Cath Lab Digest - March 2008 - (Page 56)

56 WHAT WE LEARNED MARCH 2008 With error followed by analysis comes learning, and with shared learning comes improved outcomes. c. Learn the angiographic anatomy of the region: common femoral artery, profunda femoral artery, landmarks indicating ‘high’ (above inguinal ligament/above the inferior course of the inferior hypogastric artery) and ‘low’ sticks (at or below the bifurcation of the common femoral artery into the profunda and superficial branches) and what the complications of intramural sheath placement (sheath tracks within the femoral arterial wall for more than a few millimeters before entering the lumen), perforation, and pseudoaneurysm look and feel like. With error followed by analysis comes learning, and with shared learning comes improved outcomes. d. The RAO projection is the usual preferred view because it lays out the bifurcation of the common femoral artery so that a low stick, the usual error, is identified easily. Also, if there is a hip prosthesis, it is the only view that allows you to see the artery. However, the LAO projection allows one to better see the entry of the sheath into the artery and makes it easier to see posterior wall perforations, which lay behind the artery in the RAO projection. The RAO view is obscured if a hip prosthesis is present. 14. Patients with coagulopathy: a. Warfarin (International Normalized Ratio [INR] over 1.6) — use extra caution, special techniques, or approaches. b. Warfarin (INR over 2.5) — consider fresh frozen plasma (FFP) over 4-6 hours or 1mg vitamin K intravenous (IV) 24 hours in advance of cath. For acute myocardial infarction with high INR, consider using a micropuncture technique, consider leaving the sheath in until the next morning or using a closure device, so you know whether or not you have hemostasis by the time you leave the lab. c. Don’t do high bleeding risk cases unless there is no choice. Temporize and reduce coagulopathy. d. Clopidogrel e. Glycoprotein IIb/IIIa Receptor Inhibitors f. Heparin or low-molecular-weight heparin (LMWH) g. Direct thrombin inhibitors h. Management: i. Micropuncture technique ii. Vascular ultrasound assisted access i. Obviously ‘high’ sticks: i. If you don’t routinely fluoroscope the groin, you will have more complications than if you look every time. Even those who ‘never miss’ do miss once in a while. ii. If you don’t take a picture of the groin with contrast, you won’t know about some retroperitoneal bleeds until the patient is in shock. iii. If you don’t carefully review each groin shot, you’ll still miss opportunities to reduce bleeding complications. If you review them again when a groin complication occurs, about half the time you’ll find something you missed and the next time you’ll do better. j. Patients with access issues: i. Morbidly obese: 1. Consider brachial or radial approach 2. Micropuncture technique 3. Vascular ultrasound-assisted access ii. Patients with atherosclerosis of the ileo-femoral system: 1. Firm arteries with diminished pulse and calcification make puncture and sheath insertion more difficult. Hydrophilic coated sheaths, use of extra support wires and updilating from micropuncture to 4 Fr to 5 Fr may be helpful. k. Bleed management: i. Double or multiple puncture of artery and or veins — higher probability of bleeding with multiple sticks. ii. Hematoma formation during case 1. Bleeding from around sheath: Upsize or closure device 2. Bleeding from double/multiple punctures: C-clamp with or without sheath removed, closure device, etc. iii. Closure device failures: 1. Long hold 2. C-clamp — up to an hour or more — increased risk of cutaneous or deep femoral neuropathy. 3. Early discontinuation of glycoprotein receptor inhibitors. iv. Post procedure hematomas: 1. If you don’t like the way the groin behaved: a. Clamp it — or clamp it longer b. Do an ultrasound (yes, in the lab with the patient on the table) c. Determine whether there is a pseudoaneurysm or retroperitoneal bleeding before you have a large hematoma d. Discuss the wayward groin with a cardiology colleague and/or interventional radiologist e. Let your vascular surgeon know something is afoot v. Post procedure hypotension: 1. Volume loss +/- vagal effects from pain in groin or pain in abdomen from retroperitoneal hematoma. 2. Sometimes it is the medications. 3. Get an EKG or echo if needed to rule out myocardial infarction. 4. Patients with belly pain and expanding abdomen with shock need a lot of fluid and sometimes some atropine. 5. Don’t let them succumb in the CT scanner looking for what you already know must be there. 6. Don’t forget cardiac tamponade as a possibility, especially if temporary pacer was used with glycoprotein receptor inhibitor/ heparin, or difficult stenting and significant dissection. 7. If tamponade is suspected, review films for missed perforation while an echo is being done. As soon as you see the effusion, tap it and leave a drain in; it may take 2-3 hours for the coagulopathy from heparin and glycoprotein receptor inhibitor to resolve. At that point, bleeding generally stops and the drain can be removed the next morning. Follow up echo an hour later, at the end of the day and prior to drain removal the next day can allay fears that blood has reaccumulated in the pericardium. ■ The author can be contacted at Jackson.Thatcher @ParkNicollet.com

Table of Contents Feed for the Digital Edition of Cath Lab Digest - March 2008

Cath Lab Digest - March 2008 Are You Being Paid Fair Market Value in 2008? A Cardiac Cath Lab Professionals Survey by Cath Lab Digest and the Society of Invasive Cardiovascular Professionals Saint Joseph’s Hospital Invasive Imaging Tools for Optimizing Coronary Stent Deployment Contents Clinical Editor’s Corner A Workflow Revolution in Cath Lab Reporting Advantages of a New Digital Lab at Baystate Medical Center Cardiac Computed Tomography: What Does it Mean for the Cath Lab? The Latest in Cardiac Magnetic Resonance Imaging (MRI) Cellular Cardiomyoplasty and Cardiac Regeneration Intravascular Ultrasound in the Cath Lab: A Powerful — and Underutilized — Tool to Improve Patient Outcomes The Stentplus™ Patient Success Program Cardiac Cath Lab Clutter — or, Spring into Action! Groin Bleeds and Other Hemorrhagic Complications of Cardiac Catheterization: A List of Relevant Issues Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab What Do You Think? Experience with a New Guidewire: The Terumo Runthrough NS The Ostial Pro™ Stent Positioning System: Perfecting Aorto-Ostial Stent Placement Precious Minutes The Ten-Minute Interview with…Mark Bowles, BSN, CCRN Vascular Care in the Cath Lab: Planning a Smooth Transition Cath Laughs CMS 2008 OPPS Final Rule Review An Extensive Set of Review Courses for the CCI Basic Science, Non-Invasive Echocardiography and Vascular, and ARDMS Ultrasound Exams Meetings Calendar CEU Education Center Clinical & Industry News STEMI Interventions Classifieds Advertisers Index

Cath Lab Digest - March 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.