Ultrasound-Guided Antegrade Brachial Artery Access Closure: A Staged Withdrawal Technique for Improved Hemostasis

Purpose Antegrade brachial artery access is a valuable alternative in arteriovenous fistula (AVF) interventions, but is often underutilized due to high complication rates. This study describes a novel ultrasound-guided staged sheath withdrawal technique designed to achieve safe and effective hemostasis without the need for surgical intervention. Methods From May 2014 to February 2024, 170 patients undergoing antegrade brachial artery access for AVF interventions were managed with this technique. Under real-time ultrasound, the sheath was withdrawn just outside the adventitia, followed by graded compression and 5 mm incremental retraction, allowing a thrombus plug in the tract. Hemostasis time, technical success, and complication rates were recorded. Outcomes were compared to a historical cohort of 120 patients managed with conventional compression. Results This technique achieved successful hemostasis in all 170 cases (technical success: 100%), with a mean hemostasis time of 6.2 ± 1.4 minutes. No major access-related complications were observed, including hematoma, pseudoaneurysm, thrombosis, or nerve injury. Real-time ultrasound ensured precise control of compression and flow preservation throughout. Post-procedural Doppler imaging confirmed intact antegrade flow and complete arteriotomy closure in all patients. Adoption of the ultrasound-guided staged sheath withdrawal technique significantly reduced access-related complications, including hematoma (8.3% vs 1.8%, p=0.010) and pseudoaneurysm (6.7% vs 1.2%, p=0.018), with no cases of arterial thrombosis post-adoption. Conclusion The ultrasound-guided staged withdrawal technique is a reproducible and safe method for closing antegrade brachial artery access, minimizing complications and preserving AVF integrity. This approach may expand the use of brachial arterial access in dialysis and complex endovascular interventions.