01 Nov 2018
Large retroperitoneal bleed despite state-of-the-art femoral access
Consult this Twitter case concerning a 83-year-old female with progressive symptoms admitted for complex angioplasty of distal left main
There is conventional knowledge stating that retroperitoneal bleeding, a potentially life-threatening complication of femoral access, is a consequence of a high puncture. We highlight a case in which arterial access was not high based on multiple image modalities, single arterial puncture and still developed severe retroperitoneal bleeding and pseudoaneurysm.
This case was originally published on Twitter by @lamelaspablovia #CardioTwitterCase
Clinical presentation
83-year-old female with progressive symptoms admitted for complex angioplasty of distal left main.
Case Management
A 7 Fr sheath was inserted in the first attempt into the common femoral artery using echocardiography guidance and fluoroscopic check of needle tip in mid femoral artery (Figure A). After the procedure, she received full heparin reversal with intravenous protamine (1mg for every 100 units of heparin), successful Exoseal deployment and underwent 10 minutes of femoral compression as per protocol. Hemostasis was achieved and a pressurized bandage was left in the groin. Patient developed mild hypotension after the procedure and drop in hemoglobin so a computed tomography with intravenous contrast was done showing retroperitoneal bleeding (Figure B) and arteriotomy at the mid-femoral head level with a pseudoaneurysm (Figure C). Patient was transfused and was discharged 5 days later.
Summary
This case highlights the risks of severe bleeding despite state-of-the-art precautions and management in femoral access.
Original tweet and Twitter discussion
Life-threatening complications of Femoral access still happen with "perfect technique". 2 retroperitoneal bleeds in last 2 wks despite echo and fluoro guided in both cases, single poke, common fem at mid fem head level #RadialFirstpic.twitter.com/CSWsQzoDZH
— Pablo Lamelas (@lamelaspablo) 30 septembre 2018
2 comments
What's emergency manage
What was the antiplatelte regimen used? We have seen some cases developing femoral site hematoma and pseudoaneurysm despite using imaging guidance , among underweight women who recieved ticagrelor loading. Does usage of newer antiplatelets assocaited with higher risk of access site complications?