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Femoral Site Complications
- 1. Femoral Access Site Complications FSH Care Suites Inservice
- 2. Advantages of Percutaneous Femoral Approach • Dominant technique • Does not require arteriotomy and arterial repair • Permits repeated site use for future angiograms • Suture closure of skin not necessary
- 3. Best Treatment - Prevention • Accurate puncture technique • Adequate compression for satisfactory initial hemostasis - Careful attention! • Some complications unavoidable • Early recognition and intervention is key
- 4. Femoral Anatomy Review • Common Femoral Artery (CFA) - Between femoral nerve (medial) and vein (lateral) • Superficial Femoral Artery (SFA) • Profunda (Deep) Femoral Artery (PFA or DFA) - Branches from SFA - Thinner walls; atherosclerotic changes more likely
- 6. Ideal Insertion Site • Below inquinal ligament • Above Common Femoral Artery (CFA) bifurcation
- 7. Seldinger Technique • Anterior and posterior a. wall pierced with needle encased in metal sheath • Both retracted into vessel, needle removed, outer cannula remains inside • Guidewire introduced through cannula • Less chance of intraluminal damage; but produces two holes in artery
- 8. Front Wall Technique for Vascular Access • Most likely route at FSH • Anterior wall pierced; needle immediately centered in artery lumen • Guidewire inserted through needle; needle removed; sheath fed over guidewire • Only one hole in artery; but greater chance for intraluminal damage
- 9. Anticoagulation During Catheterization • Two reasons - Reduce possibility of catheter-related embolic event (surface clots on catheter) - Decrease platelet aggregability to injured plaque • Aspirin - AM of procedure • Heparin - maintain ACT > 300 s • Possible Glycoprotein Inhibitors
- 10. When to Remove Sheath • Diagnostic procedures - immediately • Interventional procedures - 4-6 hr • Why delay for interventional procedures? - Give heparin time to dissipate - Ready access if coronary vessel closes abruptly
- 11. Time of Sheath Removal Important • Short-window of time between subtherapeutic anticoagulation range and rebound thrombin activation • FSH standing orders - remove sheath as soon as PTT < 50 s • Complications increase with cannulation time duration
- 12. Ways to Achieve Hemostasis • Manual Pressure • Sandbags • Pressure Dressing • C-Clamp • Femostop • Vessel Seal/Closure Device
- 13. Pressure Devices FemoStop® CompressAR®
- 14. Vessel Seal/Closure Devices Vasoseal® Perclose® Angioseal®
- 15. Patient Factors that Affect Complication Risk • Hypertension • Peripheral Vascular Disease • Smoking • Diabetes • Obesity • Anticoagulants • Advanced Age • Women
- 16. Procedural Factors that Affect Complication Risk • Size of introducer sheath • Repeated sheath changes • Length of cannulation • Post procedure heparin • Failure to achieve adequate initial hemostasis when removing sheath
- 17. Four Signs of Blood Loss or Hemorrhage at Access Site • Bulging mass in groin or thigh • Pulsatility • Bruit • Tenderness in inguinal area
- 18. Possible Complications • Retroperitoneal Hematoma or Bleed • Hematoma • Pseudoaneurysm • Arteriovenous Fistula • Neuropathy • Arterial Occlusion
- 19. Hematoma • Blood loss may necessitate transfusion • Usually resolves in 2-3 weeks; can take much longer
- 20. Hematoma Physical Findings Nursing Interventions • • Site pain/burning Manual pressure above site • • Difficulty moving hip/leg Notify MD if severe or evolving • Possible tachycardia or • hypotension VS q 15-30 min until hematoma stable, then • Red/purple skin q 2-4 hr discoloration • Outline hematoma • Measure thigh girth q 1 hr until hematoma stable, then q 4-8 hr
