access. One possible classification, by Sandoval et al.,⁸ divides them into intra-procedural and post-procedural, and then into bleeding and non-bleeding. These include, but are not limited to, spasm, dissection, pseudoaneurysm, nerve damage and infection. Proper care of the radial access site during haemostasis will prevent some of these complications, resulting in better patient outcomes (time to discharge, comfort) and preserving the radial artery for a possible future procedure.³

Previous studies on this subject have investigated the association between transradial haemostasis methods and their respective effects on RAO rates.⁷ However, an overview focusing specifically on the characteristics of the methods, how they are evaluated, and the associated haemostasis protocols is missing in the literature. The lack of standardised procedures or protocols to guide nursing practice or assist in the training of newer team members was objectively observed. Available evidence states that there are four types of interventions or haemostasis methods: manual compression, compression bandages, haemostatic dressing/patches and compression devices.^3,7 The variety of radial haemostasis methods and devices leads to the need for a comprehensive mapping of the evidence, justifying the use of scoping review.

Interventional cardiology is a highly technical and technological field that is ever-changing at the pace of discoveries in materials, methods and techniques. Many developments have been made over the years regarding haemostasis. Despite that, nursing practice has not changed much in over a decade, raising the concern that evidence-based nursing care might not be giving to patients after coronary angiography through the radial artery.

Review questions

Nursing care must consistently reflect current best practices and advancements in the field. The objective of this scoping review is to comprehensively map the available evidence on haemostasis methods used for radial artery access following coronary angiography. To begin this process, the following questions must be answered:

i. What are the haemostasis methods used for the radial artery after a coronary angiography?

ii. What are the characteristics of the haemostasis methods?

iii. How are the results of haemostasis methods evaluated?

iv. What haemostasis protocols are associated?

By doing so, this review seeks to address gaps in the literature, guide evidence-based nursing practices and inform the development of standardised protocols for optimal patient care in interventional cardiology.

Methods

The current review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology latest guidance.^9,10 This review was preferred over other methods of evidence synthesis, because the authors aimed to, on the one hand, systematically identify and map the breadth of evidence available, and on the other hand, clarify key concepts and characteristics related to haemostasis of the radial artery after coronary angiography.^8,9 The process included, in order, identifying the research questions, defining the inclusion criteria, identifying and selecting relevant studies, collecting the data and comprehensively summarising the results. The aforementioned were specified in advance, documented in a protocol available online at the Open Science Framework (https://osf.io/gt2j5/), and further expanded.¹¹ In line with the objectives of a scoping review, a formal critical appraisal or risk of bias assessment of the included studies was not conducted, as the primary aim is to map the scope of existing research rather than evaluate the quality of individual studies. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines throughout the process.

The PCC (Participants, Concept and Context) mnemonic was used, according to the JBI recommendations for scoping reviews to define the inclusion criteria (Table 1).^9,10

Table 1.

Inclusion criteria applied to the scoping review.

Participants
Patients who underwent coronary angiography.

Concept
All research studies that explore haemostasis methods used after a coronary angiography via radial artery.

Context
All contexts where coronary angiography via the radial artery (for diagnosis and/or intervention) are performed were considered, such as, but not limited to, outpatient clinics and hospitals, regardless of geographic location.

Type of sources
All research studies and review articles including systematic reviews, meta-analysis, meta-synthesis, narrative reviews, mixed methods reviews and qualitative reviews, as well as grey literature sources and interventional cardiology reference sites.

Date of publication
All studies published from 1989, since the transradial method was first described by Campeau,¹² until 31 December 2023.

Search strategy

Initially, a limited search was conducted in MEDLINE (PubMed) and CINAHL (EBSCO) by two reviewers. Then, relevant articles were selected and discussed with a third reviewer. Subsequently, keywords, index terms and free text of the retrieved articles were analysed and finalised for a complete search in five bibliographic databases, two unpublished grey literature databases and six publications of interventional cardiology reference sites, in January 2024 (Table 2). A detailed search strategy example is presented in Supplemental Appendix I. All the retrieved and selected articles were available online; no need for contacting original authors was required. Three articles were retrieved in a language other than English (one in Russian,¹³ two in Greek^14,15), but were easily translated and interpreted with online free access tools.

