|Year : 2017 | Volume
| Issue : 3 | Page : 259-268
Vascular complications and risk factors among patients undergoing cardiac catheterization
Mohamed El Sayed Ebeed, Nahla S Khalil, Manal S Ismaeel
Critical Care and Emergency Nursing Department, Cairo University, Giza, Egypt
|Date of Submission||07-Aug-2016|
|Date of Acceptance||18-Aug-2016|
|Date of Web Publication||1-Jun-2018|
Mohamed El Sayed Ebeed
El Manial University Hospital, postal code, 11562
Source of Support: None, Conflict of Interest: None
Aim and objectives The aim of the present study was to investigate the incidence of vascular complications and risk factors for vascular complications among patients undergoing the cardiac catheterization procedure.
Background Cardiac catheterization is one of the most crucial methods to assess and manage coronary artery diseases. Although it has a reduced morbidity and mortality, this invasive procedure is not free of complications.
Methods The descriptive exploratory design was used in this study. Demographic data, medical history and vascular complication assessment data were collected from a convenience sample of 100 patients, who underwent cardiac catheterization via the femoral artery.
Results Incidence of minor vascular complications revealed that the studied individuals had femoral oozing before sheath removal and femoral ecchymosis after sheath removal. Regarding the incidence of major vascular complications, the studied individuals had femoral haematoma after sheath removal. The common factors that placed patients at a greater risk for developing vascular complications were old age, female sex, illiteracy, and non-ST elevation myocardial infarction.
Conclusion The current study concluded that the most common vascular complications were oozing before sheath removal, and ecchymosis and haematoma after sheath removal, and the common risk factors for vascular complications were old age, female sex, increased BMI and femoral sheath size.
Keywords: cardiac catheterization, risk factors, vascular complications
|How to cite this article:|
Ebeed ME, Khalil NS, Ismaeel MS. Vascular complications and risk factors among patients undergoing cardiac catheterization. Egypt Nurs J 2017;14:259-68
|How to cite this URL:|
Ebeed ME, Khalil NS, Ismaeel MS. Vascular complications and risk factors among patients undergoing cardiac catheterization. Egypt Nurs J [serial online] 2017 [cited 2018 Aug 15];14:259-68. Available from: http://www.enj.eg.net/text.asp?2017/14/3/259/233668
| Introduction|| |
Cardiac catheterization is the most definitive method of diagnosis and management of coronary artery disease. More than five million diagnostic and interventional cardiac catheterizations are performed annually in the USA for both diagnosis and treatment. Although it has a reduced morbidity and mortality for coronary artery disease, this invasive procedure is associated with different complications (Agostoni et al., 2006).
According to the American College of Cardiology’s benchmarks, the incidence of cardiac catheterization complications should not exceed 1% for diagnostic and 3% for interventional procedures. The most common type of cardiac catheterization complication is the vascular type, which exposes the patients to additional discomfort, extended hospital stays and higher hospital costs, and reduces the patients’ outcomes (Dumont et al., 2006).
Vascular complications include retroperitoneal bleeding, pseudoaneurysms, arteriovenous fistula formation and bleeding at the access site, such as haematoma at the sheath site, which may occur if sufficient pressure is not applied manually with a mechanical compression device or with vascular closure devices (Shaffer, 2005).
Previous research has indicated that the factors that contribute the most to vascular complications are old age, repeated intervention, frequently using the same vascular access site, and anticoagulation medications. The major signs of vascular complications are swelling around the puncture site, palpable hardening under the skin and variation in size of bilateral groin areas, pain in the groin area, which can occur at rest or because of leg movement, and can result in a decrease in haemoglobin and blood pressure and an increase in heart rate, depending on severity. Many haematomas may resolve within a few weeks as the blood is absorbed into the tissue (Odom, 2008).
