0:01

So let's talk about potential complications

0:03

and ways to minimize the risk of complications

0:05

during vascular access via case examples.

0:08

So we explored some potential

0:09

complications of each access site today.

0:11

So the following cases will explore various

0:14

complications. We're going to discuss pearls

0:15

to avoid such complications, and we're going

0:17

to show how to manage these complications.

0:19

So let's start with hematoma complications.

0:22

So we have an 82-year-old woman in this particular

0:24

case, with a history of diabetes and hypertension.

0:27

So her history is one that suggests

0:30

that she has high vascular comorbidities.

0:34

She's recovering in observation after a diagnostic

0:36

angiogram with a common femoral artery access.

0:39

Her procedure was pretty uncomplicated other

0:41

than that she had prolonged bleeding after

0:43

withdrawal of the sheath during closure.

0:45

You receive a call because she has excessive

0:47

bruising and swelling at the left common

0:48

femoral arterial access site, which is, so

0:51

this is what the CT scan demonstrates.

0:54

Not a good look, fat stranding.

0:57

So what's the situation here?

1:00

Not quite fat stranding—bleeding, dissecting

1:04

into the soft tissues surrounding the access.

1:06

So you're concerned about left groin

1:09

hemorrhage in a patient who has a hematoma

1:11

that is vascular access associated.

1:14

So the question is, is there a

1:15

pseudoaneurysm underneath this little guy?

1:17

So what are some risk factors for developing

1:20

hemorrhage and hematoma formation in our patient?

1:22

Well, you know, in this 82-year-old woman,

1:24

she has diabetes, she has high blood

1:26

pressure, she has a 20-pack-year smoking

1:28

history. Again, she's a vasculopath.

1:30

From the standpoint of her comorbidities.

1:32

She had prolonged bleeding after

1:34

withdrawal of the sheath during closure.

1:36

She's a little bit sort of larger

1:38

in terms of her body habitus.

1:40

And so these are things that I think would

1:42

probably increase her risk

1:46

profile as it relates to complications.

1:50

If she was taking antiplatelets, you know, that would

1:52

clue us in to other risks.

1:53

Anticoagulation is another risk.

1:59

So how does active hemorrhage actually present?

2:01

What we notice is a

2:03

serial decrease in hemoglobin.

2:05

Of course, if we're monitoring the patient,

2:08

we can see tachycardia, a decrease

2:11

in blood pressure, dizziness, clinically

2:14

subjective reports from the patient,

2:17

orthostatic hypotension, which could be

2:20

presyncopal, and other clinical manifestations.

2:22

Or ipsilateral regional pain.

2:25

What imaging is useful for diagnosis

2:27

of hemorrhage and hematoma?

2:29

CT scans have a high

2:30

sensitivity relative to ultrasound.

2:32

They are very good at identifying the location

2:34

of bleeding, the size of the hematoma, and the

2:37

presence of any other concomitant injuries.

2:40

So when we're using a CT scan, it

2:41

provides a nice bird's-eye view of

2:43

regions that may be poorly accessible by

2:45

ultrasound, such as retroperitoneal spaces.

2:48

So how can we mitigate the

2:49

risk of hematoma formation?

2:52

So resistance to sheath and catheter

2:55

advancement should really prompt us

2:57

to say, "Let's inject a little bit of contrast

2:59

and see what's going on." If we can get

3:01

blood return and if there's any resistance, in general,

3:06

we shouldn't really bypass; we should

3:09

work this up and really understand what's

3:11

happening. We want to pause and evaluate

3:14

every situation that just doesn't feel right. So

3:18

if we do get a hematoma, how do we manage it?

3:21

So if we develop hemorrhage or

3:24

some sort of expanding hematoma,

3:26

they should be treated immediately.

3:28

There is concern for compartment syndrome.

3:30

And this is something that we want

3:31

to be very suspicious of, okay?

3:35

Large hematomas can be treated

3:36

with a blood pressure cuff to the

3:37

forearm or pressure dressings.

3:40

And that is something that deserves to

3:42

be noted, managed, and/or corrected.