Bleeding complications after cardiac catheterization

Abstract

CASEA 69-year-old woman presented to her cardiologist complaining of intermittent substernal, nonradiating, chest pressure (5/10 at its worst) for 1 to 2 days. At fi rst the chest pressure occurred only with exertion, but now it is also occurring at rest. Some of the episodes are associated with diaphoresis and light-headedness. The patient also noted increasing fatigue over the last 1 to 2 days. She has no associated shortness of breath, nausea, vomiting, lower extremity edema, or orthopnea. She has coronary artery disease, and about 4 years earlier had angina symptoms and placement of a drug-eluting stent in the mid left circumfl ex artery. At that time she was noted to have diffuse irregularities in her other coronary arteries and normal left ventricular function. The patient stated that the current episodes are similar to her previous angina.The patient's past medical history includes coronary artery disease, hypertension, hyperlipidemia, type 2 diabetes, osteoarthritis, and gastroesophageal refl ux disease. She was recently diagnosed with lung cancer. Her daily medicines are 325 mg aspirin, 2,500 international units vitamin D 3 , 4 g cholestyramine resin, 75 mg clopidogrel, 30 mg lansoprazole, and 20 mg lisinopril. She smokes one to 1.5 packs of cigarettes daily, rarely drinks alcohol, and denies illicit drug use. Her family history is signifi cant for coronary artery disease. She reports allergies to ezetimibe, simvastatin, and topical iodine.Because her symptoms are similar to her previous anginal symptoms and because of her multiple risk factors, she was taken to the cardiovascular laboratory. A 6 French catheter was placed in the right common femoral artery above the bifurcation and below the pelvic brim using a modifi ed Seldinger technique. The patient then proceeded to have a left heart catheterization, left ventriculogram, and selective coronary angiography. The studies revealed mild diffuse coronary artery disease and a patent left circumfl ex artery stent. The left ventricular ejection fraction was 60% and normal left ventricular wall motion was observed. No percutaneous cardiac intervention (PCI) was performed.After the procedures, she was returned to the cardiac short-stay unit. Because the procedure was only diagnostic, the patient had not been given anticoagulants. The sheath in the right femoral artery was removed and manual pressure applied to the puncture site for 20 minutes. Hemostasis was obtained. The patient was advised to remain lying on the bed without bending her right leg.On a routine check of the patient 75 minutes later, a large amount of fresh blood was noted on the bed between the patient's legs. Bleeding was noted from the right femoral artery puncture site. The patient looked pale and complained of nausea. She had a systolic BP of 56 mm Hg and a heart rate in the 40s. Manual pressure was immediately applied to the site of bleeding. The patient was placed in Trendelenburg position. A 1-L bolus of 0.9% sodium chloride solution was started and the rapid response team called. A sec...