Table 2.

Search sources.

Bibliographic databases	Grey literature databases	Publications of interventional cardiology reference sites
MEDLINE (PubMed)	OpenGrey.eu	European Association of Percutaneous Cardiovascular Interventions
CINAHL complete (EBSCO)	DART – Europe	European Journal of Cardiovascular Nursing
Cochrane Database of Systematic Reviews		CathLab Digest
Cochrane Central Register of Controlled Trials		The Cardiac Society of Australia and New Zealand
Scopus		Asociación Española de Enfermería en Cardiología

Study selection

Once completed, all the references were imported into citation management software Mendeley (Mendeley Desktop (2021), version 1.19.8) and duplicates were removed. Afterwards, Rayyan software was utilised to facilitate the review process. Initially, two reviewers independently reviewed titles and abstracts of the retrieved manuscripts and determined eligibility solely by inclusion criteria. The selected ones were then submitted to full text review to certify final inclusion.

Data extraction

The reviewers independently classified each reference according to the ad hoc data extraction tool developed, aligned with the objectives and research questions. Any disagreement was resolved through discussion during monthly meetings and with a third reviewer.

Results

Study inclusion

The removal of duplicate articles identified 66 references that had their titles and abstracts screened by the authors. Following the initial review, by title and abstract, 20 references were excluded per inclusion criteria, the 46 that remained underwent full text review and 43 references were included. The reasons for the excluded references are reported in the Prisma flow diagram (Figure 1).

Figure 1.

PRISMA flow diagram.

Characteristics of included studies

The retrieved manuscripts date from 2005 to 2023, and the year with the most publications was 2020, with seven articles,^15,16–21 followed by 2015^22–27 (six), and 2017 to 2019 with four^7,28–30 and three^14,31,32 respectively. Geographically, it has been revealed that the countries with the most references were Spain, with 10 references, followed by Australia (seven) and the USA (four), as reported in Figure 2.

Figure 2.

Country of origin of manuscripts.

After methodological analysis of the manuscripts, six are literature reviews (three narratives and one systematic review). The remaining 37 are trials, following a quantitative paradigm. According to manipulation, 13 are observational, and 22 are experimental (11 being randomised). According to follow up, 20 are prospective and 3 are retrospective. Table 3 presents a simplified data extraction tool, which includes the most relevant data mapped based on the questions and objectives of this scoping review.

Table 3.

Data extraction.