Other vascular complications include retroperitoneal haemorrhage, which is the bleeding that occurs behind the serous membrane lining the walls of the abdomen and pelvis. The clinical findings are moderate to severe back or flank pain, ecchymosis, and a decrease in haemoglobin (Turi, 2008). Pseudoaneurysm is the communicating tract between the tissue and one of the weaker walls of the femoral artery, causing blood to escape from the artery into the surrounding tissue. Large swelling at the insertion site, painful haematoma and ecchymosis are the most common signs (Odom, 2008). Arteriovenous fistula is a direct communication between an artery and a vein that occurs when the artery and vein are punctured by multiple attempts. Arteriovenous fistula can be asymptomatic and exhibits the features of bruit and/or thrill at the access site, swollenness, tenderness, distal arterial insufficiency and/or deep venous thrombosis (Hamel, 2009).
Arterial occlusion is an occlusion of an artery by a thromboembolism. The most common sources are vascular aneurysms or vascular atherosclerotic plaques. The classic symptoms are pain, paraesthesias, pulselessness, pallor and paralysis (Lins et al., 2006). Colonization by a pathogen may be caused by a compromised technique, poor hygiene, prolonged indwelling sheath time and femoral access closure device (because closure devices have been linked with increased occurrence of infection, pain, erythema, fever and increased white blood cell count). Treatment of pain can include analgesia and antibiotics after a culture sensitivity test (Hamel, 2009).
These previously mentioned complications and other complications associated with cardiac catheterization procedures increase the morbidity rate and reduce patient outcomes. Thus, the nurses play a vital role to prevent, early detect and manage these complications (Moser and Riegel, 2008). Vascular access complications may be a cause of discomfort, prolonged hospital stay and impaired outcomes in patients undergoing cardiac catheterization procedures. The removal of femoral sheaths and management of related complications after cardiac catheterization procedures are predominantly the responsibilities of nurses in many acute and critical care settings (Hamel, 2009). Thus, it is essential for nurses to understand the causes of and predisposing risk factors for vascular complications.
With the increasing number of cardiac catheterizations performed, evolving technology and advances in pharmaceutical therapy comes an increased risk for vascular complications. Numerous studies have focused on identifying risk factors associated with vascular complications, including old age and sex (female), obesity, coexisting conditions of hypertension and/or renal failure, and use of a large sheath, prolonged sheath time and excessive coagulation (Tiroch et al., 2010).
| Aim of the study|| |
The aim of this study was two-fold. First, we aimed to identify the incidence of vascular complications. Second, we aimed to identify the potential factors that place patients undergoing cardiac catheterization at a greater risk for developing vascular complications. To fulfil the aim of this study, the following research questions were addressed.
- What is the incidence of minor and major vascular complications after cardiac catheterization and therapeutic procedures?
- What are the common risk factors that place patients at a greater risk for developing vascular complications after cardiac catheterization procedures?
| Methods|| |
A descriptive, cross-sectional design was used in this study. It was used to observe, describe and document the frequency of occurrence of behavioural aspects in a specific situation at a specific time because it occurs naturally and occasionally serves as a starting point for hypothesis generation or theory development (Polit and Beck, 2004).
This study was performed at the Critical Care Department of Cairo University Hospitals. The study consisted of two cardiac catheterization lab rooms. Each room contained nine beds.
A convenience sample of 100 consecutive patients who underwent cardiac catheterization via the femoral artery access over a period of 3 months was included in this study. The inclusion criteria included adult male and female patients undergoing cardiac catheterization for diagnostic or percutaneous intervention. The exclusion criteria included patients who had an access site different from the right or left femoral artery, documented coagulation disorders, anticoagulation with warfarin with an international normalized ratio (INR) more than 2.0, peripheral vascular diseases, thrombocytopenia and disseminated intravascular coagulation.
Two tools were developed by the researcher using a literature review and were used to collect the data. The designed tools included the following.
- Medical data assessment: It consisted of two parts: (a) demographic data, which included data such as age, sex, BMI, smoking status, occupation and level of education; and (b) medical data history, which included detailed data on medical history, laboratory investigations, present and past medical treatment and procedure-related information.
- Observational checklist of vascular complications: This checklist was developed by the researcher using a literature review. It covered cardiac catheterization and/or percutaneous coronary intervention (PCI) complication-related data, such as haematoma, bleeding and other complications.
The designed choices of the medical data and vascular complications assessment questionnaire were ‘Yes’ or ‘No’. The response ‘Yes’ denoted the presence of disease, diagnosis or complications, and was given a score of ‘1’. However, the response ‘No’ indicated the absence of disease or complications, and was given a score of ‘0.’ This measurement was applied before and after the diagnostic or therapeutic procedure of cardiac catheterization.
