Managing Vascular Complications of Cardiac Catheterization: Your First Aid Kit

1. Managing Vascular Complications of Cardiac Catheterization: Your First Aid Kit Presented by Helen Condry, RNC, BSN, MSN

2. Objectives • Describe the process of a cardiac catheterization, angioplasty, stenting, FFR, and IVUS. • List possible vascular complications. • Describe the management of vascular complications. • Compare the various closure devices. • Articulate the care for post cath lab patients. • Discuss discharge teaching. • Demonstrate how to hold manual pressure for a hematoma. • Demonstrate how to apply femostop and manage it.

3. Cardiac Catheterization CMC.northeast.org • Left heart cath (LHC) done to visualize coronary arteries, evaluate chest pain and EF, and insert stents for blockages over 70%. • LHC uses femoral, radial, or brachial artery to aorta where dye is injected, fluoroscopy used to see arteries. • Right heart cath (RHC) done to measure pressures and O2 sats on R side of heart, pulmonary arteries & check valves. • RHC uses femoral or arm vein, catheter advanced to vena cava, R heart, to pulmonary arteries to determine wedge pressure.

4. PCI/Stenting • POBA-plain, old balloon angioplasty • Performed most often with peripheral system, often for in-stent stenosis • Stenting or ballooning involves placing wire into coronary arteries so patient receives blood thinners. • Aspirin usually given prior to procedure. • IV heparin or IV angiomax (direct thrombin inhibitor) given during procedure. • Also may receive Integrelin, a Glycoprotein IIb/IIIa inhibitors which prevents platelet aggregation. • Integrelin often given with IV heparin and will continue for 4 to 24 hours. • Arterial sheath pulled 2 hours after Angiomax. • Arterial sheath pulled usually 3-4 hours after heparin, based on ACT.

6. PCI and Stenting dynamicpatents.com

7. Anti-platelet agents • Drug-coated stents have better outcomes but patient must take anti-platelet agent x 1 year. • Patients who need surgery within 1 year should have bare metal stent. • Plavix-older drug with generic available. Given as bolus of 300mg to 600mg with 75 mg daily. • Effient (prasugrel)-newer drug indicated for STEMI, NSTEMI patients, and unstable angina. Brand-name only with bolus of 60mg and daily dose of 10 mg daily and 5 mg for patients under 60kg. • Ticagrelor (Brilinta)-newer drug, brand name only with bolus of 180 mg and twice a day dosing of 90 mg. • IMPORTANT TEACHING-patient must take anti-platelet for 1 full year for drug coated stents or stent will occlude. Patient may have a MI and die if stopped early.

8. Fractional Flow Reserve (FFR) • FFR measures blood pressure and flow through specific part of a coronary artery that determines the severity of the blockage. • Guide wire is placed at the blockage and blood flow is measured. FFR value of less than 0.80 usually requires interventional treatment. Blockages that score higher than 0.80 can generally be treated by medical therapies (Tanner Health System, 2012).

9. Intravascular Ultrasound (IVUS) • Tiny, ultrasound probe placed in coronary artery to view coronary artery. • Evaluates the amount of disease, distribution, and composition. • Determines the need for further treatment: angioplasty or bypass versus medical treatment (Cleveland Clinic, 1995-2014). http://www.cathlabdigest.com/files/photos/Figure2Kern.png www.cathlabdigest.com/files/photos/Figure2Kern.png

10. Cardiac Ablation • Used to treat a fib, a flutter, atrial tach, and SVT’s. • EPS done first to locate source of irritable cells. • Uses probe with radiofrequency waves (similar to microwave energy) or cryotherapy (freezing) to kill the irritable tissue (American Heart Association [AHA], 2014). • Access is through femoral veins, up to 3 lines with very large sheaths, up to 12 French. www.nature.com

11. Chronic Total Occlusions (CTO’s) • When occlusion is 100% or more than 3 months old. • Always needed bypass in the past. • Patient usually symptomatic. • Artery accessed x 2 through a left heart cath and retrograde through collaterals- above and below blockage. • Wire drills through blockage. • Has a very large sheath which physician perclose’s or he pulls it. • Recent meta-analysis of 23 observational studies showed better mortality & better long-term outcomes compared to conservative medical treatment (Khan et al., 2013).

12. Most Common Complication? Bleeding! 1% risk of bleeding for caths. 3% risk of bleeding for PCI’s. (Batyraliev et al., 2005) Azheart.com

13. Hematomas/Bleeding Very Large Hematoma Bleeding may be visible or may be under the skin-hematoma. For either one, your first job is to find the arterial pulse and press hard with steady pressure. Second job is to apply steady pressure to the hematoma. Don’t knead it.

