Managing vascular complications after cardiac catheterization or cardiac stents.

1. Managing Vascular
Complications of
Cardiac
Catheterization: Your
First Aid Kit
Presented by Helen Condry, RN

2. WHY ARE
YOU HERE?

3. Objectives
• Be able to briefly describe the process of a cardiac
catheterization .
• List possible vascular complications.
• Describe the management of vascular complications.
• Demonstrate how to hold manual pressure for a
hematoma.
• Discuss discharge teaching.

4. Cardiac
Cath: Why is
it done ?
Chest pain
Shortness of breath
Fatigue
Positive stress test
Dizziness
CMC.northeast.org

5. How is it
done?
Sheath to
artery
Wires to
aorta to
heart
Dye injected
Alltebfamily.com

6. Most Common
Complication?
Bleeding!
1% risk of bleeding
for cath’s.
3% risk of bleeding
for PCI’s.
(Batyraliev et al.,
2005) Azheart.com

7. Very Large Hematoma
Hematomas/Bleeding
•Hematomas-bleeding
under the skin with
pain
•For either one, your
first job is to find the
arterial pulse and
press hard!
•For hematomas-
someone else may
have to press out the
hematoma while you
put pressure on the
artery.

8. What else needs to be done?
• Get assistance from other nurses
• Pain medicine-very important for hematomas
• Monitor heart rate and bp while holding arterial pressure
• Notify the doctor
• Outline hematoma with marker, measure the arm if
applicable.
• Once bleeding stopped, then may apply sandbag or pressure
dressing
• May call prep & recovery for assistance

9. Pseudoaneurysm
Encapsulated hematoma
that has branched off from
the artery
Call MD who may order a
vascular ultrasound to
diagnose
Can be injected with
thrombin by vascular
surgeon or special
procedures to resolve it
Caused by inadequate
compression or by the
cardiologist’s technique
(Beattie, 1999)

10. Retroperitoneal Bleeding
Incidence is 0.15%
(Sedlacek &
Newsome, 2010)
S/S- hip, back, & abd.
pain, low bp
unresponsive to fluid
bolus, tachycardiac,
drop in H&H, bruising.
Call Md. Confirmed
by CT scan.
Transfer to ICU, blood
transfusions, possible
surgery.

11. Arteriovenous Fistula
• Rare complication if both artery and vein have been
punctured.
• Blood flows directly from the artery to the vein causing pain,
swelling, and purplish, bulging veins that look like varicose
veins. Can cause heart failure if not treated.
• Hospital policy dictates that the arterial line is removed with
hemostasis prior to removing the venous line to prevent an
AV fistula.
• Fixed through a stent or OR.

12. Angiograms show arteriovenous fistula in the deep femoral artery before
and after implantation of a covered stent.
( Thalhammer, Kirchherr, Uhlich, Waigand, & Gross, 2000)

13. Radial Approach
Less risk of
complications but still
at risk.
The patient needs to
use that hand
minimally for 24
hours.
No blood draws, bp’s
or IV’s in that arm x 1
week.
If hematoma is
suspected, measure
arm.

14. Contrast Induced Nephropathy
Occurs between 1-
10% of all cases
depending on
preexisting
conditions (Parfrey
et al., 1989)
Report any
increase of
creatinine to MD
Protect the kidneys
w/ mucomyst, IV
fluids, Na bicarb.

15. Loss of Peripheral
Pulses
•Check pulses with the
groin checks
•For new onset of
absent pulses, call Md
immediately who will
consult a vascular
surgeon
•Pt needs to go to OR
•Occurs from a clot ,
or cholesterol
gla.ac.uk
breaking off.

16. Stroke
healthmango.com
Strokes rates after cardiac cath range from
0.03% to 0.3% (Lazar et al., 1995)
Ischemic stroke can be caused by plaque
that is dislodged during the cath or from
thrombus on the catheters or guide wires.
If a stroke is suspected, call rapid response
team.

17. Your First Aid Kit
Monitor groin and peripheral pulses.
Monitor vital signs, labs, pain, restlessness,
hematoma’s.
Mark areas of swelling and measure arm if brachial or
radial.
Call prep & recovery for assistance or questions.
Give IV fluids as ordered.
Maintain bedrest or light activity with arm as ordered.
Monitor bp and pulse while holding arterial pressure.

18. Discharge Instructions
Radial’s-no blood draws or BP’s
that arm x 1 week
Femoral sheaths-may shower the
next day, remove dressing and
leave open to air, no lifting more
than 5 lbs x 1 week.
Closure devices-wait 24 hours for
shower, apply clean band-aid daily
until healed and no lifting more
than 10 lbs x 3 days.
Bruising may continue up to 1 (mmc.org)
week for all patients.

19. Questions?
Comments?

20. Now it is your turn to talk! Tell me
stories of cases you have seen.
CASE
STUDIES

21. Case Study # 1
You received report from prep & recovery that your female
patient had a negative cath, had a arterial sheath in the right
groin that was removed at 0900 with hemostasis at 0930.
The vital signs are: 130/76, SR 76.
It is now 1030 and your patient just arrived on a stretcher. You
couldn’t find the slide board so your co-workers and you
pulled and tugged her over onto the bed. You check the groin
and it is soft with no bruising.
You come back to the room at 1100 and find the patient with
both knees bent. What do you do?

