pg. E3 - E4
ABSTRACT: The use of radial artery for vascular access for cardiac catheterization and intervention has gained increasing acceptance over the last few years as result of the lower risk of vascular complications compared to use of the femoral artery. The strong evidence showing that major bleeding (commonly access site related) is an independent predictor of mortality in acute coronary syndrome patients undergoing intervention has only accelerated this change. This case highlights that although the risk of access site complications is reduced with the radial approach there remains a risk of spontaneous bleeding elsewhere due to the use of multiple potent anti-platelet and anticoagulant therapy in the treatment of acute coronary syndromes. Early recognition of bleeding is of the utmost importance as delay increases the likelihood complications of bleeding including death.
J INVASIVE CARDIOL 2010;21:E3–E4
Key words: retroperitoneal haemorrhage, coronary angiography, enoxaparin, femoral neuropathy
The use of radial artery for vascular access for cardiac catheterization and intervention has gained increasing acceptance over the last few years as a result of the lower risk of vascular complications compared to use of the femoral artery. The strong evidence showing that major bleeding (commonly access-site related) is an independent predictor of mortality in acute coronary syndrome patients undergoing intervention has only accelerated this change. This case highlights that although the risk of access site complications is reduced with the radial approach there remains a risk of spontaneous bleeding elsewhere due to the use of multiple potent anti-platelet and anticoagulant therapy in the treatment of acute coronary syndromes. Early recognition of bleeding is of the utmost importance as delay increases the likelihood complications of bleeding including death.
Case Report. We report a 77-year-old man who presented with prolonged typical cardiac chest pain. His cardiac risk factors included hypertension and a previous myocardial infarction. Electrocardiography demonstrated anterior T wave changes from V1 to V4. Troponin T was elevated at 0.076 mcg/L (ULN 0.03). An initial clotting screen, electrolytes, renal and liver function tests were normal. The estimated GFR was 72 ml/min/1.73m2. Hemoglobin on admission was 13.5 g/dl with normal platelet count. He was treated with aspirin, clopidogrel and 1 mg/kg of enoxaparin twice daily as per local protocol. Based on a diagnosis of non-ST elevation myocardial infarction, he underwent an urgent cardiac catheterization. This was performed via the right radial artery and demonstrated severe triple vessel coronary artery disease. Percutaneous coronary intervention was deemed inappropriate due to his pattern of coronary disease and he was referred for coronary artery bypass surgery. Glycoprotein (GP) IIb/IIIa inhibitors were not used. Low molecular weight heparin administration was continued following the procedure while he awaited surgery.
He developed left hip and groin pain five days after his angiogram. This was initially thought to be due to arthritis. He then complained of left leg weakness and numbness in the medial aspect of his thigh and calf and was unable to walk without support. Examination confirmed absent knee reflexes on the left side with weakness of hip flexion, consistent with a femoral neuropathy. It was noted that his hemoglobin had fallen to 10.3 g/dl although he remained haemodynamically stable. As the procedure was done via the radial route, the attending doctor thought a retroperitoneal bleed was unlikely. Following further and more senior medical review, a CT scan of the abdomen and pelvis was requested to investigate the possibility of a retroperitoneal bleed. This confirmed a 9.6 cm x 6.5 cm hematoma within the left iliacus muscle extending inferiorly to the common iliopsoas tendon. The left psoas muscle was displaced anteriorly (Figure 1). The enoxaparin was stopped and the patient made a slow but full recovery on conservative management. Coronary artery bypass surgery was later undertaken with a successful result.
Discussion. The femoral nerve is formed by the second to fourth lumbar nerve roots and provides motor innervations to the quadriceps, sartorius, pectineus, and iliopsoas. It supplies sensory innervation to the anteromedial thigh and medial leg. The nerve lies in the groove between the iliacus and psoas muscles. Entrapment of the femoral nerve by an iliopsoas hematoma is the most likely cause of the femoral nerve palsy. Weakness of the quadriceps muscle and decreased patellar reflex are the most striking examination findings. Femoral nerve palsy is commonly due to hemorrhage due to hemophilia, anticoagulation therapy, or trauma.1,2 It is recognized to occur during prolonged heparin or enoxaparin therapy.2,3 Dual-antiplatelet therapy with clopidogrel and aspirin, even in the absence of other anticoagulant therapy, has also been implicated.4
Rectus sheath hematoma is also increasing in frequency with the more widespread use of powerful anticoagulant therapy including low-molecular-weight heparins.5 These are superficial and usually palpable on the abdominal surface and painful on movement. They can present acutely as hypovolemic shock or pseudo sepsis and early recognition is important to reduce morbidity and mortality.6
Use of the transradial approach is associated with fewer vascular access complications. In a recent large single center series of patients undergoing PCI with a high rate use of GP IIb/IIIa inhibitors, propensity scoring was used to randomly match 3,198 patients in each access site group. The rate of vascular access site complications was lower (1.5% vs. 0.6%) with radial artery access and hospital stay was reduced.7 Transradial access was an independent predictor of lower risk. A meta-analysis of randomized studies showed that radial access reduced major bleeding by 73% compared to femoral access (0.05% vs. 2.3%).8
The purpose of this report is to remind cardiologists that although bleeding rates with radial artery access are low, they are not zero and spontaneous bleeding from sites other than the access site can still occur, particularly when powerful anti-coagulant therapy is continued. In the OASIS 5 trial of patients with acute coronary syndromes treated with enoxaparin or fondaparinux for a maximum of 8 days, the incidence of major bleeding during enoxaparin therapy was 5.1%.9 RPH is an uncommon but potentially fatal complication of cardiac catheterisation. The reported incidence of RPH was 0.47% for patients undergoing cardiac catheterization and 1% for patients undergoing a percutaneous coronary intervention.10 Consistent with our case report, a study of bleeding complications after femoral artery puncture found that 25% of RPH were remote from the site of femoral artery puncture, with the majority of these being on the contra lateral side to the puncture site.11 Cardiologists need to keep in mind that RPH can occur even after radial artery catheterization particularly if low molecular weight heparin is continued along with dual-antiplatelet therapy in elderly patients.
From Queen Elizabeth Hospital, Birmingham, United Kingdom.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted June 18, 2009, provisional acceptance given June 24, 2009, final version accepted July 7, 2009.
Address for correspondence: Yogesh Raja, MD, MRCP, Department of Cardiology, Queen Elizabeth Hospital, Edgbaston Road, Birmingham B15 2TH United Kingdom. E-mail: dryogeshraja@gmail.com
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