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Prevention and Treatment Of GroinComplicationsPresented By Jacob Mason CIS

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Anatomy

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Angiographic anatomyThe optimal puncture site for femoral artery access is 1-2 cm below the inguinal ligament.

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The boney area is use to helpachieve hemostasis by giving you a solid foundation to compress the femoral.

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BleedingVascular complications are a major preventable cause of morbidity and mortality from invasive cardiac procedures.

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Is bleeding really an issue? Bleeding is the most common complication seen post PCIs. 90% of bleeding occurs at the access site. The most common access site complication is a hematoma. Femoral access complication rates are 1.0% for diagnostic and 4% for interventional procedures

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Bleeding type Lower the head of the bed for better control of bleeding ( Femoral artery anatomically goes deeper. )

Sterilely apply light manual pressure approximately 5-8 minutes

Uncomplicated oozing ( Bleeding from small capillaries or tissue ) NuisanceTreatment:

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Bleeding

Manual compression must be applied to prevent further enlargement of hematoma.

Assign someone to call the physician while you hold pressure or vise versa.

Mark the boundaries of the hematoma to monitor growth and effectiveness. Controlled PressureBleeding typeTreatment:

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Symptoms and Causes

Pain at the groin or lower back Swelling at the insertion site ( Hematoma ) Numbness in leg of sheath insertion Loss of pedal pulse in affected leg Tingling odd sensation in the leg with the punctureMost common signs and symptoms

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Increased blood pressure Ineffective closure device Ineffective hemostasis achieved from manual pressure Need to urinate Obesity Pharmaceutical therapy Advanced age decreasing vessel elasticity A rapidly falling hematocrit post catherization

Possible causes

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High-Risk PatientsThe common risk factors and predictors for complications: Age Diabetes Female gender Morbid obesity Uncontrolled hypertension Large sheath size Out patients

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Vascular Complications

Hematoma: Blood collects in soft tissue Psendoaneurysm: A dilation of an artery with actual disruption of one or more layers of its walls.

Arteriovenous Fistula ( AV ): A direct communication forms between an artery and a vein.

Retroperitoneal Bleed ( RPH ): The hematoma extends into the retroperitoneal space, which lies deep the abdominal cavity.

Powerful vigorous anticoagulation is the cornerstone of acute interventional today, While the medications prevent blood fromclotting in the culprit vessel, they also promote greater risk post operatively for the development of the vascular complications.Types of groin complications

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Loss of blood under the skin directly as a result of arterial/venous injury.What is a hematoma?A hematoma is more than just a bruise in that it forms a lump which hardens.

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When does a hematoma becoming serious? Distal pulses become diminished

Hematoma greater than 4cm x 5cm The area around the access site become firm.

Unable to control or manage bleeding

Physical appearance becomes the obvious

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HematomaLoss of blood under the skin directly as a result of arterial/venous injury.Treatment A stable hematoma may require no more than marking the boundries

An Unstable hematomaDirect pressure 1-2 cm superior, or inferior to the insertion site depending on the origin of bleeding, arterial or venousMonitor vital signs

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Retroperitoneal hematoma ( RPH )Bleeding into retroperitoneal cavity

TreatmentStop anti-coagulation medicationsFluid replacementBlood transfusion Surgical repair if hemodynamically unstableClose and constant monitoring of patientRetroperitoneal hematoma ( RPH )

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May or may not see hematoma at siteFlank or lower back painHypotensionTachycardia Abnormal hematocrit/hemoglobinDiaphoresis Abdominal distensionRetroperitoneal hematoma ( RPH )

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This 85-year-old woman was on anticoagulation therapy for PCI.Retroperitoneal hematoma ( RPH )

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After the inferior epigastric artery the Illiac artery takes a dive.

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Correct Hand Position

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Access siteApply direct pressure 1-2 cm above site Hand position

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Good Hand PositionCorrect Compression Method IncorrectYou will find pressing down with your finger tips is less fatiguing. On the obese patient, you will not be able to get enough force down to the arteriotomy.