14. What else needs to be done? • Get assistance from other nurses. • Pain medicine-very important for hematomas. • Monitor heart rate and bp while holding arterial pressure. • Notify the doctor. • Outline hematoma with marker, measure the arm if applicable. • Once bleeding stopped, then may apply pressure dressing. • If bleeding or hematoma returns, may apply femostop. • May call prep & recovery for assistance-47214.

15. Femostop • Femostop is compression device. • Needs a doctor’s order. • Used for bleeding or hematomas. • Apply dome pressure to arterial pulse. • Belt placed around hips or just below. • Maintain sterile technique to place dome over artery. • Increase pressure on dome to map-displayed on portable monitor. • Device loses pressure automatically but if not, should decrease pressure. • Always see policy and procedure. cathlabdigest.com

16. Vasovagal Reaction • Pressure on a large artery, pain, and anxiety can stimulate the vagus nerve, causing slowing of the heart rate and drop in blood pressure. • Early signs include pallor, nausea, yawning, and cold sweat which often present with a slowing of the heart rate before a drop in blood pressure. • Treat with IV fluid bolus, oxygen, head flat, and if possible some release of pressure on artery. • If still symptomatic, give atropine 0.6mg IVP. • Holmes has standing orders. http://morestarsthanintheheavens.files.wordpress.com

17. β adrenergic receptors in heart for norepinephrine and epinephrine α1 adrenergic receptors In vascular smooth muscles studyblue.com

18. Pseudoaneurysm Encapsulated hematoma that has branched off from the artery Call MD who may order a vascular ultrasound to diagnose Can be injected with thrombin by vascular surgeon or special procedures to resolve it Caused by inadequate compression or by the cardiologist’s technique (Beattie, 1999)

19. Retroperitoneal Bleeding Incidence is 0.15% (Sedlacek & Newsome, 2010) S/S- hip, back, & abd. pain, low bp unresponsive to fluid bolus, tachycardiac, drop in H&H, bruising. Call Md. Confirmed by CT scan. Transfer to ICU, blood transfusions, possible surgery.

20. Arteriovenous Fistula • Rare complication if both artery and vein have been punctured. • Blood flows directly from the artery to the vein causing pain, swelling, and purplish, bulging veins that look like varicose veins. Can cause heart failure if not treated. • Hospital policy dictates that the arterial line is removed with hemostasis prior to removing the venous line to prevent an AV fistula. • Fixed through a stent or OR.

21. Angiograms show arteriovenous fistula in the deep femoral artery before and after implantation of a covered stent. ( Thalhammer, Kirchherr, Uhlich, Waigand, & Gross, 2000)

22. Contrast Induced Nephropathy Occurs between 1-10% of all cases depending on preexisting conditions (Parfrey et al., 1989) Report any increase of creatinine to MD Protect the kidneys w/IV fluids, Na bicarb.

23. Loss of Peripheral Pulses Check pulses with the groin checks For new onset of absent pulses, call Md immediately who will consult a vascular surgeon Pt needs to go to OR Occurs from a clot , or cholesterol breaking off. gla.ac.uk

24. Stroke Strokes rates after cardiac cath range from 0.03% to 0.3% (Lazar et al., 1995) Ischemic stroke can be caused by plaque that is dislodged during the cath or from thrombus on the catheters or guide wires. If a stroke is suspected, call rapid response team. healthmango.com

25. Other Complications • Thrombus formation • Aortic dissection • Dysrhythmias • MI • Puncture of the ventricles, cardiac septum or lung tissue • Death (RARE) Allergic reactions to contrast media Looping Kinking Breaking off of the catheter Infection

26. Radial Approach Less risk of complications The patient needs to use that hand minimally for 24 hours. No blood draws, bp’s or IV’s in that arm x 1 week. If hematoma is suspected, measure arm.

27. Vascular Closure Device (VCD) • Decreased bed rest time for patient. • Higher risk for groin infection (Biancari et al., 2010). • Meta-analysis showed no difference in groin hematomas, bleeding, pseudoaneurysm, and need for blood transfusions between manual compression and closure devices (Biancari et al., 2010). • Other studies show trend towards more complications with VCD’s (Patel et al., 2010). • AHA says that the use VCD’s is reasonable to decrease time to ambulation and hemostasis but site must be evaluated Adds cost to procedure. • With any closure device with bleeding present, use sterile gloves to hold pressure.