The content validity of the tools was reviewed by a panel of three experts in the Critical Care Medicine and Critical Care Nursing. The designed medical data questionnaire was investigated for reliability using the inter-rater reliability with a κ coefficient=0.95. With regard to the observational checklist of vascular complications, Cronbach’s α was calculated to assess the reliability of the tool, and an α=0.89 reflected the degree of internal consistency among variables.
A pilot study was performed on 10 patients to test the feasibility, objectivity and applicability of the study tools. Carrying out the pilot study gave the investigator the experience to interact with the included participants, and the data collection tools. On the basis of the results of the pilot study, the needed refinements and modifications were performed, and the pilot study participants were excluded from the actual study sample.
Before commencement of the data collection, a formal request for ethical approval was made to the required departments. First, permission to proceed with the study was attained from the Ethics Committee of the Faculty of the Nursing Cairo University. Subsequently, approval was obtained from the Research Ethics Committee at the Critical Care Medicine Department. Next, the researcher distributed letters with a copy of the research proposal to the Directors of Nursing and Medical Managers at the research sites requesting permission to conduct the study. Furthermore, the researcher ensured that the confidentiality of each individual respondent and cardiac catheterization unit was maintained throughout the study.
This study was performed in two phases: the designation and implementation phases.
It involved preparing the study tools using the literature review and ensuring the content validity and reliability of the developed tools.
Once the official permission was granted to proceed with the proposed study, a planned schedule of assigned patients admitted for cardiac catheterization and/or PCI was obtained. The patients’ demographic data were obtained, and the medical assessment sheet was completed by the researcher. Next, the vascular complication assessment sheet (tool 3) was immediately completed by the investigator by observing and recording the signs and symptoms of vascular complications for each patient at the time of sheath removal until the patient’s discharge. The data were collected in the morning and afternoon shifts between March and May 2014.
Data were analysed using ‘statistical package for the social science’, version 20 (USA). Continuous variables were expressed as mean±SD and frequencies were expressed as percentages. For the purpose of comparison of frequency distribution of vascular complications among the studied patients of their demographic, procedural and haemodynamic factors, the χ2-test was used. The significance level was set at a P-value of less than or equal to 0.05.
| Results|| |
[Table 1] shows the percentage distribution of the studied patients by their demographic characteristics. It revealed that the ages of the most of the studied patients ranged between 50 and 59 years, with a mean age of 58±6.38 years, and that 53% of the studied patients were men. Regarding the educational level, 42% of the studied patients were illiterate. In relation to patients’ smoking status and BMI, most of the patients were nonsmokers (71%) and overweight (64%).
[Table 2] illustrates the prevalence of major and minor complications among the studied patients before and after sheath removal. It revealed that the most common minor complication was oozing before femoral sheath removal (20%) when compared with after sheath removal (12%). On the other hand, the most common major vascular complication was haematoma after sheath removal only (22%).
|Table 2 Percentage distribution of major and minor complications among the studied patients before and after sheath removal|
Click here to view
[Table 3] shows frequency distribution of the femoral oozing by demographic and procedure-related factors among the studied patients before and after sheath removal. It revealed that there was a significant statistical difference among patients regarding the occurrence of oozing by their age before and after sheath removal (χ2=8.3, P=0.010 and χ2=9.3, P=0.009, respectively). Moreover, there was a significant statistical difference among patients’ occurrence of oozing by their smoking status before sheath removal among the studied patients (χ2=6.3, P=0.040), as the current smokers developed higher frequencies of oozing than did previous and nonsmokers.
|Table 3 Frequency distribution of femoral oozing by demographic and procedure-related factors among the studied patients before and after sheath removal (n=100)|
Click here to view
In relation to procedure-related factors, there was a significant statistical difference among the patients’ development of oozing by femoral sheath size before and after sheath removal (χ2=13.2, P=0.000 and χ2=20.8, P=0.000, respectively), as the patients who had a sheath size of 7 Fr developed femoral oozing before and after sheath removal when compared with patients who had a sheath size of 6 Fr.
