GROIN MANAGEMENT by Josh Marshall, RTR, RCIS. Trish O’Sullivan, RN. OBJECTIVES IDENTIFY FEMORAL ARTERY, AND WHY IT’S COMMONLY USED FOR ACCESS. LOOK AT OTHER ACCESS SITES. CURRENT METHODS FOR GROIN HEMOSTASIS MANAGEMENT OF PATIENT FOLLOWING SHEATH PLACEMENT AND REMOVAL COMPLICATIONS AND WARNING SIGNS POST PROCEDURE CARE FROM A NURSING PERSPECTIVE

What is Angiography? An x-ray exam of the blood vessels using contrast media to diagnose blockages and other blood vessel problems

What is PVD PVD is a disease of the blood vessels outside of the heart and brain. It is a common circulation problem in which arteries that carry blood to the legs or arms become narrowed or clogged. PVD is also referred to as peripheral arterial disease or PAD. Atherosclerosis is the predominant factor contributing to PAD. It is gradual, progressive and irreversible process directly related to risk factors. 3

PVD Uncontrollable risk factors Diabetes Age Gender Family history

PVD Risk factors…Cont Modifiable risk factors Cigarette smoking High lipid diet HTN Sedentary lifestyle

Signs and Symptoms Pain Pallor Pulselessness Coolness Paresethesia Paralysis

Objective signs in patients with PVD Leg hair loss Callus formation Ulceration Tissue loss Gangrene Impotence

Indications for Angiography Diagnosis of PVD Pre op definition of vascular anatomy. Access for endovascular therapy which include: PTA STENTING ATHRECTOMY THROMBOLYTIC THERAPY EMBOLIZATION (These procedures are often done in conjunction with one another)

Stent procedure

Athrectomy CSI Diamond back is used to change vessel compliance and allow optimal results from PTA balloons, by de-bulking hard clacific and other types of blockages from blood vessels

Pre procedure Management Indication for study Review Med Surg history Lab data Current meds Allergies NPO status ABI Consent Education

On the with the case!!! Pt prepped and draped. attached to Monitor system. Local anesthetic for access site. Medications given for sedation or necessary pre-treatment.

Anatomy

Angiogram Femoral

Femoral access Most common method is the Seldinger technique. Used mostly in the cath lab 1-2cm below the inguinal ligament in the common femoral above the bifurcation of profunda and SFA Cutdown technique…. not so common

Why we use the femoral artery Large caliber vessel anywhere from 4-6mm large enough to use large sheaths. Compressible over the femoral head high sticks can cause retroperitoneal bleeds and low sticks have been linked to psuedoaneurysm, and AV fistulas Body habitus factors into sheath placement at times

Other access sites….. Brachial Radial

Popliteal Artery

Axillary artery

Femoral approach to cardiac cath & vascular arteriogram

Catheter placement For an Ao gram is just above The Renal arteries.

Antegrade V.S. Retrograde Retrograde: going against the flow of blood. ( as seen with heart caths and most vasculars) Antegrade: Going with the flow of blood. (as seen with vascular cases) Note that an arterial stick above the inguinal ligament could result in a life threatening retroperitoneal bleed. Pay close attention to patients with antegrade sticks!!!! Question back pain and Changes in BP/vital signs.

Contralateral approach

Reasons for complications Technique (ie. multiple sticks, Lack of pulse assessment) Antiplatlet & Anti-thombotic adjunctive treatments (Important to note patient INR results) Patient complexity Female gender Obesity vs. low Body mass index Age Catheter size Bad luck

Facts Estimated that 5-10% of all arterial access will result in a hematoma, infection, pseudoaneurysm, or retroperitoneal bleed. Most complications are from initial puncture or insertion of sheath Specific problems include…vessel thrombosis, dissection, poorly controlled bleeding at site Management of these problems is challenging with the use of anticoagulation

How to minimize risk!!! Patient history- past procedures (scar tissue) surgeries, and response to medications, INR results 1.5 and below is considered safe for access. Knowledge of co morbidities such as: diabetes Hypertension Stroke Smoking PVD Elderly, females, and low body weight

Co-morbid conditions Diabetes- patients usually have small diffuse arteries which are prone to disease and are also at risk for infection Hypertension-Are at risk for bleeding with sheath insertion and removal. Anti-hypertension medication may be required to stabilize the blood pressure prior to sheath removal. Multiple procedures- Re-access is not only uncomfortable but difficult for operator to penetrate the subcutaneous scar tissue, which could cause the sheath to bend or break upon insertion into artery

Co-morbid Conditions Cont. Thin patients- minimal tissue for secure sheath placement and homeostasis post sheath removal can be difficult Atherosclerosis- patients with extensive vascular disease have brittle or friable vessels, which are not only difficult to access but can also lead to distal embolization due to calcification. Tortuous iliac artery- requires careful sheath insertion and a longer sheath may be necessary to bypass the the tortuosity. Obesity-the position of the inguinal ligament to skin crease, may be misleading. Often large panis must be taped up or moved for access, and groin hold can be challenging for operator Known PVD, or CAD. This information will help make assessment of access sites easier to understand..