28. Angioseal Collagen re-absorbs in 60-90 days http://professional.sjm.com

29. StarcloseDisc-shaped nitinol clip placed extravascular-stays in body forever

30. PercloseSuture closes artery-used for large sheaths in this facility. No collagen but technically more difficult. http://www.auntminnie.com

31. ExosealExtravascular placement of a polyglycolic acid plug that absorbs in 60-90 days Fda.gov http://article.wn.com

32. Vascade/BoomerangCollagen deployed extravascular through boomerang device cardivamedical.com medgadget.com

33. Topical Hemostatic DevicesStatseal & Thrombix Statseal • Forms a physical seal through clumping of blood solids and proteins and rapidly dehydrating the blood. • When dressing is removed the next day, the brown scab should be left in place. Statseal.com

34. Thrombix • Non-woven pad with thrombin, sodium carboxymethylcellulose and calcium chloride that converts fibrinogen directly to fibrin when activated by a small amount of blood. • Used for most of special procedure patients. • Patch may be removed next day. Cxvascular.com

35. Your First Aid Kit • Use slide board to get patient into bed from stretcher to avoid popping groin. • Monitor groin and peripheral pulses. • Monitor vital signs, labs, pain, restlessness, hematoma’s. • Mark areas of swelling and measure arm if brachial or radial. • Call prep & recovery for assistance or questions. • Give IV fluids as ordered. • Maintain bed rest or light activity with arm as ordered. • Monitor vital signs every 5 minutes while holding arterial pressure for bleeding or hematoma.

36. Discharge Instructions • Radial’s-no blood draws or BP’s that arm x 1 week. • Femoral sheaths-may shower the next day, remove dressing and leave open to air, no lifting more than 5 lbs x 1 week. • Closure devices-wait 24 hours for shower, apply clean band-aid daily until healed and no lifting more than 10 lbs x 3 days. • Bruising may continue up to 1 week for all patients. • No soaking in tub, pool, hot tub x 1 week. • Call 911 for bleeding. • Use teach-back for discharge instructions. • Use cardiology discharge instruction sheet as MD’s are not using correct instructions with electronic orders.

37. Questions?Comments?

38. Now it is your turn to talk! Tell me stories of cases you have seen. Case studies

39. Case Study # 1 You received report from prep & recovery that your female patient had a negative cath, had a arterial sheath in the right groin that was removed at 0900 with hemostasis at 0930. The vital signs are: 130/76, SR 76. It is now 1030 and your patient just arrived on a stretcher. You couldn’t find the slide board so your co-workers and you pulled and tugged her over onto the bed. You check the groin and it is soft with no bruising. You come back to the room at 1100 and find the patient with both knees bent. What do you do?

40. Case study # 1 continued You check the groin and find a hard knot below the exit site. What happened? What do you do?

41. Case study # 1 continued You start pressing out the hematoma and the patient starts crying from the pain. What do you do? The hematoma resolves in 5 minutes. What do you teach the patient?

42. Case study # 1 continued You come back in one hour (because you had something else happen in another room) and find the swelling has returned and it is bigger! What do you do?

43. Case study # 1 continued You start pressing it out again and the patient says, “I don’t feel good. I am going to throw up.” What is probably happening? What do you do?

44. Case study #1 continued You put oxygen on, open up your IV fluids, immediately check the bp and pulse. The bp is 70/40 and the pulse is 56. If those things don’t work, what is next?

45. Case study #1 continued Atropine 0.6mg IVP quickly-you are covered with the post cardiac cath orders and you can override med from pixus.

46. Case study # 2 You receive report that your patient had a negative cath with a right radial access. The patient had a TR band on for 2 hours and air was gradually removed until the TR band was removed at 3 ½ hours at 1300. You receive the patient at 1330. The patient steps off the stretcher onto his bed. He is careful with not using his right arm or putting pressure on it. You check the radial and ulnar pulses and find both are strong and he has good capillary refill. You check him at 1430, he complains of some numbness in his fingers and pain. What might be going on?

47. Case study # 2 continued You check the pulses and there isn’t any change. You don’t see any swelling so decide to check it again soon. 1 hour later, you find that the arm has swelling above radial access site, on the forearm. What do you do?

48. Case study # 2 continued Measure swelling and mark it. Listen for bruit. You do not hear a bruit. What is the next step?

49. Case study # 2 continued Hold pressure on artery and try to press out the hematoma. Call MD

50. Case study # 2 continued The hematoma won’t press out. He is c/o pain, numbness & swelling. What do you think it is? What test might the doctor order?