[Table 4] illustrates the frequency distribution of minor complications as indicated by femoral ecchymosis among patients by demographic and procedure-related factors before and after sheath removal. It revealed a significant statistical difference among patients’ ecchymosis by their age before and after sheath removal (χ2=5.0, P=0.080), as the age group 60–70 years developed higher frequencies of femoral ecchymoses than did other age groups. Moreover, there was a significant statistical difference among patients’ ecchymosis by their educational level before and after sheath removal (χ2=7.5, P=0.020 and χ2=6.69, P=0.030, respectively). In addition, there was another significant statistical difference among patients’ incidence of ecchymoses by smoking status after sheath removal (χ2=6.62, P=0.030).
|Table 4 Frequency distribution of femoral ecchymosis before and after sheath removal by demographic and procedure-related factors among the studied patients (n=100)|
Click here to view
On the other hand, as regards patient-related factors, there was a significant statistical difference between the frequency of puncture and occurrence of femoral ecchymosis after sheath removal among the studied patients (χ2=5.16, P=0.080). Moreover, there was a significant statistical difference between sheath size and the occurrence of femoral ecchymosis before and after sheath removal among the studied patients (χ2=13, P=0.000 and χ2=5.86, P=0.010, respectively), as the nonsmokers developed femoral ecchymoses after sheath removal when compared with current and previous smoker groups.
[Table 5] shows frequency distribution of femoral haematoma by demographic and procedure-related factors among patients after femoral sheath removal. It showed a significant statistical difference among patients’ femoral haematoma by their age (χ2=7.9, P=0.010). Moreover, there was a significant statistical difference among patients regarding the incidence of femoral haematoma by sex after sheath removal (χ2=5.2, P=0.030), as female patients were more prone to developing femoral haematoma than were male patients.
|Table 5 Frequency distribution of femoral haematoma after sheath removal by demographic and procedure-related factors among the studied patients (n=100)|
Click here to view
Finally, there was a significant statistical difference among the patients’ development of a femoral haematoma by femoral sheath size after sheath removal (χ2=10.7, P=0.001). As the patients who had a sheath size of 7 Fr developed femoral haematoma after sheath removal when compared with patients who had a sheath size of 6 Fr.
| Discussion|| |
The discussion part of this study is presented in four main sections. The first section is devoted to the demographic characteristics of the study sample. Sections two and three cover the interpretation and discussion of findings pertinent to the stated research questions.
Section one: Demographic characteristics of the study sample
The study sample in the present study included 100 patients. Most of the patients were men (53%), and their age ranged from 50 to 59 years, with a mean age of 58±6.38 years. With regard to the educational level and smoking status, nearly half of the studied patients were illiterate (42%) and smokers (46%). With regard to the BMI, two-thirds of the study sample was overweight (64%).
Section two: Answers the first research question, ‘What is the incidence of minor and major vascular complications post diagnostic and therapeutic cardiac catheterization procedures?’
Our research analysed the incidence of minor vascular complications after diagnostic and therapeutic cardiac catheterization, including both femoral oozing and femoral ecchymosis. It revealed that 10% of the examined patients had femoral oozing before sheath removal and that 20% had femoral oozing after sheath removal by manual compression for 15–30 min.
Compared with other studies, the findings of this study were in line with the results obtained by Chlan et al., (2005), who found that the incidence of femoral oozing after sheath removal using the manual compression method was 3%. Similar results were obtained by Hassan et al., (2014), who reported that the incidence of femoral oozing after sheath removal was 4%. In contrast to our study, Sabo et al., (2008) analysed minor vascular complications and found that the incidence of femoral oozing before sheath removal was 18.9% but decreased to 10.5% after compression was released.
However, the present study revealed that only 4% of the studied patients had femoral ecchymosis as a minor vascular complication before sheath removal, but that 12% of the studied patients had femoral ecchymosis after sheath removal.
The findings of the present study were in agreement with those of a similar study by Mohammed et al., (2013), who found that the incidence of femoral ecchymosis after sheath removal using the manual compression method was 10%. In contrast, Hassan et al., (2014) found that the incidence of femoral oozing after sheath removal using the manual compression method was 32%. This finding was consistent with the results obtained in a study by Sabo et al., (2008), who studied the relationships among patient characteristics, comorbidities and vascular complication after PCI, and found that the incidence of femoral ecchymosis before sheath removal was 18.6% but that it increased to 21% after the compression was released; they also reported that femoral ecchymosis was a frequently observed complication.
