6.3 Access-Site & Vascular Emergencies

Access-Site and Vascular Emergencies

Once catheters are in the body, the ARRT Patient Care 1.H list continues with cerebrovascular accident (CVA) / transient ischemic attack (TIA), embolism (air and thrombotic), thrombosis, dissection and perforation, access-site management, bleeding (including hemothorax and hematoma), and pneumothorax. These are the emergencies a needle, a wire, a dry manifold, or a high femoral stick can create — and the ones you catch only if you keep looking after the dressing looks fine.

Quick Answer: A quiet groin does not rule out retroperitoneal bleeding. A dry manifold is how coronary air becomes VF. Sudden aphasia is a stroke until the operator says otherwise. Distal wire exits are perforations that may need a covered stent and pericardiocentesis.

Access-site bleeding: hematoma, retroperitoneal bleed, radial complications

Expanding groin hematoma. A firm, growing mass, ecchymosis, and pain at the femoral puncture. Hold pressure correctly — above the skin nick if the puncture is higher than the incision — and call the operator before the hematoma becomes a transfusion. Distinguish this from a pseudoaneurysm (pulsatile mass, to-and-fro Doppler neck) and an arteriovenous fistula (continuous bruit after a stick that caught artery and vein, often a low or side-wall puncture). Ultrasound makes the diagnosis; thrombin injection or surgery is not a technologist solo procedure, but recognition is.

Retroperitoneal bleed is the high-femoral-puncture disaster. The dressing can be dry. Hallmarks: back or flank pain, unexplained hypotension, a falling hematocrit, restlessness, and a patient who just does not look right after a puncture above the inguinal ligament / superior to the femoral head. Management: fluids and blood, reverse anticoagulation as directed, urgent computed tomography (CT) if the patient is stable enough, return to the lab for covered-stent reconstruction, or surgery. Do not sit the patient up to make them more comfortable while the retroperitoneum fills.

Radial hematoma and compartment syndrome. A loose hemostasis band plus anticoagulation produces a forearm hematoma; an over-tight band produces ischemia. Pain out of proportion, pain on passive finger stretch, rising narcotic need, and a tense forearm are compartment syndrome until proven otherwise — loosen the band, notify the operator, and do not wait for an absent radial pulse, which is a late finding.

Access-site management after any emergency is the same sequence: mark the borders of a hematoma, document distal pulses and Doppler, hold pressure or adjust the band, keep the limb still, and re-check. A closure device does not erase a high stick.

Embolism and thrombosis

Air embolism. Never let the manifold run dry. Never connect an unflushed line. Coronary air is sudden ST elevation, chest pain, bradycardia or VF in the injected territory. Stop injecting, aspirate if you can, give 100% oxygen so nitrogen resorbs faster, support blood pressure, and defibrillate VF. Venous air (sheath hubs, internal-jugular lines) is managed conceptually with Trendelenburg and left-side (Durant) positioning, aspiration from the right atrium if a catheter is there, and oxygen. Prevention is the real treatment.

Thrombotic embolism. Clot from a stagnant sheath, an unheparinized guide, a left-ventricular thrombus, or a scraped aortic atheroma. Coronary thrombus is no-reflow and ST elevation. Distal embolization of a leg is a cold, painful, pulseless foot after femoral work. Thrombosis of the access vessel itself — radial artery occlusion or femoral thrombosis — is a lost pulse compared with the documented baseline. Check pulses before the patient leaves the lab.

Dissection, perforation, and coronary Ellis types

Iliac or femoral dissection from a sheath or wire is pain, a dissection flap on angiography, and sometimes limb ischemia. Keep the wire in the true lumen if you have it; the operator may stent the dissection.

Coronary perforation is contrast leaving the artery. Teaching Ellis types: Type I is an extraluminal crater without extravasation; Type II is myocardial or pericardial blush without a jet; Type III is frank extravasation, including cavity spilling. Type III is the tamponade pathway. Immediate actions: balloon tamponade of the hole, a covered stent if needed, protamine as directed if the artery will not stay open without heparin, and pericardiocentesis if the pericardium is filling (section 6.2). Distal wire perforations can look small and still kill.

Aortic or coronary dissection from a guide catheter shows as a new false lumen and new ST elevation. Stop injecting into the false lumen. The operator may stent the entry or send the patient to surgery.

CVA / TIA

Stroke during catheterization clusters with aortic stenosis, transcatheter aortic valve replacement (TAVR), a calcific or atheromatous aorta, left-ventricular thrombus, and aggressive arch manipulation. Recognition: aphasia, facial droop, unilateral weakness, sudden confusion, or visual loss — not the patient is sleepy from fentanyl. Notify the operator immediately. Stop unnecessary catheter movement. Protect the airway. Activate the stroke pathway and prepare for urgent CT (and possible intervention) as the institution practices. Document the time last known well — that clock started in your lab.

Pneumothorax and hemothorax

Pneumothorax follows subclavian or internal jugular access, or a high stick that wandered. Sudden dyspnea, ipsilateral decreased breath sounds, rising airway pressure if ventilated, and sometimes hypotension if it is under tension. Stop long enough to diagnose: fluoroscopy may show a visceral pleural line; a chest radiograph or ultrasound confirms. Tension physiology needs immediate decompression and a chest tube, not a completed coronary run.

Hemothorax is blood in the same pleural space after arterial subclavian injury, a pacemaker-wire exit, or a perforated central vein. Hypotension plus dullness and respiratory distress. Fluids, reverse anticoagulation as directed, chest tube, and surgical or endovascular control. This is bleeding, not sedation hypoventilation.

Scenario and traps

A 74-year-old after a difficult femoral stick has a perfect dressing and a systolic pressure of 78 mm Hg with left-flank pain. That is retroperitoneal bleeding, not a vasovagal hangover. A TAVR patient who stops speaking mid-case is a stroke, not quiet sedation. A manifold that sucked air before an RCA injection is air, and VF is the next screen.

Traps: treating a dry dressing as proof of hemostasis. Attributing aphasia to midazolam. Leaving a coronary wire in the pericardium and calling the hypotension vasovagal. Ignoring a pleural line after a subclavian attempt because the coronaries are more interesting. Waiting for an absent radial pulse before treating a tense, painful forearm as compartment syndrome.