A 56-year-old man complains of pain in his right groin 3 days after cardiac catheterization. He underwent the procedure after 2 months of intermittent chest pain. The coronary angiogram showed mild nonobstructive coronary disease. He has no fever, chest pain, leg numbness, or cold feet.
Vital signs are normal. The puncture site at the right femoral artery shows no erythema or ecchymosis. A tender mass is palpated below the right inguinal ligament near the puncture site. Bilateral popliteal and posterior tibial pulses are full.
Which of the following is the best next step in management of this patient?

Question

A 56-year-old man complains of pain in his right groin 3 days after cardiac catheterization.  He underwent the procedure after 2 months of intermittent chest pain.  The coronary angiogram showed mild nonobstructive coronary disease.  He has no fever, chest pain, leg numbness, or cold feet.
Vital signs are normal.  The puncture site at the right femoral artery shows no erythema or ecchymosis.  A tender mass is palpated below the right inguinal ligament near the puncture site.  Bilateral popliteal and posterior tibial pulses are full.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

The presence of a painful, tender mass near the puncture site below the right inguinal ligament after an endovascular intervention is suggestive of hematoma with pseudoaneurysm formation. Local vascular injuries at the site of catheter insertion are the most common complications associated with cardiac catheterization. These include hemorrhage or hematoma formation in the groin or retroperitoneal space, arterial dissection, arterial thrombosis, pseudoaneurysm, and formation of arteriovenous fistula. The patient should have a Doppler ultrasound to assess for the presence of hematoma and/or pseudoaneurysm formation. An arterial pseudoaneurysm is a hematoma that remains in continuity with the arterial lumen with blood flow into and out of the hematoma cavity. It is usually detected by the presence of a pulsatile mass with a systolic bruit over the mass; diagnosis is confirmed by duplex ultrasonography. Pseudoaneurysms are at risk of expansion and rupture and should be treated with ultrasound-guided compression or ultrasound-guided thrombin injection into the pseudoaneurysm cavity. (Choice B) This patient likely has a pseudoaneurysm at the catheter insertion site, and needle aspiration is contraindicated. Ultrasound of the mass should be performed first to assess for an arterial pseudoaneurysm. (Choice C) Noncontrast CT scan of the pelvis is occasionally performed in patients with suspected retroperitoneal hemorrhage (eg, back pain, hypotension). This patient has no such indications. (Choice D) There are no signs of infection (no erythema or fever), and oral antibiotics are not indicated at this time. Pseudoaneurysms rarely can become infected and require intravenous antibiotics and surgical debridement. Other indications for surgical management of pseudoaneurysm include rapid expansion, large size causing compression or skin necrosis, and failure of thrombin injection. (Choice E) A pseudoaneurysm can continue to expand, with the risk of rupture and catastrophic bleeding. Reassurance and local compresses alone without further evaluation are inappropriate. Educational objective: Pseudoaneurysm formation and/or rupture is a potentially catastrophic vascular complication of cardiac catheterization. Patients with a tender or pulsatile mass at the catheter insertion site should be evaluated by duplex ultrasonography to assess for pseudoaneurysm. __________

A 56-Year-Old Man Complains of Pain in His Right Groin