A Groin Story

This article has supporting videos to Figures 1-2:

Video 1 (Figure 1)

Video 2 (Figure 2)
 

The day started as any other, with a full board of diagnostic caths and scheduled interventions. With a seasoned, small group of tightly knit interventional attendings, our center decided within the last several years to become a radial-first lab, which was reflected on our schedule that day, except for one case. The patient was a 75-year-old moderately obese male with prior history of coronary bypass who had undergone cath via femoral approach one week prior by my partner. The patient was found to have multiple graft lesions/occlusions and had been turned down for repeat bypass. The interventional fellow and I carefully reviewed the patient’s diagnostic images and opted to proceed with treatment of a moderately complex, highly stenotic, ostial right coronary artery (RCA) lesion with some degree of calcium. The choice of access site remained up in the air. Ultimately, we opted to proceed via a femoral approach.

Fluoroscopy of the mid-femoral head was performed without ultrasound guidance, which is not regularly used at our center, and access was obtained. Limited femoral angiography was performed through the microsheath and the arteriotomy, although on the lower third of the femoral head, was not felt to be prohibitive to proceeding with intervention. The percutaneous coronary intervention (PCI) was performed with a 6 French (Fr) system and was uncomplicated. A drug-eluting stent was deployed without need for atherectomy. Due to concern over mild disease at the arteriotomy, use of a vascular closure device was deferred, which is our typical practice, anatomy permitting.

As the activated clotting time (ACT) remained elevated, the patient was taken to our pre-operative area to recover while awaiting sheath removal. We proceeded to begin another long, complex PCI procedure. In the interim, staff called to note the patient had developed a recurrent hematoma and were subsequently instructed to continue to hold manual pressure until we were free to further assess the patient.

As the complex PCI was finishing, the advanced fellow went to assess the patient, held additional pressure, and the hematoma appeared to resolve. However, upon arrival to the floor, the patient was noted to have an even larger recurrent hematoma despite the additional manual pressure. As I arrived at bedside, the patient’s blood pressure had declined, and he appeared clammy and nauseated. As I took over manual pressure myself, I noted several important details regarding this patient’s groin. In addition to obesity, the patient had residual redundant loose tissue/skin from prior significant weight loss. By the time I comfortably achieved adequate hemostasis with manual pressure, my hand, which is albeit on the smaller side, was completely encased within the patient’s groin to where only my wrist was visible. The decision was made to move the patient to the cardiac intensive care unit and vascular surgery was urgently called. I decided I would continue to hold pressure while the patient was being transferred. While we moved, I received multiple bruises on my hips and legs from inadvertently bumping into various pieces of hospital equipment in the hallways. These bruises paled in comparison to the appearance of the patient’s groin.   

In the interim, the patient’s hemoglobin, which at baseline had been 8 mg/dL, now returned at 4 mg/dL. Fortunately, the patient’s hemodynamic status had stabilized with fluids and un-crossmatched blood. However, due to unclear etiology of continued bleeding and anticipated need for hematoma evacuation, the decision was made to proceed to the operating room (OR) for groin exploration and possible repair. As the patient was wheeled to the OR after talking to family, I took over manual compression again for transport. I hopped onto the bed (fortunately, I am petite), as I wanted to avoid compromising manual compression as well as avoid any further injury to myself. Our vascular colleagues graciously allowed me to scrub in. I watched and felt nauseous as they evacuated two units worth of congealed blood from the groin and found continued, active bleeding from the arteriotomy site. The site was easily sutured without evidence of other frank vessel injury. Extensive skin excision was required due to excessive skin compromise and a wound vac was placed. The patient remained stable and otherwise did well post operatively.

I felt compelled to share this experience for several reasons:

1) Sharing complications is just as important as sharing successes;

2) I have always considered myself a very careful operator in a high-complexity PCI center. Although I had heard the horror stories of femoral cases gone wrong, I had yet to see it up close until now, and it was life/practice changing;

3) Although our lab is #radialfirst, it is still balanced with #safefemoral — or so I thought;

4) I traditionally have modestly used ultrasound with femoral access. Although it could be argued ultrasound use may not have changed the outcome, I believe more strongly that it is essential for femoral access;

5) This case has also shown me the necessity of a default #radialfirst approach and if that requires “upping the game” of the operator to demand more advanced skills, then so be it;

6) I had bruises on my legs from transporting/compressing while walking and swollen hands from manual compression for several days afterwards. However, it pales in comparison to what could have led to a fatal complication in this patient. This case was a perfect example of the “swiss cheese” model of complications: suboptimal manual pressure initially, likely due to obesity, excessive residual groin tissue, and a suboptimal arteriotomy site, leading to hematoma, which further limits ability to hold manual pressure, and thus leading to a vicious cycle of continued bleeding.

So, what did I learn from this case? I initially shared this experience on social media. I wanted to not only review the case details and choice of access site with peers from around the country and world, but more importantly, in the spirit of humility, I wanted to share this unfortunate case as a learning opportunity for others. I strongly feel that if one feels completely at ease in the cath lab, no matter your years of experience, it is time to get out of the lab.

Since first being posted on Twitter, this case garnered over 30,000 impressions and prompted significant discussion of several points of the case. Was the choice of access site appropriate? What is the optimal use of ultrasound for femoral access and what is the role of vascular closure devices in reducing bleeding complications, particularly in obese patients? Is there an appropriate indication for the FemoStop device (Abbott Vascular)? Should we have considered contralateral access to assess the source of bleeding and potentially treated this complication without the need for vascular surgery? Although such questions may arise on a smaller scale at individual institutions, social media platforms such as Twitter allow unparalleled access to a larger audience, facilitating the discussion and review of such cases. By sharing this experience, I not only have been able to review this case with my peers, but more importantly, I have been able to amplify the personal lessons learned to a much broader audience — and all these things made the story of this groin worth telling. 

Ki Park, MD, is on Twitter:

@cardioPCImom.

She can also be contacted via email at ki.park@medicine.ufl.edu.