1. 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

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

3. 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

4. PVD Uncontrollable risk factors
Diabetes
Age
Gender
Family history

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

6. Signs and Symptoms Pain Pallor Pulselessness Coolness Paresethesia
Paralysis

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

8. 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)

10. Stent procedure

11. 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

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

13. 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.

14. Anatomy

15. Angiogram Femoral

17. 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

18. 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

19. Other access sites…..
Brachial
Radial

20. Popliteal Artery

21. Axillary artery

22. Femoral approach to cardiac cath & vascular arteriogram

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

24. 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.

25. Contralateral approach

26. 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

27. 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

28. 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

29. 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

30. 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..

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

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

33. 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 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.

34. Distal Pulse Check Sites
Dorsal Pedis
Post Tib
Pop
Radial

35. Dorsal Pedis

36. Post Tib

37. Post Brachial access check radial

39. For antegrade sticks hold above
And on the site

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

41. Pre angioseal Femoral angiogram
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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.

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

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

46. 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

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

48. 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

49. CT of a severe femoral hematoma

50. 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

51. CT of a retroperitoneal bleed

52. 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

54. 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.

55. 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

56. 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)

57. 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.

58. Nurse to patient instructions
Head of bed may be elevated 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

59. 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.

60. 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.

61. 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.

62. Questions??