Post-Catheterization Prevention of Peripheral Vascular Complications

Training for Mount Carmel East CCU Staff By Jennifer Rossow, RN, BSN, CCRN

Objectives


To educate how to recognize peripheral vascular complications as a result of percutaneous coronary intervention To differentiate complications such as bleeding/hematoma, retroperitoneal hematoma, pseudoaneurysm, arteriovenous fistula, arterial occlusion, and infection To teach the procedure and necessity of performing auscultation of a systolic bruit during groin assessment

Peripheral Vascular Complications



 

The use of complex antithrombotic and antiplatelet protocols used during percutaneous coronary interventions (PCI) increases the risk of femoral vascular complications Vascular complication incidence can range from 5.4% to 37% Factors relating to complications include sheath removal techniques, training of the caregiver, location and number of groin pokes, and patient characteristics. Patient risk factors include women, ages older than 65, those with peripheral vascular disease, and any patient with a small body surface area Peripheral vascular complications can occur up to 72 hours post catheterization

Bleeding


Bleeding will present on any occasion when inadequate pressure is applied to the groin site after sheath pull Bleeding is more frequent when the vessel has been poked more than once and when anticoagulation protocols are ordered Bleeding through the skin incision requires pressure applied 12cm above the site and 1 cm medially until hemostasis occurs Please refer to the Mount Carmel Policy/Procedure document for arterial and venous sheath removal.

Hematoma


A hematoma is bleeding into the soft tissue. It is usually accompanied with a large amount of ecchymosis and can become sore, enlarged, firm To monitor the size, good practice is to outline the circumference with a washable marker Large amounts of bleeding and hematomas require serial hemoglobin and hematocrit monitoring Hematomas can compress the femoral nerve and cause permanent neuropathy. Muscle weakness to the quadriceps for several months can also occur Hematomas can take several weeks for the bruising to disappear

Bleeding/Hematoma Physical Findings



    

Scant or excessive bleeding at the insertion site Pain or burning at the puncture site An expanding mass at the insertion site Ecchymosis Swelling Tachycardia or hypotension (late signs)

Retroperitoneal Hematoma
 

 

A retroperitoneal hematoma is bleeding into the lower back in the area known as the retroperitoneal space It can occur when the common femoral artery is punctured above the inguinal ligament (Cath Lab calls it a high poke) It can often go undetected since the cavity is so large A rare complication but may lead to shock and can be potentially fatal These hematomas also place pressure on nerves causing permanent neuropathy Pressure on organs can lead to organ failure

Retroperitoneal Hematoma Physical Findings



 

Moderate to severe pain in the back, flank, lower abdominal quadrant, or groin Low hemoglobin and hematocrit counts Tachycardia or hypotension (late signs)

Pseudoaneurysm
 

 

Pseudoaneurysm is an encapsulated hematoma which has branched itself off of an artery. It is the most common peripheral complication occurring at 0.2% to 2% of cases. It is most often caused by an arterial puncture into one of the two distal, fragile, and thin-walled branches of the common femoral artery. It also occurs when inadequate pressure is applied to the groin site after sheath pull or by long sheath dwell time. Common when large sized sheaths are used. Usually when their size is less than 3 cm, careful observation is all that is necessary. Greater than 3cm requires surgery, ultrasound-guided compression or thrombin injection.

Pseudoaneurysm Risk Factors

     

Obesity Difficulty accessing compression site Advanced age Hypertension Hemodialysis Heavily calcified arteries

Pseudoaneurysm Physical Findings

    

Groin pain or burning Swelling at insertion site Ecchymosis Systolic bruit auscultated near insertion site A pulsating mass

Arteriovenous Fistula


 

Arteriovenous (AV) fistulas occur as a result of puncture to both an artery and vein which produces a direct communication between both vessels Because of the pressure gradient, blood will flow from the area of higher pressure (arterial) to lower pressure (venous) and can lead to heart failure and cardiac volume overload AV Fistula has an incidence rate of less than 1% Requires surgery for repair

AV Fistula Physical Findings

    

Pain and swelling at insertion site A continuous bruit Palpable thrill Low diastolic pressure Tachycardia

Arterial Occlusion


Less common due to anticoagulant therapy being used with most PCI procedures Can occur when a thrombus develops at the puncture site More common following insertion of intraaortic balloon pump Left undetected can result in loss of limb

Arterial Occlusion Physical Findings

    

Sudden onset of severe pain Numbness or tingling Pallor or cyanosis Cooling of foot and leg Loss of distal pulses

Infection


Phlebitis, bacteremia and infection can occur days after procedure Occurs more frequently when the catheter has been passed through a femoral graft or multiple procedures during the same hospitalization

Infection Physical Findings

   

Swelling Redness Warm skin Purulent drainage

Auscultation of Femoral Bruit

 

Bruits are rushing sounds heard over large and medium-sized arteries as a result of vibration in the vessel wall caused by turbulent blood flow They are usually detected near the insertion site or may be transmitted further along the vessel Presence of a bruit following sheath removal must be reported to the physician Some femoral bruits can be pre-existing prior to catheterizations, especially in patients with PVD Since peripheral vascular complications can occur up to 72 hours post procedure, bruit auscultation should be performed with every groin assessment Auscultation and documentation of the absence or presence of femoral bruits is a requirement of the Mount Carmel Sheath Removal Policy

References
 

Beattie, S. (1999). Cut the risks for cardiac cath patients. RN, 62(1), 1-8. Benson, L. M., Wunderly, D., Perry, B., Kabboord, J., Wenk, T., Birdsall, B., et al. (2005). Determining best practice: Comparison of three methods of femoral sheath removal after cardiac interventional procedures. Heart & Lung, 34(2), 115-121. Chlan, L. L., Sabo, J., & Savik, K. (2005). Effects of three groin compression methods on patient discomfort, distress, and vascular complications following a percutaneous intervention procedure. Nursing Research, 54(6), 391-398. Goldshtein, L., Rassin, M., Cohen, I., & Silner, D. (2006). managing pseudoanuerysm after cardiac catheterization. Nursing 2006, 36(5), 64cc164cc2. Sulzbach, L. M., Ratcliffe, S. J., Kimmel, S. E., Kolansky, D. M., & Polomono, R. (2010). Predictors of complications following sheath removal with percutaneous coronary intervention. Journal of Cardiovascular Nursing, 25(3), E1-E8. Walker, S. B., Cleary, S., & Higgins, M. (2001). Comparison of the Femsotop device and manual pressure in reducing groin puncture site complications following coronary angioplasty and coronary stent placement. International Journal of Nursing Practice, 7(1), 366-375.