Distal Aortic disease Femoral pulses could be weak or absent, ultrasound may be used for access

Methods of hemostasis Manual compression (gold standard) Mechanical compression (femstop) Vascular closure devices such as Angioseal, Mynx Hemostatic patches (D-stat dry patches)

Rules for manual compression check the site for hematoma and distal pulses. Post Tib and DP for groin access, and radial for brachial access. Manual compression above sheath access point. 15-20 min is normally adequate. Note patients starting BP and heart rate. Patients can vagal during sheath pulls. ( atropine , fluids, trendelenburg) If hematoma occurs firm compression is best first response.

Distal Pulse Check Sites Dorsal Pedis Post Tib Pop Radial

Dorsal Pedis

Post Tib

Post Brachial access check radial

For antegrade sticks hold above And on the site

Use of Vascular closure devices in the Lab. Reduce time to ambulate Reduce time to discharge Improve Patient satisfaction Can Reduce cost

Pre angioseal Femoral angiogram xxxxxxxxxxxxxx xxxxxxxxxx xxxxxxxxxxx xxxxxxxxxxxxx Placement depends upon: 1. Sheath in non-diseased segment of femoral artery 2. Above the bifurcation of the SFA, and Profunda, 3. Vessel is of large enough caliber.

Vascular closure device limitations Pvd Bifurcation sticks Re-access issues Small femoral vessel Obesity/ low BMI Double wall sticks

Femoral artery complications with vascular closure device Bleeding Embolization: device or collagen Direct vessel trauma Vessel occlusion infection

Predictors of access site complications Anticoagulant used- heparin, GP11b/111a, high INR’s Patient demographics/ underlying co-morbidities Sheath insertion technique, multiple sheath insertions. Sheath removal technique Poor manual compression Improper use of mechanical devices Closure device failure

Angiographic complications Neurological Puncture site ( more detail to follow) Catheter thrombosis Contrast induced allergy/ anaphylaxis Contrast induced renal failure infection

Hematoma Swelling, enlarged area usually around the access site, may or may not be associated with strong bleeding Possible source: Multiple sticks, posterior wall stick Inadequate manual compression Action Firm compression over site, or possible surgical intervention

CT of a severe femoral hematoma

Retroperitoneal bleed Although rare 0.75%, is a potentially fatal complication The bleeding occurs inside the peritoneal cavity. Patients often complain of back/ flank pain and will have changes in vital sings ie.. Drop in Bp, and changes in mentation: confusion, lethargy Sources: high stick, posterior wall stick, female gender, low body surface area

CT of a retroperitoneal bleed

Psedudoaneurysms Sometimes referred to as a false aneurysm The are vascular anomalies where a collection of blood begins to form within the intimal arterial wall. Generally evident within 12 hrs of the procedure. Symptoms include groin pain, or pulsatile mass, may hear a bruit

AV Fistula A communication between artery and vein caused by a puncture Many are small and resolve. Typically asymptomatic, However surgical repair is required to fix enlarging fistulas Often associated with low puncture site in the Sfa or profunda arteries.

Post procedure care nursing standpoint What you need to know: Closed? Sheath size Anticoagulant used? Heparin, ect… Closing act Puncture issues Vital signs Distal pulses

Vasovagal reaction Is caused by stimulation of the Vagus nerve. Which triggers the parasympathetic nervous system. (decreases the sympathetic) PT symptoms: A. hypotension B. Bradycardia C. Sweaty, nausea, diaphoretic Treatment: Fluids, atropine, reverse trendelenberg, less pressure at site, and Discontinue meds that lower BP (NTG)

Nursing care and patient assessment Check arterial access site for bruising, bleeding, swelling, and hematoma Assess presence and quality of distal pulses Lower extremity for: color, temp, sensation, and movement Check vital’s per protocol Keep site clean and dry Ok to change dressing if pt oozes.

Nurse to patient instructions Head of bed may be elevated 30-40 degrees Pt must keep head flat on pillow and effected leg straight. Pt should support puncture site when coughing, straining, or sneezing and should alert nurse if sensation of bleeding occurs

If bleeding occurs Do not leave the patient, apply firm pressure to the site. If hematoma is present, mark the boundaries with a marker Bed rest will start over once hemostasis has occurred. Notify physician of status change with Pt.

If bleeding occurs (cont)…. Regardless of the type of arterial access (Antegrade or Retrograde) you want to hold manual pressure just above the insertion site until the bleeding stops. The only exception to this is in the case of a high antegrade stick (this access site will be in the mid to low abdominal area). In this case, you will hold pressure below the site. If the bleeding is venous in origin, hold pressure just below the access site. It will take less time to re-establish hemostasis with this, thus less time holding pressure.

Post procedure care - Vital signs per orders/ Distal pulse check Q 15min - 4-6hr post manual hold 1-2 hr closure device Diet Elimination( watch for full bladder) Written discharge instructions Ambulation - Avoid strenuous activity, no driving for 24hrs, limit lifting until site heals Bruising may be seen at site, even without a hematoma.

Questions??