Critical Care Medicine-Neurologic Disorders>>>>>Acute Coronary Syndrome
Question 7#

A 76-year-old female undergoes uncomplicated coronary angiography via the right femoral artery for evaluation of a newly diagnosed cardiomyopathy. She is found to be without obstructive coronary artery disease. The patient is admitted to the intensive care unit for further monitoring.

Her femoral angiogram is shown in the figure below:

Two days following admission, the patient begins to cough. Shortly thereafter, she is observed to have sudden and rapid expansion of her right lower quadrant, with associated hypotension.

Which of the following is the most appropriate next step?

A. Computed tomography (CT) imaging of the abdomen without contrast
B. Initiation of a massive transfusion protocol
C. Manual pressure proximal to the angiography access site
D. Urgent surgical exploration

Correct Answer is C

Comment:

Correct Answer: C

Routine diagnostic coronary angiography with percutaneous coronary intervention can be performed via the radial or femoral artery. The radial artery approach carries similar procedural success with lower rates of bleeding and vascular complications compared to the femoral artery. When femoral artery access is utilized, cannulation of the common femoral artery (CFA) should occur above the femoral artery bifurcation and below the internal epigastric artery. This target can be identified fluoroscopically by visualizing the femoral head, which typically lies above the CFA bifurcation and below the internal epigastric artery and permits easy compression of the common femoral artery following the procedure. In patients with a “high stick,” that is a stick arterial puncture site at or above the superior border of the femoral head, there is an increased risk of retroperitoneal bleeding. Conversely, “low sticks” at or below the inferior border of the femoral head carry an increased risk of pseudoaneurysm formation.

Access site bleeding should be suspected in postprocedural patients with hypotension, lower abdominal or back pain, or rapidly expanding hematoma. The first step in managing active hemorrhage centers on primary bleeding control with manual compression of the common femoral artery. Thereafter, anticoagulation should be reversed and blood products should be administered. Computed tomography of the abdomen can be utilized when the diagnosis is uncertain and hemodynamic parameters have stabilized. While most bleeding stops with manual pressure, surgical exploration can be considered following failure of manual compression.

References:

  1. Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and outcomes of radial and femoral approaches to percutaneous coronary intervention: a report from the National Cardiovascular Data Registry. JACC Cardiovasc Interv. 2008;1(4):379-386.
  2. Mason PJ, Shah B, Tamis-Holland JE, et al. An update on radial artery access and best practices for transradial coronary angiography and intervention in acute coronary syndrome: a scientific statement from the American Heart Association. Circ Cardiovasc Interv. 2018;11:e000035.