The investigator interpreted the reasons for minor vascular complications in light of the previous literature, which noted that the mechanisms of complications after catheterization were dependent on the proper catheterization technique, the vessel pathology (atherosclerotic plaque at the site of catheterization), the method, strength and duration of manual compression applied, and the control of concomitant antithrombotic medications and hypertension. The lack of consistency in the presence and significance of these factors motivated our study.
The incidence of major vascular complications after diagnostic and therapeutic cardiac catheterization procedures
The findings of the current study demonstrated that the incidence of femoral haematoma was 22% of the studied patients after sheath removal. The findings of the current study were partially consistent with those obtained by Sabo et al., (2008), who studied the relationships among patient characteristics, morbidities and vascular complications after PCI in 306 patients who were scheduled for diagnostic angiography and potential PCI. They reported that the incidence of femoral haematoma was 59 (19.3%) patients before sheath removal and 54 (17.6%) patients after compression release.
Conversely, the current findings were contradicted by Augustin et al., (2010), who conducted a study entitled ‘Early sheath removal and ambulation in 172 patients submitted to PCI that aimed to assess the safety of the same day discharge’. Their study reported that the incidence of haematoma less than 10 cm before sheath removal was 2.3% but that the incidence of haematoma less than 10 cm after sheath removal was 7.5%, suggesting that additional compression or a lower heparin dose could have decreased the incidence of haematoma.
Section three: Responses to the second research question, ‘What are the common risk factors that place patients at a greater risk of developing vascular complications post diagnostic and therapeutic cardiac catheterization procedures?’
Risk factors can be classified as follows: (a) demographic-related factors, such as age, sex, BMI, smoking status, educational level and present and past medical history; (b) procedure-related factors, such as a previous catheterization procedure, frequency of puncture, sheath size, platelet antagonists (aspirin and clopidogrel) and glycoprotein IIb/IIIa inhibitors (tirofiban); and (c) haemodynamic factors, such as laboratory results including haemoglobin and INR.
With regard to the demographic-related risk factors, such as age, the current study illustrated that older patients with a mean of 58±6.38 years were more likely to have a femoral haematoma, but not oozing or ecchymosis, after sheath removal than were younger patients (χ2=7.3, P=0.01). This relationship may be correlated with an increased variability of vasculature, resulting in increased subcutaneous bleeding. Another explanation for the increased risk in older patients may be related to age-related changes in the associated arterial wall associated, which is mediated by increasing calcification and loss of elastin.
The results obtained in similar previous studies are consistent with our findings, suggesting that advanced age is directly linked to an increased incidence of vascular complications and that age is among the strongest predictors of major bleeding (Smith et al., 2006; Dumont, 2007; Manoukian et al., 2007; Yatskar et al., 2007; Sabo et al., 2008; Turi, 2008; Manoukian, 2009; Sulzbach-Hoke et al., 2010; Tiroch et al., 2010; Merriweather and Sulzbach-Hoke, 2012).
The findings of the present study are in agreement with those obtained in a recent study by Ortiz et al., (2014), who carried out a retrospective study and found that older patients with a mean age of 69.68±11.37 years and P-value less than 0.0001 exhibited a higher risk for femoral access site complications. On the other hand, findings of our study were in contrast to those obtained by Ohlow et al., (2009) and Ahmed et al., (2009), who reported that advanced age was not a significant risk factor for vascular complications.
Other patient demographic-related risk factors, such as female sex, were found to be significantly correlated with the incidence of femoral haematoma after sheath removal (χ2=5.2, P=0.03). This finding could be interpreted in light of Kelm et al., (2002), who reported that male patients were protected against vascular complications, which could be explained by larger arteries and the inherent ease of cannulation. However, the higher risk for vascular complications in females might be explained by the small vessel diameter in female patients, which requires more punctures to achieve femoral arterial access. Similarly, the current finding is supported by Dencker et al., (2016), who studied major vascular access complications after coronary diagnostic and interventional procedures in Denmark and found that older patients (P=0.01) and the female sex (P<0.001) were independently associated with major vascular access complications.
