The management and prevention of groin complications post cardiac catheterization procedures. Let's get back to the BASICS.

1. Prevention and Treatment Of Groin
Complications
Presented By Jacob Mason CIS

2. Anatomy

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

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

5. Bleeding
Vascular complications are a major preventable cause of morbidity and
mortality from invasive cardiac procedures.

6. Is bleeding really an issue?
 Bleeding is the most common complication seen post PCI’s.
 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

7. 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 ) Nuisance
Treatment:

8. “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 Pressure
Bleeding type
Treatment:

9. Symptoms and Causes

10.  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 puncture
Most common signs and symptoms

11.  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

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

13. Vascular Complications

14.  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 from
clotting in the culprit vessel, they also promote greater risk post operatively for the development of the vascular complications.
Types of groin complications

15. 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.

16. 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

17. Hematoma
Loss 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” hematoma
• Direct pressure 1-2 cm superior, or inferior to the insertion site depending on the
origin of bleeding, arterial or venous
• Monitor vital signs

18. Retroperitoneal hematoma ( RPH )
Bleeding into retroperitoneal cavity

19. Treatment
• Stop anti-coagulation medications
• Fluid replacement
• Blood transfusion
• Surgical repair if hemodynamically unstable
• Close and constant monitoring of patient
Retroperitoneal hematoma ( RPH )

20.  May or may not see hematoma at site
 Flank or lower back pain
 Hypotension
 Tachycardia
 Abnormal hematocrit/hemoglobin
 Diaphoresis
 Abdominal distension
Retroperitoneal hematoma ( RPH )

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

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

23. Correct Hand Position

24. Access site
Apply direct pressure 1-2 cm above site
Hand position

25. Good Hand Position
Correct Compression Method
Incorrect
You 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.

26.  Closure device
 Sheath size
 Anticoagulant ( Heparin or Angiomax )
 Closing ACT
 Puncture site issues
 Vital signs
Factors that can affect hemostasis

27. 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

28. Nick and spread technique used for deployment of the starclose

29. Angio- Seal
The mechanism of closure devices
Star Close

30. Assess
Diagnose
Intervene

31. 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 ?

32. 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 )

33. 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

34. Key Points and Myths

35. 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.

36. 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 can’t 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)

37. Complications and reasons why we don’t seal
every patient.

38. Profunda
Bifurcation of the profunda and superficial femoral artery
High Stick
Sheath inserted above the inferior epigastric artery

39. Vessel size
Calcium
Femoral artery diameter here is less than 3 cm

40. Type A Dissection
A tear in the wall of the iliacs that causes blood to flow between the layers
of the wall.
RFA Occluded from sheath
Diseased and small right femoral artery

41. Femoral Puncture

42. Hemostat placement
Femoral head
Landmarks

43. Anatomical layout

44. Incorrect femoral artery puncture
Entry site complications results from poorly placed femoral artery punctures.
A. Too low has an increase chance
of site thrombosis
B. Deep femoral artery stick maybe
difficult to compress
C. The needle may disrupt plaque on
posterior wall
D. Puncture wall stick too proximal
increases the chance of a
retroperitoneal bleed

45. Transradial Procedure

46. Ulnar artery
Is the blood vessel, with oxygenated
blood, of the medial aspect of the forearm
Radial artery
is the main blood vessel with oxygenated blood
of the lateral aspect of the forearm.
Anatomic Review

47. Allen Test
Is used to test blood supply to the hand. It is performed prior to cannulation

48. Allen’s test
1) The hand is elevated and the patient is asked to
make a fist for about 30 seconds.
2) Pressure is applied over the ulnar and the
radial arteries so as to occlude both of them.
3) Still elevated, the hand is then opened. It
should appear blanched (pallor can be
observed at the finger nails).
4) Ulnar pressure is released and the color
should return in 7 seconds.

49. Both arteries are open
Release ulnar with radial occluded
Occlude both ulnar and radial

50. Diagnostic
Release slowly over 60 minutes
Post Cardiac Catherization Orders
Intervention
Release slowly over 90 minutes

51. zero tolerance
Having a
For bleeding

52. 4 x 6 resource flyer
Cut out and laminate