1 TLB PowerPoint presented By Takaya L. Brown, BSN, BSN, CMSRN

TLB 1

MANAGING RISK OF

COMPLICATIONS AT FEMORAL

VASCULAR ACCESS SITES IN PCI

PowerPoint presentedBy

Takaya L. Brown, BSN, BSN, CMSRN

TLB 2

WHAT IS PCI?Percutaneous Coronary Intervention :

a nonsurgical procedure that is done to open narrowed coronary

arteries; performed by introducing a catheter through the skin into an artery (groin or arm).

This procedure is performed when a patient has an acute coronary syndrome or a non-ST elevation MI.

PCI reduces morbidity and mortality from cardiovascular disease.

http://www.emedicinehealth.com/percutaneous_coronary_intervention_pci/article_em.htm

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FEMORAL VASCULAR ACCESS COMPLICATIONS

Because PCI requires the use of potent antithrombotic agents/Antithrombin medications, there is an increased risk of:

• Hematoma• Retroperitoneal hematoma• Pseudoaneurysm• Arterial occlusion• Arteriovenous fistula• Increased morbidity/mortality• Increased costs

FVACs reported during PCI are 5.5-20%.

Merriweather, N. & Sulzbach-Hoke, L. (2012). Managing risk of complications at femoral vascular

access sites in PCI. Critical care nurse, 32(5): 16-29.

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RISKS FACTORS FOR FVACS

Modifiable Procedural technique Medications Hemostasis method

Non-modifiable Sex Age BMI Blood pressure



Since nurses are generally the ones to pull the catheters or sheaths, it is important to understand causes and predisposing risk factors of VASCs.

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FEMORAL ACCESS

Many VASCs are related to punctures being madeeither too high or too low below the inguinalligament.Low sticks can lead to pseudoaneurysm, hematoma, or AV fistula.



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Table 1 Femoral puncture location and associated complicationsa

Femoral puncture location: definition•Low stick: puncture below the femoral bifurcation•High stick: puncturing the inferior epigastric artery•Posterior wall puncture: puncture through the backwall of the arteryComplications•Pseudoaneurysm•Hematoma•Arteriovenous fistula•Retroperitoneal hemorrhage•Retroperitoneal hemorrhage

a Based on data from Turi,7 Ragosta,8 Baim and Simon,15 Kamineni and Butman,18 and Rashid and Bailey



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MEDICATIONSCombinations of oral, IV antiplatelet, and antithrombin therapy are used for patients with

ACS (USA and non-STEMI).

They reduce mortality rates

They reduce adverse ischemic events, such as recurrent MI

They reduce short and long term complications of PCI

Antithrombin AntiplateletsInhibits the coagulation factors that act in the clotting cascade to form fibrin strands1. Unfractionated heparin (UFH)2. Low molecular weight heparin

(LMWH): little effect on measurements of activated clotting time

3. Direct thrombin inhibitors (bivalrudin, argatroban): interact directly with thrombin without the need for cofactor

Prevent formation of clots by allowing platelets to be activated1. Glycoprotein Iib/IIIa (reopro,

integrilin, aggrastat)2. Adenosine diphosphate inhibitors

(plavix, prasugrel)3. aspirin



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These organizations support early administration of glycoproteinIIB/IIIa inhibitors for patients at high risk for thromboticevents related to bleeding.



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HEMOSTASIS METHODSThere are three main techniques for

obtaining hemostasis:1. Manual compression2. Mechanical compression3. Vascular closure devices



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MANUAL PRESSUREThis is the gold standard for pulling sheaths and obtaining hemostasis.•Place index and middle fingers 1-2cm above puncture site and applypressure for 15-20 minutes.•This can lead to VASCs due to varying amounts of pressure being applied as a result of hand and arm fatigue.



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MECHANICAL PRESSUREApplying constant pressure on the artery by use of:C-clamp

Pneumatic device(Fem-stop)



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VASCULAR CLOSUREThis method was first approved in the 1990’s as a means for reducing lengthof bedrest, improving hemostasis, and for patient’s comfort. Methods used:

-sutures for tying of the femoral artery-collagenlike plugs which seals the puncture site by stimulating platelet aggregation-staples/clips which seal off puncture site in the artery

starclose

angioseal perclose



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NURSING IMPLICATIONSCritically ill patients are at high risk for VASCs because of comorbid

conditions, such as,

-renal failure

-hypertension

-advanced age

The goal for nursing is to maintain hemostasis at the puncture site. This goal will be attained by frequent assessment of VASCs:

-frequent vital sign checks

-frequent puncture site checks for bleeding or hematoma

-frequent pulse checks of affected limb



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REFERENCEShttp://www.emedicinehealth.com/percutaneous_coronary_intervention_pci/article_em.htm



http://www.emedicinehealth.com/percutaneous_coronary_intervention_pci/article_em.htm

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ARTICLEArticle can be found on the AACN (C1253)

website. After completing the test, you will receive 1.0 contact hours.

http://www.aacn.org/wd/Cetests/media/C1253.pdf



Documents

1 TLB PowerPoint presented By Takaya L. Brown, BSN, BSN, CMSRN