BMI was another risk factor that may increase the occurrence of minor and major vascular complications in either diagnostic or therapeutic cardiac catheterization. Our study revealed that there was a correlation between BMI and the incidence of both femoral and ecchymosis before and after sheath removal. This finding indicated that moderate and severe patients showed significant oozing and ecchymosis development.
The findings of the present study were in contrast to those obtained in studies by Dencker et al., (2016) and Ortiz et al., (2014), who found that the highest rates of access site vascular complication occurred in patients with a BMI less than 18.5 (P=0.001). Moreover, the findings of our study contradicted those obtained by Sulzbach-Hoke et al., (2010) and Ohlow et al., (2009), who reported that the BMI did not affect the complication rate.
With regard to other patient demographic-related factors such as smoking status and educational level, the findings obtained in the current study revealed that illiterate patients had a risk for developing femoral ecchymosis before and after sheath removal (χ2=7.5, P=0.02 and χ2=6.69, P=0.03, respectively) because many patients did not understand or follow the instructions related to the cardiac catheterization procedure. Moreover, the findings of the present study revealed that nonsmokers developed a higher incidence of ecchymosis after sheath removal only (χ2=6. 62, P=0.03) compared with smokers. These findings were in agreement with those obtained by Dencker et al., (2016), Sulzbach-Hoke et al., (2010) and Tiroch et al., (2010), who reported that former and current smokers are associated with a significant decrease in vessel size, which reflects smaller rates of vascular complications and the positive effect of smoking cessation on body circulation. On the other hand, the results of the present study contradict those obtained by Castillo-Sang et al., (2010), who reported that current smokers were associated with higher rates of vascular complications (P=0.005).
With regard to the procedure-related factors, such as frequency of puncture and previous catheterization, the results of the present study demonstrated no risk for femoral vascular complications before and after sheath removal. This finding might be attributed to the fact that the majority of operators perform a femoral puncture guided by palpation and by superficial landmarks, but only a few operators perform the puncture under fluoroscopic guidance to locate the level of the head of the femur. An increased risk of femoral ecchymosis before and after sheath removal is possible. Moreover, when the operators knew that the patient had a previous catheterization, they occasionally became more meticulous in their technique.
These findings were in contrast to the results obtained in studies by Merriweather and Sulzbach-Hoke (2012) and Turi (2008), who reported that repeated or multiple punctures of the artery increased the likelihood that another artery or vein would be punctured, resulting in the development of vascular complications. On the other hand, the findings of our study were in agreement with those of a study by Tiroch et al., (2010), who found no overall significant changes in the femoral artery after multiple catheterizations. Moreover, ElMahdy et al., (2014) and Castillo-Sang et al., (2010) reported that a history of catheterization at the same site had no significant relevance and was protective against complications. Thus, the scar tissue created around the site may be protective against significant extravasation after percutaneous interventions.
With regard to the procedure-related factors such as sheath size, the findings of the present study revealed significant correlation between femoral sheath size and incidence of vascular complications before and after sheath removal, as patients who had a femoral sheath size of 7 Fr developed more vascular complications than did those who had a sheath size of 6 Fr. One possible explanation may be correlation with different patient populations, operator skills and/or overwhelming antiplatelet medication, which caused other additional potential risk factors. Moreover, this may be because most of the sample (94%) used 6 Fr sheaths; thus, the relationship was unclear. However, other studies by Merriweather and Sulzbach-Hoke (2012), Ahmed et al., (2009) and (2009) reported that the use of an arterial sheath with a diameter greater than 6 Fr had been identified as an independent predictor of vascular complication, such as major femoral artery bleeding.
With regard to the procedure-related factors, the present study showed that the administration of glycoprotein IIb/IIIa inhibitors (tirofiban) was associated with and increased the incidence of femoral oozing before sheath removal (r=0.429, P=0.00), increased the incidence of femoral ecchymosis after sheath removal (r=0.387, P=0.00) and increased the incidence of haematoma after sheath removal (r=0.269, P=0.007). The potential scientific explanation for this is that these inhibitors prevent the final pathway of platelet aggregation by attaching to fibrinogen and other proteins, thereby blocking platelet aggregation and preventing thrombosis. This explanation is supported by the findings obtained by Merriweather and Sulzbach-Hoke (2012).