Date	Reference	Method of haemostasis	Characteristics of the haemostasis method	Evaluation of results of haemostasis methods	Haemostasis protocol
2005	Choi E et al.	Haemostatic patch and compression device	Haemostatic patch (Clo-sur pad); pneumatic compression device (Radistop)	Palpation; visual evaluation; Allen’s test	Yes
2005	Fernández M et al.	Compression bandage	Compression bandage	Visual evaluation	Yes
2005	Fernández M et al.	Haemostatic patch manual compression	Haemostatic patch (Syvekpatch); manual compression	Visual evaluation	Yes
2010	Rathore S et al.	Compression device	Pneumatic compression device (TR Band and Radistop)	Ultrasound; reverse Allen’s test (RAT); oximetry; visual evaluation; comfort	Yes
2010	De Raya M et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2011	Lombardo-Martínez J et al.	Compression device and compression bandage	Pneumatic compression device (TR Band); compression bandages	Visual evaluation; reverse Barbeau test (RBT); ultrasound	Yes
2011	Kanei Y et al.	Compression devices	Not mentioned	Not mentioned	No
2012	Fech J et al.	Haemostatic patch and compression device	Clo-sur haemostatic patch; pneumatic compression device (TR Band)	Allen’s test; plethysmography; pulse oximetry	Yes
2013	Lee V et al.	Compression device	Pneumatic compression device TR Band	Visual evaluation	Yes
2013	Sławin J et al.	Compression device	Pneumatic compression device (TR Band)	Palpation; plethysmography; ultrasound	Yes
2014	Chow C; Mutha V; Farouque O	Compression device	Pneumatic compression device (TR Band)	Visual evaluation; ultrasound	Yes
2015	De Raya M et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	No
2015	Tian J et al.	Compression bandage	Compression bandage	Visual evaluation; palpation; Allen’s test	Yes
2015	Pancholy S et al.	Compression device	Pneumatic compression device (TR Band)	RBT; visual evaluation	Yes
2015	Rodríguez S; De La Tassa C	Manual compression	Manual compression; compression bandage	Visual evaluation; ultrasound	No
2015	Fernández M et al.	Compression bandage	Compression bandage	Visual evaluation; ultrasound	Yes
2016	Bromley T	Compression device	Pneumatic compression device	Visual evaluation	Yes
2016	Elmahdy M et al.	Compression device	Compression device	Visual evaluation	No
2016	Rubio V et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2017	Zhang WJ; Yan JC; Wang ZQ	Compression bandage	Compression bandage w/wo interventional limb raising management strategy	Visual evaluation; pulse oximetry; pain; index finger swelling; comfort	Yes
2017	Fernandez R; Lee A	Compression device compression bandage haemostatic patch	Pneumatic compression device (TR Band map-guided, TR Band, T-band, Hemoband and Radistop) haemostatic patch (chitosan clo-sur pad); compression bandage (Velcro strap elastic bandage); patent haemostatic method	Ultrasound; visual evaluation	No
2017	Avelar A; Campos M	Compression bandage	Compression bandage	Ultrasound	Yes
2017	Roberts JS Niu J Pastor-Cervantes JA	Haemostatic patch compression bandage and compression device	Pneumatic compression device (TR Band); haemostatic patch (Quikclot radial)	RBT; visual evaluation; pain	Yes
2018	Ognerubov D et al.	Compression bandage	Compression bandage	RBT; pulse oximetry; ultrasound	Yes
2018	Rubio Alcañiz V et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2018	Williams T et al.	Compression device	Compression device	Visual evaluation; ultrasound	No
2018	Campos M et al.	Compression bandage	Compression bandage	Visual evaluation; palpation; ultrasound	Yes
2019	Kang S et al.	Compression device and haemostatic patch	Rotatory compression device; haemostatic chitosan-based patch	Visual evaluation	No
2019	Rubio V et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2019	Ognerubov D et al.	Compression bandage	Compression bandage	Visual evaluation; RBT	Yes
2020	Krishnamoorthy R et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2020	Labrador L et al.	Compression device	Pneumatic compression device TR Band	Visual evaluation palpation; ultrasound	Yes
2020	Pawel L et al.	Haemostatic patch compression bandage manual compression	Haemostatic patch (Quikclot radial); compression bandage	Visual evaluation; comfort	Yes
2020	Ognerubov D et al.	Compression bandage	Compression bandage	Plethysmography; ultrasound	No
2020	Kiat J et al.	Compression device	Stepty P haemostatic band	Visual evaluation; ultrasound	Yes
2020	Kyriakopoulos V	Compression device	Pneumatic compression device; compression device	Visual evaluation; pulse oximeter	No
2021	Due-Tønnessen N et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2021	Ruiz Perez H	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2022	García D et al.	Compression device	Pneumatic compression device (TR Band)	Visual evaluation	Yes
2023	Johansson U et al.	Compression bandage	Conventional pressure dressing	Ultrasound; RBT	Yes
2023	Tsigkas G et al.	Several disclosed	Several disclosed	Several disclosed	Yes

Review findings

Haemostasis methods

Four haemostasis methods were identified for the radial artery after coronary angiography: manual compression (n = 5; 8%), compression bandages (n = 16; 27%), compression devices (n = 30; 51%) and haemostatic patches (n = 7; 14%). Although haemostatic patches are not solo haemostasis methods, they are adjuvant to the other three haemostatic methods found.