- 21. Pseudoaneurysm Often associated with puncture below CFA bifurcation and initial inadequate hemostasis
- 22. Pseudoaneurysm Physical Findings Nursing Interventions • • Groin pain/burning Assess VS, groin site, pedal pules, and bruit • Back pain q 15 min while enlarging, • Swelling at groin site then q 2 hr when stable • • Ecchymosis Thigh girth q 1 hr • • Pulsatile mass CBC, PTT until < 30 s • Bruit
- 23. Ultrasound-Guided Compression • Probe locates tract between artery and pseudoaneurysm; also used for pressure • Surgery when >2 cm 4-5 days after catheterization complicated by significant groin hematoma
- 24. Arteriovenous Fistula • Rare • Usually forms when needle punctures artery and vein - More likely when artery is punctured > 3 cm below inquinal ligament where veins are inferior to arteries
- 25. Arteriovenous Fistula Physical Findings Nursing Interventions • • Swelling at groin site, leg Notify MD pain • Heart and lung sounds • Possible signs high-output q 2 hr heart failure (arterial blood • Check for decreased pedal shunting into venous bed) pulses • Possible tachycardia and • Check for bruit decreased BP
- 26. Neuropathy • Rare • After large hemorrhage or pseudoaneurysm - Pressure exerts on medial and intermediate cutaneous nerve - Usually resolves when cause resolves • Late complication from chronic accumulation of fluid that causes pressure/irritability - Usually resolves when cause resolves
- 27. Neuropathy Physical Findings Nursing Interventions • • Pain, tingling at groin site Notify MD • • Numbness at site or distal Check for altered sensation leg and/or motor ability • • Motor difficulty in affected Compare reflexes and ROM leg to unaffected leg • • Possible decreased patellar In intermediate recovery phases, check VS, groin site tendon reflex and pulses per protocol, • Possible weakness of knee then q 2 hr until symptoms extension resolve • Symptoms may occur as late as 3 months post procedure
- 28. Arterial Occlusion • Very rare • Can occur from large thrombus at puncture site. Use of anticoagulants occurance unlikely. • Large catheter most likely used in a small CFA - Diabetes - Female
- 29. Arterial Occlusion Physical Findings Nursing Interventions • • Pain Notify MD • • Pallor Assess VS, leg, pedal pulses q 15-30 min until • Paresthesia circulation restored • Pulseless • Use Doppler Ultrasound for pulse assessment
- 30. Care Post (4 fr.) Sheath Removal • Site check with VS per unit protocol • Instruct patient to call nurse for any sign of bleeding and apply manual pressure to site - Apply pressure to site while coughing, laughing, or sneezing • BR for 2 hr - Light restraint on affected limb - May elevate HOB 30º
- 31. Site Assessment • Groin - How much ecchymosis and redness? - Is there any bleeding? How much? - Is there a raised mass? Does it pulsate? - Is there a bruit? • Distal extremity - CMS (Color - Motion - Sensory)
- 32. Documentation • Vital signs - HR, BP, RR, rhythm • Neurovascular checks - affected limb • Unexpected outcomes • Nursing interventions/actions taken • Evaluation
- 33. Mayo Study • Implemented a new care standard - BR 3-4 hr (vs. 6) - HOB elevation (vs. flat) - Pressure dressing (vs. sandbag) • 306 retrospective chart audits • Compared complication rates for new vs. old standards McCabe, et.al. (2001)
- 34. Minor Bleeding Mayo Study • Defined as spurting, trickling, or oozing of blood not contained by Band-aid® - Possible redressing of site and/or additional compression (not > 30 min) - BR extended for more than small ooze - No hemodynamic instability - No medical or surgical intervention McCabe, et.al. (2001)