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Closure device Sheath size Anticoagulant ( Heparin or Angiomax ) Closing ACT Puncture site issues Vital signsFactors that can affect hemostasis

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Safety is defined as the percentage of patients with major or minor vascular complications. Minor vascular complications are hematoma greater than 10 cm, arteriovenous fistulas, or pseudo aneurysm. Major vascular complications are death due to vascular complications, vascular repair, major vascular bleeding where hemoglobin level decreases more than 3 g/dL due to bleeding at the access site or retroperitoneal bleeding, vessel occlusion, and loss of pulse. Effectiveness is defined as the percentage of patients in whom the device was deployed successfully and the femoral artery was closed.Safety of manual compression versus closure device

Nick and spread technique used for deployment of the starclose

Angio- SealThe mechanism of closure devicesStar Close

AssessDiagnoseIntervene

Assess Is the bleeding new or old?

Is it deteriorating into a more serious condition?

Are vital signs becoming compromised?

Do I need help?

Does your patient have some of the common risk factors and predictors for complications ?

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Diagnose Where is the bleeding originating? ( Artery VS Vein, Proximal VS Distal )

Why did the bleeding start? ( Elevated BP, need to urinate, non compliant patient )

Uncomplicated oozing? ( Is there oozing from a failed closure device, sub-que tissue bleeding

Frank bleeding ( Double wall stick, high grade stick, failed closure device, improper hand position )

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Intervene Appropriate intervention: Uncomplicated oozing Frank bleeding

Manual compression holds ( poor hand positions is one of the most common mistakes. )

Compression device ( Femstop )

Changing a saturated dressing

Vascular surgery

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Key Points and Myths

Key points to remember regarding manual compression: Firm occlusive pressure is not applied during the actual removal of the sheath to avoid dislodging any clot that may be present on the sheath. Gradually lessening the pressure over the course of the compression time allows blood flow to distal anatomy.

If pressure is removed to evaluate the arteriotomy before the planned compression time is finished and oozing is observed, the original compression time should be extended by 50%. If pressure is removed to evaluate the arteriotomy and pulsatile bleeding is observed, the planned compression time should start over. A contributor to Vagel Response can also be the fear of pain, so keeping the patient calm and relaxed, and treating him/her gently, may also help.

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Myths associated with groin management The more pressure the better (This may cause distal embolism ) Using a step stool gives you better hemostasis ( Increase discomfort for patient as well as your wrist ) Using your fist is the best way to manage a hematoma ( It takes 50 lbs of pressure to achieve hemostasis) More tape means more pressure (If you cant visualize the area how do you manage it) Patients have to lay completely flat while sheath is in place (Head can be elevated up to 35 degrees without causing complications)

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Complications and reasons why we dont seal every patient.

ProfundaBifurcation of the profunda and superficial femoral arteryHigh StickSheath inserted above the inferior epigastric artery

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Vessel sizeCalciumFemoral artery diameter here is less than 3 cm

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Type A DissectionA tear in the wall of the iliacs that causes blood to flow between the layers of the wall.

RFA Occluded from sheathDiseased and small right femoral artery

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Femoral Puncture

Hemostat placementFemoral headLandmarks

Anatomical layout

Incorrect femoral artery punctureEntry site complications results from poorly placed femoral artery punctures.Too low has an increase chance of site thrombosis

Deep femoral artery stick maybe difficult to compress

The needle may disrupt plaque on posterior wall

Puncture wall stick too proximal increases the chance of a retroperitoneal bleed

Transradial Procedure

Ulnar arteryIs the blood vessel, with oxygenated blood, of the medial aspect of the forearmRadial artery is the main blood vessel with oxygenated blood of the lateral aspect of the forearm.Anatomic Review

Allen TestIs used to test blood supply to the hand. It is performed prior to cannulation

Allens test

The hand is elevated and the patient is asked to make a fist for about 30 seconds.

Pressure is applied over the ulnar and the radialarteries so as to occlude both of them.

Still elevated, the hand is then opened. It should appear blanched (pallor can be observed at the finger nails).

Ulnar pressure is released and the color should return in 7 seconds.

Both arteries are openRelease ulnar with radial occludedOcclude both ulnar and radial

Diagnostic Release slowly over 60 minutesPost Cardiac Catherization OrdersIntervention Release slowly over 90 minutes

zero tolerance Having a For bleeding

4 x 6 resource flyerCut out and laminate