Characteristics of the haemostasis methods

The most common compression device found was the TR Band (Terumo) with 21 references, followed by Radistop (Abbot) with four. Other compression devices were Vitatech (KDL Medical Group), Stepty P (Nichiban), HemoBand (HemoBand Incorporated) and the T-band, found once each. Eight haemostatic patches references were found, three of those characterised this method: two described kaolin-based patch Quikclot Radial pad (Teleflex Incorporated),^18,29 another two Clo-Sur pad (Merit Medical Systems),^33,34 and four chitosan-based pads. As for compression bandages, elastic bandages, Velcro straps or adhesive were used. The only compressive dressing reference found specifically described the method as starting with initial inflation of a ‘sphygmomanometer cuff in the arm, at 200 mmHg, followed by removal of the sheath’ after which ‘a gauze pad and four strips of micropore tape, in the shape of an “X,” were positioned’ and over it ‘other gauze pads, previously folded into quadrangular shapes’, finishing the compression dressing with adhesive tape.²³ Finally, the manual compression references that were reported, one detailed the technique as follows: using three fingers – index, middle finger and ring finger.

Evaluation of results of haemostasis methods

A total of nine techniques were described to evaluate the haemostasis methods results. The leading technique to evaluate results of haemostasis was visual inspection with 34 references, seconded by Doppler ultrasound with 17. Allen’s and Barbeau’s test, both normal and reverse modalities were described four and eight times, respectively. Other means of evaluation found were pulse oximetry (n = 5), palpation (n = 4) and plethysmography (n = 3). The least used means to evaluate the results were patient’s pain and comfort assessment with only two references, as shown on Figure 3.

Figure 3.

Evaluation of results of haemostasis methods.

Haemostasis protocols associated

A comprehensive analysis of the manuscripts revealed that only nine of the haemostasis methods did not have an associated haemostasis protocol. However, different haemostasis protocols were found to refer to the same haemostasis methods, with no protocol being repeated.

Discussion

This is the first scoping review to map the evidence available concerning transradial haemostasis methods, their characteristics of said methods, and related haemostasis protocols and practices. Supporting this fact is the lack of retrieved references regarding this type of review. In addition, of all the manuscripts found, only one is a systematic review; however, its objective clearly focuses on the effects of haemostasis methods used to achieve haemostasis on RAO rates, which clearly differs from this review.

It was found that the most used haemostasis method for the radial artery, after coronary angiography, is the pneumatic compression device, specifically, TR Band, which is in line with other reviews published on the subject. Likewise, various deflation protocols associated with this haemostasis method were found, regardless of the manufacturer’s recommended deflation protocol, which is based on a compilation of best practices. The evidence supporting the variation of the different TR Band deflation protocols found throughout the manuscripts was unclear, and when comparing different protocols, the manufacturer’s procedure was not always used as a control. The reasons for testing these variations often focus on reducing the nurses’ workload, sometimes at the cost of a longer time to haemostasis.

The nine different techniques or tests used to evaluate the results of the haemostasis methods are consistent with contemporary best practice regarding radial artery access for coronary angiography and PCI.³⁵ These techniques may be grouped into the following categories: clinical evaluation, comprising visual inspection, palpation, pain and comfort assessment, Doppler ultrasonography, pulse-oximetry, plethysmography and specific tests (Allen and Barbeau’s). Clearly superior to clinical evaluation is Doppler ultrasonography, which has proven capable of detecting RAO and providing further anatomic information, such as the presence of thrombus, thus reducing post-radial artery access-related complications.^35,36 Despite this, clinical evaluation techniques are the preferred method because they are more accessible and do not require specific training or hardware. It is worth mentioning that a combination of different techniques was found to evaluate the results of the haemostasis methods.

