A 62-year-old man comes to the office for a follow-up visit a week after undergoing percutaneous coronary intervention. In the past 2 months, he has had several episodes of retrosternal chest pain, and a myocardial perfusion scan revealed an area of reversible ischemia on the lateral wall. Coronary angiography was performed through a right femoral access, and a drug-eluting stent was placed in the left circumflex artery. The patient has had some discomfort in the right groin since the procedure. He has had no further episodes of chest pain or dyspnea. Other medical issues include hypertension and hyperlipidemia. The patient has smoked a pack of cigarettes daily for 35 years and stopped smoking after he was diagnosed with heart disease. Temperature is 37.1 C (98.8 F), blood pressure is 130/70 mm Hg, and pulse is 86/min. Heart sounds and lung auscultation are normal. There is mild swelling in the right inguinal area with a palpable thrill and a continuous murmur on auscultation. Lower extremity deep tendon reflexes are normal. Which of the following is the most likely cause of this patient's current findings?

Question

A 62-year-old man comes to the office for a follow-up visit a week after undergoing percutaneous coronary intervention.  In the past 2 months, he has had several episodes of retrosternal chest pain, and a myocardial perfusion scan revealed an area of reversible ischemia on the lateral wall.  Coronary angiography was performed through a right femoral access, and a drug-eluting stent was placed in the left circumflex artery.  The patient has had some discomfort in the right groin since the procedure.  He has had no further episodes of chest pain or dyspnea.  Other medical issues include hypertension and hyperlipidemia.  The patient has smoked a pack of cigarettes daily for 35 years and stopped smoking after he was diagnosed with heart disease.  Temperature is 37.1 C (98.8 F), blood pressure is 130/70 mm Hg, and pulse is 86/min.  Heart sounds and lung auscultation are normal.  There is mild swelling in the right inguinal area with a palpable thrill and a continuous murmur on auscultation.  Lower extremity deep tendon reflexes are normal.  Which of the following is the most likely cause of this patient's current findings?

Quizplus · Accepted Answer

11ec25c8_d8a3_72f5_bc81_ef734f752112_MD0003_00 The femoral artery is the most common vascular access point in patients undergoing cardiac catheterization. A number of local complications can occur; this patient has likely developed an arteriovenous fistula (AVF). The femoral vein can be inadvertently punctured during needle insertion attempts to obtain femoral arterial access. Following the procedure, inadequate hemostasis may allow persistent bleeding from the arterial puncture site to track into the venous puncture site, creating an AVF. Most patients are initially asymptomatic but gradually develop mild swelling and localized tenderness. As arterial pressure exceeds venous pressure throughout the cardiac cycle, a continuous bruit with a palpable thrill is typically present. In addition, distal pulses may be diminished in the affected extremity. An untreated AVF can progressively enlarge and lead to limb edema (due to venous hypertension), limb ischemia (due to redirection of arterial blood flow), and high-output heart failure (due to blood returning to the right atrium without passing through peripheral resistance). The diagnosis is typically confirmed by duplex ultrasound. Management of small AVFs involves observation (sometimes resulting in spontaneous closure) or ultrasound-guided compression. Large AVFs typically require surgical repair. (Choice B) Femoral artery pseudoaneurysm develops when an inadequately sealed arterial puncture site leads to a hematoma contained within periarterial connective tissue. Ongoing communication with the arterial lumen creates a tender, pulsatile mass with an audible systolic (rather than a continuous) bruit. (Choices C and G) Atherosclerotic arterial occlusion and deep venous thrombosis are not typical complications of cardiac catheterization, and a continuous bruit with a palpable thrill would not be expected. (Choice D) A potentially fatal complication of cardiac catheterization is an expanding hematoma with extension into the retroperitoneum. Patients typically have flank pain and hypotension within 24 hours of the procedure. (Choice E) Iatrogenic peripheral nerve injury can occur during vascular access due to close proximity of the femoral artery and femoral nerve. Discomfort or paresthesias in the ipsilateral thigh accompanied by patellar tendon hyporeflexia would be expected. femoral artery and femoral nerve (Choice F) Femoral artery dissection (separation of arterial wall layers) can occur following vascular access. Patients may be asymptomatic or develop symptoms of acute lower extremity ischemia (eg, pain, pallor). However, a bruit or thrill is not typical. Educational objective: An arteriovenous fistula can develop as a complication of vascular access during cardiac catheterization. Patients typically have mild localized pain and swelling and a continuous bruit accompanied by a palpable thrill over the fistula site. References: Access site complications following cardiac catheterization assessed by duplex ultrasonography. (http://www.ncbi.nlm.nih.gov/pubmed/18756886)

A 62-Year-Old Man Comes to the Office for a Follow-Up