- 35. Major Bleeding Mayo Study • Spurting or brisk bleeding not controlled by site compression - Possible hemodynamic instability - Possible need for diagnostic tests and medical or surgical consultations McCabe, et.al. (2001)
- 36. Minor Hematoma Mayo Study • Collection of extravasated blood under skin that forms a soft raised surface - easily palpable - Controlled by manual compression - No hemodynamic instability - No neurovascular compromise of affected limb - No medical or surgical intervention McCabe, et.al. (2001)
- 37. Major Hematoma Mayo Study • Collection of extravasated blood that may or may not be palpable. May occur under skin, in surrounding tissues, or extend into retroperitoneum - Some classify size > 10 cm - Increased risk for hemodynamic instability - Possible neurovascular compromise - Medical and/or surgical consultation with likely surgical intervention McCabe, et.al. (2001)
- 38. Complication Rate Mayo Study Complication No. % Hematoma - Minor 18 5.9 Hematoma - Major 9 2.9 Bleeding - Minor 13 4.2 Bleeding - Major 1 0.3 Pseudoaneurysm 3 1.0 Arteriovenous fistula 0 0.0 Thorombosis of affected limb 0 0.0 Any major complication 10 3.3 Any complication 15 11.4 McCabe, et.al. (2001)
- 39. Timing After Sheath Removal Mayo Study N = 300 Total Major 15 Number of Patients With 10 End of BR Complications 5 0 0-1 1-2 2-4 4-12 >12 Hours After Sheath Removal McCabe, et.al. (2001)
- 40. Amsterdam Study • Coronary angioplasty, stenting, or both using femoral 6 fr. approach and Heparin 5,000 IU - Also aspirin and Plavix • Manual compression followed by compression bandage • Ambulation at 2 hr
- 41. Amsterdam Study Results • N = 300 (32% stent placements) • Mean time to hemostasis = 9.6 min • 5 (1.7%) bled at ambulation • 9 had 5x5 cm hematoma at 48 hr • All treated conservatively • No late bleeding or vascular complications
- 42. U Minnesota Study (1) • How well does a 4.5 kg (36 cm x 16 cm) sandbag with cross-sectional diameter of 576 cm2 work? - It applies compression force of 3.4 g/cm2 to stop bleeding in artery with intraluminal pressure ≥ 100 mmHg • Randomized study compared complications after angiography with and without sandbags Christensen, et. al. (1998)
- 43. U Minnesota (2) Post Sheath Removal Sandbag Bandage n = 174 n = 176 Rebleeding 22 14 Ecchymosis 13 8 Hematoma 23 20 Christensen, et. al. (1998)
- 44. U Minnesota Study (3) Sandbag Bandage New fem bruit - 6 hr 0 0 New fem bruit - next AM 0 1 Ecchymosis - 6 hr 24 18 Ecchymosis - next AM 41 33 Hematoma - 6 hr 23 20 Hematoma - next AM 13 20 Christensen, et. al. (1998)
- 45. U Minnesota Study (4) Early Complications (< 24 h) Sandbag Dressing Any Bleeding 18 16 -Ooze 8 7 -Brisk Bleeding 10 9 -Other 2 1 Christensen, et. al. (1998)
- 46. U Minnesota Study (5) Late Complications (1-30 days) Sandbag Dressing 2 1 Pseudoaneurysm 1 0 AV Fistula 3 2 Late Bleeding 1 0 Stroke 1 0 Loss of Pulse 1 2 Vascular Surgery 2 2 Other Christensen, et. al. (1998)
- 47. U Minnesota Study (6) • Incidence of vascular complications not statistically significant between groups • Differences in patient satisfaction was statistically significant Sandbag Bandage n = 174 n = 176 Severe 18 4 Discomfort Moderate 6 0 Discomfort Christensen, et. al. (1998)
- 48. Comparison of Physical Findings Overview Bulging Pulsatile Bruit* Tenderness Mass Mass +/- pulse Hematoma varies no yes waves Pseudoaneurysm yes yes yes yes AV Fistula no no yes no * Some elderly adults have femoral bruits - atherosclerosis. It’s a good idea to ascultate the groin pre procedure.
- 49. Patient Scenario - AV Fistula Secondary to Pseudoaneurysm (1)
- 50. Patient Scenario - AV Fistula Secondary to Pseudoaneurysm (2)
- 51. Patient Scenario - AV Fistula Secondary to Pseudoaneurysm (3)