In agreement with these results, this study showed that the administration of clopidogril (plavix) was associated with an increasing incidence of femoral oozing before sheath removal (r=0.454, P=0.00), and femoral haematoma after sheath removal (r=0.319, P=0.001). This oral antiplatelet agent specifically inhibited the P2Y12 adenosine diphosphate receptor on the platelet surface and prevented the activation of the glycoprotein IIB/IIIa receptor complex, thereby reducing platelet aggregation, which is consistent with the findings of Merriweather and Sulzbach-Hoke (2012).
The findings of the present study were in agreement with those obtained by Castillo-Sang et al., (2010) and Dumont et al., (2006), who reported that glycoprotein IIb/IIIa inhibitors and clopidogril (plavix) were associated with an increased incidence of vascular complications. On the other hand, Ortiz et al., (2014) and Sulzbach-Hoke et al., (2010) reported that there were no significant differences in vascular complications when using this medication.
With regard to the haemodynamic factors, the present study revealed that an abnormal result INR greater than the normal range was associated with a risk for femoral ecchymosis both before and after sheath removal. The findings of the current study were not consistent with the results obtained by Kassem et al., (2013), who reported that transfemoral angiography in patients with an INR of 2.0–3.0 in some series was safe.
| Conclusion|| |
It can be concluded that femoral oozing and femoral ecchymosis are common minor vascular complications. However, haematoma was a common major vascular complication after sheath removal. The common risk factors for developing minor and major vascular complications after diagnostic and therapeutic cardiac catheterization procedures include old age, female sex, illiterate patients, increased BMI, and sheath size.
On the basis of the findings of the present study, the following recommendations were made:
- Close clinical observation and monitoring are required to manage minor and vascular complications.
- Significant risk factors should be determined to facilitate the identification of patients at risk for vascular complications before cardiac catheterization.
- Nurses should be provided with educational modules concerning the care of cardiac patients undergoing cardiac catheterization.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agostoni P, Anselmi M, Gasparini G, Morando G, Tosi P, de Benedictis ML et al.
(2006). Safety of percutaneous left heart catheterization directly performed by cardiology fellows: a cohort analysis. J Invasive Cardiol 18:248–252.
Ahmed B, Piper WD, Malenka D, VerLee P, Robb J, Ryan T et al.
(2009). Significantly improved vascular complications among women undergoing percutaneous coronary intervention: a report from the Northern New England Percutaneous Coronary Intervention Registry. Circ Cardiovasc Interv 2:423–429.
Augustin AC, de Quadros AS, Sarmento-Leite RE (2010). Early sheath removal and ambulation in patients submitted to percutaneous coronary intervention: a randomised clinical trial. Int J Nurs Stud 47:939–945.
Castillo-Sang M, Tsang AW, Almaroof B, Cireddu J, Sferra J, Zelenock GB et al.
(2010). Femoral artery complications after cardiac catheterization: a study of patient profile. Ann Vasc Surg 24:328–335.
Chlan LL, Sabo J, Savik K (2005). Effects of three groin compression methods on patient discomfort, distress, and vascular complications following a percutaneous coronary intervention procedure. Nurs Res 54:391–398.
Dencker D, Pedersen F, Engstrøm T, Køber L, Højberg S, Nielsen MB et al.
(2016). Major femoral vascular access complications after coronary diagnostic and interventional procedures: a Danish register study. Int J Cardiol 202:604–608.
Dumont CJ (2007). Blood pressure and risks of vascular complications after percutaneous coronary intervention. Dimens Crit Care Nurs 26:121–127.
Dumont CJ, Keeling AW, Bourguignon C, Sarembock IJ, Turner M (2006). Predictors of vascular complications post diagnostic cardiac catheterization and percutaneous coronary interventions. Dimens Crit Care Nurs 25:137–142.
ElMahdy MF, Kassem HH, Ewis EB, Mahdy SG (2014). Comparison between ultrasound-guided compression and para-aneurysmal saline injection in the treatment of postcatheterization femoral artery pseudoaneurysms. Am J Cardiol 113:871–876.
