Femoral artery hemorrhage

Retroperitoneal hematoma following cardiac catheterization is an infrequent but significant complication with a worldwide incidence of 0.15%.

The true incidence may be higher than 0.15% , as most cases are undereported or unrecognized.

The common femoral artery is the most frequently used access site for percutaneous coronary angiography and interventions.

A retroperitoneal hematoma may be associated with femoral artery puncture with or without the use of a closure device after the intervention.

Caused by inadvertent puncture of the posterior wall of the femoral or iliac artery during cannulation.

Bleeding may be exacerbated by the fact that most coronary patients are likely to receive antiplatelet therapy in the form of aspirin, clopidogrel or dipyridamole, and are being anticoagulated with heparin.

Highest frequency of this complication may be seen after coronary artery stenting when the sheaths utilized to cannulate the artery are of large caliber.

Higher risk in females due to smaller artery size, in the presence of thrombocytopenia, anticoagulant use, obese individuals, patients with hypertension, individuals over the age of 70 years, and those undergoing multiple procedures and multiple sticks.

High femoral artery puncture is associated with higher risk of retroperitoneal hemorrhage.

Higher risk of hemorrhage seen in patients with peripheral arterial disease.

The presentation may be vague, and diagnosis is often delaye.

Uncontrolled bleeding in the retroperitoneum initially exhibit very subtle clinical signs of hemorrhage.

Hypotension and tachycardia that transiently improves with administration of fluids suggests the diagnosis.

Patients may be unable to mount tachycardia in the presence of beta-blocker usage.

Patients may have back, lower abdominal or groin discomfort and swelling.

Patients may progress to hemodynamic instability, collapse, diaphoresis and progressive anemia.

Retroperitoneal hematoma near or within the iliopsoas muscle usually presents as femoral neuropathy, with groin pain, and leg weakness.

CT scans play an important role in the diagnosis of retroperitoneal hematoma as it is highly sensitive, with the hematoma appears as an abnormal soft tissue density which compresses adjacent normal structures.

CT angiography may show the site of the bleed.

Management includes careful monitoring, fluid resuscitation, blood transfusion and normalization of coagulation factors.

Hemodynamically stable patients with no evidence of on-going bleeding conservative management is recommended.

Growing trend in the use of endovascular techniques as an alternative to open surgery in the management of retroperitoneal hemorrhage, using intra-arterial embolization.

Embolization uses a combination of agents, such as coils, gelatin and/or polyvinyl alcohol, and indications for use are based on the haemodynamic stability of the patient and the degree of blood loss.

Closure of arteriotomy site is usually achieved by manual compression.

Vascular devices are implanted to close the arteriotomy site of the vessel wall by targeted force.

Vascular closing devices may be intra or extra vascular.

Vascular closing devices have increased efficacy compared to manual compression.

Vascular closing devices may have increased vascular complinations such as groin hematoma, and , arterial pseudo aneurysm in comparison with manual compression.

There was once a view that all retroperitoneal haemorrhage should be treated conservatively, as it was believed that open surgery may disturb the tamponade effects of the retroperitoneum.

Open surgery is indicated if the patient remains unstable despite adequate fluid and blood product resuscitation, or if interventional radiology is not successful or unavailable.

These patients are inevitably critically ill.

The coagulopathy should be totally corrected prior to surgery.

The primary aim for surgery is to control all actively bleeding points, and the secondary aim is to remove the large hematoma.

The retroperitoneum may need to be packed and re-explored at 24-48 h.

Another indication for open surgery is the development  abdominal compartment syndrome as a result of the large retroperitoneal hematoma.

If untreated, patients may develop signs of increased intra-abdominal pressure with impaired respiratory, cardiovascular and renal function.

Once these complications have developed, urgent decompression of the abdomen is indicated.

Measurement of intra-abdominal pressure can be easily performed via a urinary catheter.

Surgery is often guided by preoperative CT findings.

An upper abdominal midline supra-mesocolic retroperitoneal haematoma is associated with bleeding from the supra-renal aorta, coeliac axis or the superior mesenteric artery.

The mid-abdominal midline infra-mesocolic retroperitoneal hematoma is associated with proximal renal artery, infra-renal aorta or caval injury.

A peri-nephric hematoma is associated with renal artery rupture.

A midline hematoma is mostly associated with pelvic fracture, bladder injury or iliac vessel injury.

A right lateral retroperitoneal haematoma suggests a high infra-renal or retro-hepatic caval injury, which is associated with hepatic injury and a high mortality.

Retroperitoneal hemorrhage is a rare clinical entity which requires a high index of clinical suspicion.

If treated inappropriately, retroperitoneal bleeding is associated with high morbidity and mortality.

It should be suspected in elderly patients by anticoagulants or renal dialysis and those patients who have had an invasive procedure via the femoral artery or vein.

Correction of underlying coagulopathy and resuscitation with fluids and blood products is essential.

CT imaging is mandatory to document the type, site and extent of the haematoma.

Most patients with spontaneous or iatrogenic retroperitoneal haematoma can be monitored closely and treated conservatively without further intervention.

Emergency angiography with a view to embolize or stent-graft the bleeding vessel(s) is indicated if the CT examination shows active extravasation of contrast.

Surgery with removal of the hematoma may increase bleeding by removing the tamponade effect, and packing with large abdominal gauze may be the only surgical option,

Abdominal compartment syndrome may require decompression laparoscopy.


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