Percutaneous brachial artery access (PBA) for coronary and iliac peripheral interventions is beginning to be seen more frequently in interventional cardiology. One of the existing hurdles to clinicians widely adopting this technique in the United States is the achievement of secure hemostasis after removal of the brachial sheath. Although manual compression is the gold standard for PBA hemostasis, there are inherent challenges with maintaining good focal compression on the artery by a hand grip with limited use of supportive body weight. The brachial artery has a tendency to roll from beneath the interventionist's fingers during holding pressure, making initial hemostasis challenging. Furthermore, delayed development of hematoma or pseudoaneurysm is common. Although there have been case reports on the use of vascular closure devices on the brachial artery, this is not routinely performed or recommended. In this article, we report on the method of using the TR Band radial compression device (Terumo Interventional Systems, Somerset, NJ) in the brachial position as an alternative to manual compression (Figure 1).

In the standard fashion of placement, a large (29 cm) TR Band is placed in the brachial position (Figure 2). An arm board is put under the patient's elbow to keep it straight, and the green marker is aligned just proximal to the skin puncture site (Figure 3). If the arm girth allows, fasten the strap in a parallel and not slanted fashion. At this time, a piece of silk tape is used on the back of the TR Band covering the band on both sides of the fastened strap to ensure secure placement (Figure 4). We have observed that the silk tape forms a very strong bond with the TR Band material, which is very difficult to separate once applied. This allows for additional security in maintaining adequate pressure when the compression balloon is inflated. We have used this method even when the fastening straps did not meet due to large arm size. Once in place, 18 to 20 mL of air is injected using the TR Band inflator, and the sheath is pulled out. On rare occasions, 2 to 3 mL of additional air inflation is needed to achieve hemostasis. The radial pulse is palpated to ensure blood flow to the hand. The duration of the compression is dictated by the presence or absence of anticoagulation. Typically, in interventional cases, the band is loosened by removing 5 mL of air at 4 hours and is deflated completely 1 hour later. However, it is often left in place for another hour in case of breakthrough bleeding and the need for immediate reinflation. We leave the arm board in place overnight to keep the elbow straight and remove it after inspection the next morning.

Safe removal of a PBA sheath is challenging. In our experience from May 2008 to November 2009, a total of 25 PBA TR Band closures were performed with no complications, including no significant hematomas or thrombosis. The mean body mass index of these patients was 30.2 (range, 17.6–42). The completion of a brachial access case can be safely achieved by using the TR Band with only slight modifications. Given its ease of use and our clinical success, this has become our first-choice method for PBA hemostasis.

Andrzej Boguszewski, MD, is Chief Interventional Cardiology Fellow, St. John Hospital and Medical Center in Detroit, Michigan. He has disclosed that he holds no financial interest in any product or manufacturer mentioned herein. Dr. Boguszewski may be reached at (313) 343-4612; andy.boguszewski@stjohn.org.

John Frank, MD, is an Interventional Cardiology Fellow, St. John Hospital and Medical Center in Detroit, Michigan. He has disclosed that he holds no financial interest in any product or manufacturer mentioned herein.

Deepak Koul, MD, is an Interventional Cardiology Fellow, St. John Hospital and Medical Center in Detroit, Michigan. He has disclosed that he holds no financial interest in any product or manufacturer mentioned herein.

Abdulwahhab Alroaini, MD, is an Interventional Cardiology Fellow, St. John Hospital and Medical Center in Detroit, Michigan. He has disclosed that he holds no financial interest in any product or manufacturer mentioned herein.

Hiroshi Yamasaki, MD, FACC, is Director of the Interventional Cardiology Fellowship Program, St. John Hospital and Medical Center in Detroit, Michigan. He has disclosed that he is a paid consultant to Terumo Interventional Systems.