22. Case study # 1 continued
You check the groin and find a
hard knot below the exit site.
What happened? What do you
do?

23. Case study # 1 continued
You start pressing out the hematoma and
the patient starts crying from the pain.
What do you do? The hematoma
resolves in 5 minutes. What do you
teach the patient?

24. Case study # 1 continued
You come back in one hour (because
you had something else happen in
another room) and find the swelling
has returned and it is bigger! What
do you do?

25. Case study # 1 continued
You start pressing it out again and
the patient says, “I don’t feel
good. I am going to throw up.”
What is probably happening?
What do you do?

26. Case study #1 continued
You put oxygen on, open up your
IV fluids, immediately check the
bp and pulse. The bp is 70/40
and the pulse is 56. If those
things don’t work, what is next?

27. Case study #1 continued
Atropine 0.6mg IVP quickly-you are
covered with the post cardiac
cath orders and you can override
med from pixus.

28. Case study # 2
You receive report that your patient had a negative cath with a
right radial access. The patient had a TR band on for 2 hours
and air was gradually removed until the TR band was
removed at 3 ½ hours at 1300.
You receive the patient at 1330. The patient steps off the
stretcher onto his bed. He is careful with not using his right
arm or putting pressure on it.
You check the radial and ulnar pulses and find both are strong
and he has good capillary refill.
You check him at 1430, he complains of some numbness in his
fingers and pain. What might be going on?

29. Case study # 2 continued
You check the pulses and there isn’t
any change. You don’t see any
swelling so decide to check it again
soon.
1 hour later, you find that the arm has
swelling above radial access site, on
the forearm. What do you do?

30. Case study # 2 continued
Measure swelling and mark it.
Listen for bruit. You do not hear
a bruit. What is the next step?

31. Case study # 2 continued
Hold pressure on artery and try to
press out the hematoma.
Call MD

32. Case study # 2 continued
The hematoma won’t press out. He
is c/o pain, numbness & swelling.
What do you think it is? What
test might the doctor order?

33. Case study # 2 continued
Vascular ultrasound to check for
pseudoaneurysm.
How would it be treated?

34. Case study # 2 continued
Treated with thrombin injection by
vascular surgeon or special
procedures.
What would the symptoms of an
AV fistula be?

35. Case study # 2 continued
Pain, tingling, numbness, and
itching in the hand and arm with
generalized edema. Pt has to go
to OR or special procedures for
stent.

36. Questions?

37. References
• Batyraliev, T., Ayalp, M. R., Sercelik, A., Karben, Z., Dinler, G., Besnili, F., Perchucov,
I. (2005). Complications of cardiac catheterization: a single-center study.
Angiology, 56, 75-80. doi: 10.1177/000331970505600110
• Beattie, S. (1999, January). Cut the risks for cardiac cath patients. RN, 62(1), 50-55.
Retrieved from http://www.rnjournal.com/
• Herrada, B., Agarwal, J., & Abcar, A. (2005, Spring). How can we reduce the
incidence of contrast-induced acute renal failure? The Permanente Journal, 9(3),
58-60. Retrieved from http://xnet.kp.org/permanentejournal/sum05/renal.pdf
• Lazar, J. M., Uretsky, B. F., Denys, B. G., Reddy, P. S., Counihan, P. J., & Ragosta, M.
(1995, May 15). Predisposing risk factors and natural history of acute neurologic
complications of left-sided cardiac catheterization. The American Journal of
Cardiology, 75, 1056-1060. doi: 10.1016/S0002-9149(99)807424-3

38. References
• Parfey, P. S., Griffiths, S. M., Barrett, B. J., Paul, M. D., Genge, M., Withers,
J.,...McManamon, P. J. (1989, January 19). Contrast material-induced renal failure
in patients with diabetes mellitus, renal insufficiency, or both. New England
Journal of Medicine, 320, 143-149. Retrieved from
http://www.nejm.org.ezproxy.lib.ucf.edu/doi/full/10.1056/NEJM198901193200303
• Sedlacek, M., & Newsome, J. (2010, May/June). Identification of vascular bleeding
complications after cardiac catheterization through development and
implementation of a cardiac catheterization risk predictor tool. Dimensions of
Critical Care Nursing, 29(3), 145-152. doi: 10.1097/DCC.0b013e3181d24e31
• Sanmartin, M., Cuevas, D., Goicolea, J., Ruiz-Salmeron, R., & Gomez, M. (2004).
Vascular complications associated with radial artery access for cardiac
catheterization. Revista Espanola De Cardiologia, 57(6), 581-584. Retrieved from
http://www.revespcardiol.org/en

39. References
• Thalhammer, C., Kirchherr, A. S., Uhlich, F., Waigand, J., & Gross, M.
(2000, January). Post catheterization pseudoaneurysms and arteriovenous
fistulas: repair with percutaneous implantation of endovascular covered
stents. Radiology, 214, 127-131. Retrieved from radiology.rsna.org