A 67-year-old man undergoes coronary angiography due to stable angina and a positive stress test. Medical history is notable for type 2 diabetes mellitus, hypertension, and peripheral arterial disease. Access is obtained through the right femoral artery, and a high-grade lesion is diagnosed in the mid left anterior descending artery. A drug-eluting stent is successfully placed. After the procedure, the femoral arterial sheath is removed and manual compression is applied. The patient is discharged the next morning. Two days later, he comes to the office for follow-up due to right groin pain and discomfort that he thought would be gone by now. He has no chest pain, dyspnea, lightheadedness, or abdominal pain. The patient has been taking dual antiplatelet therapy prescribed on discharge. Blood pressure is 118/74 mm Hg and pulse is 82/min. Physical examination shows mild swelling and bruising of the right groin with accentuated pulsation. Skin color and perfusion are normal over both lower extremities. Popliteal and dorsalis pedis pulses are symmetric. Which of the following is the best next step in management of this patient?

Question

A 67-year-old man undergoes coronary angiography due to stable angina and a positive stress test.  Medical history is notable for type 2 diabetes mellitus, hypertension, and peripheral arterial disease.  Access is obtained through the right femoral artery, and a high-grade lesion is diagnosed in the mid left anterior descending artery.  A drug-eluting stent is successfully placed.  After the procedure, the femoral arterial sheath is removed and manual compression is applied.  The patient is discharged the next morning.  Two days later, he comes to the office for follow-up due to right groin pain and discomfort that he thought would be gone by now.  He has no chest pain, dyspnea, lightheadedness, or abdominal pain.  The patient has been taking dual antiplatelet therapy prescribed on discharge.  Blood pressure is 118/74 mm Hg and pulse is 82/min.  Physical examination shows mild swelling and bruising of the right groin with accentuated pulsation.  Skin color and perfusion are normal over both lower extremities.  Popliteal and dorsalis pedis pulses are symmetric.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be61_4974_8f63_1795bee943c3_MD0005_00 This patient with persistent pain, swelling, and accentuated pulsation near the access point for recent cardiac catheterization likely has a pseudoaneurysm of the right common femoral artery. Pseudoaneurysm occurs when bleeding from an inadequately sealed arterial puncture site remains confined within the periarterial connective tissue. The result is a contained hematoma that has ongoing communication with the arterial lumen. Diastolic pressure equalizes between the artery and the confined hematoma, resulting in blood flow in and out of the hematoma cavity with systole. An arterial pseudoaneurysm usually presents as a tender, pulsatile mass with a systolic bruit, and the diagnosis is confirmed by ultrasonography. Small pseudoaneurysms can be treated with ultrasound-guided compression or thrombin injection into the pseudoaneurysm cavity. Larger or rapidly expanding pseudoaneurysms are at risk of rupture and should be managed with surgical repair. diagnosis is confirmed The main risk factor for pseudoaneurysm formation is inadequate post-procedural manual compression to achieve arterial hemostasis. (Choice A) Femoral arteriovenous fistula presents with localized pain, no mass, and a continuous bruit, and is sometimes evaluated by lower extremity angiography if initial ultrasonography is incompletely diagnostic. Angiography can also be used to evaluate for femoral artery dissection or thrombosis in a patient with evidence of distal leg ischemia. This patient has intact lower extremity pulses and angiography is not indicated. (Choice B) Noncontrast CT scan of the abdomen and pelvis is indicated for suspected retroperitoneal hematoma, a serious complication of cardiac catheterization that involves massive extension of post-procedural arterial bleeding. The condition presents with rapidly developing hemodynamic instability and ipsilateral flank or back pain, both of which this patient lacks. (Choices C and D) Reassurance and symptomatic treatment alone is appropriate for a small, localized hematoma (evidenced by non-pulsatile swelling and no bruit); however, it is not appropriate for pseudoaneurysm, which carries the risk of expansion, rupture, and catastrophic bleeding. Temporary discontinuation of dual antiplatelet therapy carries significant risk of stent thrombosis in this patient with a drug-eluting stent placed 2 days previously, and is not recommended in the absence of life-threatening bleeding. drug-eluting stent Educational objective: Pseudoaneurysm is a potential complication of arterial access for cardiac catheterization; it occurs when arterial bleeding remains confined within the periarterial connective tissue, resulting in a contained hematoma that communicates with the arterial lumen. Patients typically have a tender, pulsatile mass with a systolic bruit at the puncture site, and the diagnosis is confirmed by ultrasonography. References: Contemporary management of postcatheterization pseudoaneurysms. (http://www.ncbi.nlm.nih.gov/pubmed/17515479) Access site complications following cardiac catheterization assessed by duplex ultrasonography. (http://www.ncbi.nlm.nih.gov/pubmed/18756886) Incidence and outcome of femoral vascular complications among 18,165 patients undergoing cardiac catheterisation. (http://www.ncbi.nlm.nih.gov/pubmed/18617281)

A 67-Year-Old Man Undergoes Coronary Angiography Due to Stable Angina