Hamel WJ (2009). Femoral artery closure after cardiac catheterization. Crit Care Nurse 29:39–46.
Hassan AKM, Hasan-Ali H, Ali AS (2014). A new femoral compression device compared with manual compression for bleeding control after coronary diagnostic catheterizations. Egypt Heart J 66:233–239.
Kassem H, Elmahdy FM, Mahdy GS (2013). Incidence and predictors of post-catheterization femoral artery pseudoaneurysms. Egypt Heart J 65:213–221.
Kelm M, Perings SM, Jax T, Lauer T, Schoebel FC, Heintzen MP et al.
(2002). Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment. J Am Coll Cardiol 40:291–297.
Lins S, Guffey D, VanRiper S, Kline-Rogers E (2006). Decreasing vascular complications after percutaneous coronary interventions partnering to improve outcomes. Crit Care Nurse 29:39–46.
Manoukian SV (2009). Predictors and impact of bleeding complications in percutaneous coronary intervention, acute coronary syndromes, and ST-segment elevation myocardial infarction. Am J Cardiol 104:9C–15C.
Manoukian SV, Voeltz MD, Eikelboom J (2007). Bleeding complications in acute coronary syndromes and percutaneous coronary intervention: predictors, prognostic significance, and paradigms for reducing risk. Clin Cardiol 30(Suppl 2):II24-II34.
Merriweather N, Sulzbach-Hoke LM (2012). Managing risk of complications at femoral vascular access sites in percutaneous coronary intervention. Crit Care Nurse 32:16–29.
Mohammed H, Said H, Salah M (2013). Determining best nursing practice: effectiveness of three groin compression methods following cardiac catheterization. J Am Sci 9:274–285.
Moser DK, Riegel B (2008). Cardiac nursing: nurse’s role in the cardiac catheterization laboratory. St Louis, MO: Saunders Elsevier: 345–346.
Odom B (2008). Management of patients after percutaneous coronary interventions. Crit Care Nurse 28:26–41.
Ohlow MA, Secknus MA, von Korn H, Neumeister A, Wagner A, Yu J, Lauer B (2009). Incidence and outcome of femoral vascular complications among 18 165 patients undergoing cardiac catheterisation. Int J Cardiol 135:66–71.
Ortiz D, Jahangir A, Singh M, Allaqaband S, Bajwa TK, Mewissen MW (2014). Access site complications after peripheral vascular interventions: incidence, predictors, and outcomes. Circ Cardiovasc Interv 7:821–828.
Polit DF, Beck CT (2004). Nursing research: appraising evidence for nursing practice. 7th ed. Philadelphia, PA: Wolters Klower/Lippincott Williams & Wilkins.
Sabo J, Chlan LL, Savik K (2008). Relationships among patient characteristics, comorbidities and vascular complications post percutaneous coronary intervention. Heart Lung 37:190–195.
Shaffer RB (2005). Arterial and venous sheath removal. In: Wiegand DJ, Carlson KK, editors. AACN procedure manual for critical care. 5th ed. St Louis, MO: Elsevier Saunders: 602–609.
Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB et al.
(2006) ACC/AHA/SCAI practice guidelines, February 21, 2006. Circulation 113:e166–e286.
Sulzbach-Hoke LM, Ratcliffe SJ, Kimmel SE, Kolansky DM, Polomano R (2010). Predictors of complications following sheath removal with percutaneous coronary intervention. J Cardiovasc Nurs 25:E1–E8.
Tiroch KA, Matheny ME, Resnic FS (2010). Quantitative impact of cardiovascular risk factors and vascular closure devices on the femoral artery after repeat cardiac catheterization. Am Heart J 159:125–130.
Turi Z (2008). Optimal femoral access prevents complications. Cardiac Interv Today 1:35–38.
Yatskar L, Selzer F, Feit F, Cohen HA, Jacobs AK, Williams DO, Slater J (2007). Access site hematoma requiring blood transfusion predicts mortality in patients undergoing percutaneous coronary intervention: data from the National Heart, Lung, and Blood Institute Dynamic Registry. Catheter Cardiovasc Interv 69:961–966.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]