PCI—arterial access complications

Complications that arise following a PCI can be difficult to spot. In this video, you'll learn how to identify and manage PCI complications such as pseudoaneursyms, hematomas, retroperitoneal hemorrhage, and distal embolization.

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PCI complications: pseudoaneurysm 

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Pseudoaneurisms, or false aneurisms, can form in any part of the arterial circulation as a result of iatrogenic trauma weakening the wall. They are characterized by swelling, pulsation, pain, and bruits on auscultation. An urgent ultrasound should be requested to confirm the presence of a pseudoaneurysm.

Ultrasound for pseudoaneurysm

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Pseudoaneurisms can initially be managed symptomatically with analgesia. They can then be manually compressed, preferably under ultrasound guidance, or injected with thrombin if they have a narrow neck, or treated surgically. Surgery should, however, be avoided if possible as ordinarily, the patient will be on dual antiplatelet therapy.

PCI complications: hematoma

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Hematoma is a common complication associated with arterial access as well as the use of anticoagulant and antiplatelet agents all utilized in PCI. They're usually mild and self-limiting, but can look fairly alarming to the patient. Very rarely, if extensive in the arm, they can result in compartment syndrome requiring surgical decompression.

Management of hematomas after PCI

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Most management for hematomas is usually just conservative and includes analgesia, compression if acute or evolving, and rest and elevation of a limb if it's the arm that's affected. If severe hematomas are tender, you should consider ultrasound to exclude a pseudoaneurysm.

Recognizing retroperitoneal hemorrhage after PCI

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Retroperitoneal hemorrhage is a dangerous complication associated with PCI that can sometimes be difficult to recognize as bleeding into the retroperitoneal space cannot be seen externally. Clinicians should suspect retroperitoneal hemorrhage if the hemoglobin value falls, especially in the context of a post-procedural drop in blood pressure. Another sign will be abdominal pain on a straight leg raise examination or Cullen's and Grey Turner signs, which usually occur late in the presentation as discoloration or bruising around the umbilicus and abdominal flanks.

Diagnosis and treatment of retroperitoneal hemorrhage

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Early diagnosis of retroperitoneal hemorrhage is imperative. Fluid resuscitation should be initiated as soon as possible for circulatory support, and emergency CT scanning of the abdomen should be obtained if there is concern of retroperitoneal hemorrhage to confirm the diagnosis. Manual compression of the bleeding site may help if the femoral vessels are easily compressible and the hemorrhage may require emergency blood transfusion, reversal of anticoagulation, and even interventional radiology to stent or open vascular surgical repair.

Distal embolization and renal injury as PCI complications

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Distal embolization may occur as a consequence of instrumentation of the aorta. Introduction of instruments into the aorta may cause cholesterol embolization from existing plaques. This embolization can involve peripheries and also renal and other end organs, which may present with organ-specific findings such as renal impairment.

Key points about PCI complications

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After performing a PCI, it's important to monitor patients for clinical and vital signs that indicate bleeding due to arterial access complications. Remember, you have to think about retroperitoneal hemorrhage if the patient is shocked with no obvious external bleeding since it can often be occult. Other complications of arterial access and instrumentation of the aorta include distal embolization or renal injury.