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Femoral Access Complications Prevention
- 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) ⢠SuperďŹcial 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 FemoStopÂŽ CompressARÂŽ
- 14. Vessel Seal/Closure Devices VasosealÂŽ PercloseÂŽ AngiosealÂŽ
- 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 ⢠⢠DifďŹculty 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 signiďŹcant 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 ďŹuid 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 difďŹculty in affected Compare reďŹexes and ROM leg to unaffected leg ⢠⢠Possible decreased patellar In intermediate recovery phases, check VS, groin site tendon reďŹex 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. ďŹat) - 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 ⢠DeďŹned as spurting, trickling, or oozing of blood not contained by Band-aidÂŽ - 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 ďŹstula 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 ⼠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 signiďŹcant between groups ⢠Differences in patient satisfaction was statistically signiďŹcant 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. Itâs 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)