The role of nurses in radial artery haemostasis after coronary angiography is pivotal. Nurses are primarily responsible for applying and managing haemostasis methods, monitoring the access site and ensuring patient comfort. Their expertise in assessing the efficacy of haemostasis techniques through clinical evaluations, such as visual inspection, palpation and patient-reported pain and comfort, is critical. The use of ultrasound, not being a transversal competence for all nurses in the various clinical contexts around the globe, does not present a problem. As pointed out by Jirous et al.,³⁷ detecting radial artery patency and occlusion using the reverse Barbeau test and Doppler ultrasonography is comparable, which makes it more accessible to a wider range of nurses to detect RAO. The variability in protocols and methods highlights the need for standardised training and practices, emphasising the importance of nurses in implementing best practices and adapting them to new evidence-based methods.

Strengths and limitations

The strengths of this review include the systematic search process that incorporated unpublished literature, which minimised publication bias, and the added value of improving the evidence provided by Fernandez and Lee,⁷ with more specific review questions and a larger pool of manuscripts. All of this contributed to descriptively mapping and explaining the nature of the evidence investigated in accordance with the best practice guidance for scoping reviews.⁹ Despite this, both this study and Fernandez and Lee’s suffer from the same limitation, that is, the lack of evidence to support one haemostasis method over another one.⁷ Another strength of this review is that no language exclusion was performed, which provides a better picture of the available evidence.

The identified gaps concerning the evaluation of the results of haemostasis methods and protocols concern the great variability found between methods and related protocols.

Conclusion

Overall, the authors believe that this study can provide valuable evidence shaping research priorities, enhancing clinical practice, and setting the path for policymaking decisions, ultimately leading to improved patient care and outcomes in access site management.

Implications for research

Upon completion of this review, the authors consider that further research is needed to determine: (1) the best radial artery haemostasis method, (2) a superior radial artery haemostasis method and (3) the most precise associated deflation protocol. A systematic review with meta-analysis may be appropriate for achieving the first two. Regarding the latter, primary research in the area may be the way to determine the best associated haemostasis protocol. Another aspect that needs to be considered is the cost-effectiveness analysis of haemostasis methods. Certain haemostasis methods are not only more effective but also more economical, influencing purchasing decisions and healthcare budgeting.

Supplemental Material

sj-pdf-1-jva-10.1177_11297298241290567 – Supplemental material for Radial artery haemostasis after coronary angiography: A scoping review

Supplemental material, sj-pdf-1-jva-10.1177_11297298241290567 for Radial artery haemostasis after coronary angiography: A scoping review by David José Teixeira Rodrigues, César Teixeira, Vitor Parola and Paulo Marques in The Journal of Vascular Access

Footnotes

Acknowledgements

We wish to acknowledge Cecilia Rodrigues, PhD, for assistance with the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This article was supported by National Funds through FCT - Fundação para a Ciência e a Tecnologia, I.P., within CINTESIS, R&D Unit (reference UIDB/4255/2020 and reference UIDP/4255/2020).

Ethical approval

This scoping review was conducted in accordance with the ethical standards laid out by the International Committee of Medical Journal Editors (ICMJE). Given that the study involved a review of existing literature and did not involve human or animal subjects, no formal ethical approval was required. The authors adhered to the principles of transparency, accountability and integrity throughout the research process. All data sources were publicly available, and proper citations were provided to acknowledge the original authors’ contributions. Any potential conflicts of interest among the authors were disclosed and managed appropriately to ensure the objectivity of the findings.

Informed consent

As this scoping review did not involve primary data collection or interactions with human participants, obtaining informed consent was not applicable. The study utilised secondary data from previously published research, which are publicly accessible and ethically cleared by their respective original studies. The authors confirm that all referenced studies followed appropriate ethical guidelines, including obtaining informed consent from participants, where applicable.

ORCID iD

David José Teixeira Rodrigues

Supplemental material

Supplemental material for this article is available online.

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