Bleeding Complications Post Femoral Artery Coronary Angioplasty: Risks And Prevention

Femoral Artery Approach and Risks

Mrs Elizabeth Green is a 78 year old woman who lives alone in a single-storey unit. Elizabeth has one son, one daughter and five grandchildren. Elizabeth was washing the dishes at home this morning when she experienced 10 minutes of unrelieved central chest and left shoulder pain. After calling an ambulance, she was admitted to the emergency department. After review by the cardiac team, Elizabeth has been admitted for an angiogram, during which, she may need to have a stent inserted. We follow her journey from pre-hospital to discharge post a cardiac event.  A coronary angioplasty is performed using a femoral artery approach. A blockage is found in Elizabeth’s left anterior descending artery which is successfully stented. Discuss about this Case Study.

Mrs. Elizabeth Green is a 78 year old woman, who had to undergo a coronary angioplasty after she was admitted to hospital for central chest and left shoulder pain. The review of her journey from pre-hospital to discharge post cardiac event suggest that the coronary angioplasty was performed using a femoral artery approach and the blockage found in left artery was stented.  Coronary angiography is the gold standard test for the detection and diagnosis of coronary artery disease. One of the potential problems that Mrs. Green can face post angiography includes bleeding complication. Bleeding related problems can be seen in patient due to vascular access site complications. It is the most challenging complications post coronary angiography and post procedural bleeding increases length of stay and long-term survival rate for patient (Tavakol, Ashraf and Brener 2012).

Bleeding has been specifically chosen as a problem for Mrs. Green because coronary angioplasty was performed for her using the femoral artery approach. The femoral approach technique is the most common approach to perform coronary angioplasty. This approach has gained universal acceptance because of easy access and workforce experience (Nardin et al. 2018). However, the disadvantage of the femoral artery approach is that it increases risk of vascular complication in patient. There is significant risk of vascular complication due to transfemoral approach. This form of complication leads to deaths caused by major vascular bleeding. Risk of bleeding also increases due to blood transfusion and vessel occlusion (Wu et al. 2015). Bleeding has been regarded as one potential problem for Mrs. Green because her observations revealed 10-20% occlusion of cardiac vessels.

Many research studies give the evidence regarding access site bleeding as the most common vascular complication in femoral approach. As Mrs. Green is a 78 year old patient, she is most prone to risk because of bleeding complication. Femoral artery is the most common access vessel during angioplasty and vascular access process is optimized by the use of ultrasound guidance and micropuncture needle. In case of angiography procedure, ideal entry position is between the lateral circumflex artery and the femoral bifurcation. However, access outside the zone increases the rate of access site complication (Kwok et al. 2015).

Anti-Platelet Therapy and Bleeding Complications

Shanmugam et al.  (2017) explains that bleeding remains a problem after angioplasty because of the use of anti-platelet and anti-thrombotic agents during the procedure. These agents are given to patient to improve ischemic outcomes. However, it increases risk of access site bleeding and bleeding in the gastrointestinal system and the central nervous system. If the patient is older, the use of blood products increases compared to younger patient. Anti-platelet therapy is regarded as one of the variable that increases bleeding or blood transfusion post angioplasty (Ho and Mok, 2016). The dosage of anti-platelets given during the procedure may be a predictor of bleeding. To reduce such complication, providing appropriate dosage of anti-platelet agents and selection of anti-platelets based on individual risk for ischemic and bleeding complication is needed for Mrs. Green (Numasawa et al. 2017).

The need for blood transfusion after bleeding problem also increases risk for Mrs. Green. This can be said because of pro-inflammatory and thrombotic effects of red blood transfusion. Doyle et al. (2008) suggest worst outcome in patient due to transfusion of more than 3 units. Therefore, a causal relationship between post angioplasty blood transfusion and mortality is evident. This evidence also suggests improvement in access strategies to prevent complication in patients like Mrs. Green.

In case of Mrs. Green, bleeding complication may increase length of hospital stay, long-term mortality and risk of non fatal myocardial infarction and stroke for patient. Major femoral bleeding complication and blood transfusion can also increase the risk of death by causing severe comorbidities (Shanmugam et al. 2017). Taking adequate steps for identification of bleeding complication is also necessary to prevent additional treatment, longer hospital stay and high health care cost (Bhatty et  al. 2011). 

As chances of bleeding may increase co-morbidity and length of hospital for Mrs. Green post angioplasty, the goal of care is to prevent bleeding and reduce complications and discomfort for patient. As anti-platelet therapy, access site complication and age of patient has been regarded as a predictor of bleeding, the need for dosage of certain drugs and preventive measures for the health and recovery of patient must be considered (Mattea et al. 2017). The rational for platelet activation, adverse effects of blood transfusion, discontinuation of anti-platelets and prevalence of co-morbidities should be considered to identify the problem and modify dosage or schedule of certain treatment for Mr. Green.

• The first care plan for patient is to conduct physical assessment of Mrs. Green to identify individual risk for bleeding complication. It is necessary to obtain all relevant information related to the history of coronary angioplasty. For example, identification of patient age and access site such as arterial or venous site during angioplasty is necessary to understand whether age or procedure related factors increases risk of bleeding for Mrs. Green. Inquiry should also be done regarding the use of anticoagulants during the angioplasty procedure as this may help to evaluate whether anti-coagulant use can increase the risk of bleeding post angio or not. Initial assessment of the above mentioned factors for Mrs. Green will be important to understand the impact of oral anti-coagulants and anti-platelet therapy for patient. Nathan, Sen and Yeh (2017) suggest that anti-platelet therapies treat acute thrombosis, however use or continuation of anti-platelet agents is dependent on bleeding risk.
• The next course of action is to conduct puncture site assessment for Mrs. Green and assess other forms of potential complication in patient. Assessment of puncture site is necessary to check for signs of bleeding, hematoma and infection near the puncture site. If bleeding has been found as an issue for Mrs. Green, assessment for presence of signs like tachycardia, pulse pressure, decrease hemoglobin level, agitation and hypotension will also be done. These steps will be crucial to identify problems in patient.
• As vascular site complication and bleeding occurs because of the use of anti-coagulant and anti-platelet agents, reviewing and considering the type of anticoagulant agents to be used for patient will also be necessary. Certain agents like heparin increase risk of bleeding in patient (Kasapis et al. 2010). Hence, adjusting the dose of heparin or combining it with other drugs can reduce complication for Mrs. Green.
• The use of appropriate closure device can also be considered for Mrs. Green. Arterial closure device can promote early mobility of patient and improve comfort level for Mrs. post angiography. It can reduce health care cost and promote early discharge of patient too (Bhatty et 2011)..
• To control bleeding, manual compression can be implemented as the first intervention. However, if this intervention fails, anticoagulant therapy can be discontinued for Mrs Green and signs of hypotension due to bleeding should be managed by fluids and blood products (Bhatty et 2011).
• The post discharge goal for Mrs. Green after the femoral procedure will be to provide adequate patient education to prevent complications. Mrs. Greens needs to be educated regarding abstaining from heavy lifting till 1 week. She must be discouraged from participating in strenuous activities. In case of bowel movement, straining should be avoided to prevent bleeding from the catheter site. To maintain arterial patency, smoking cessation can also be implemented after the angioplasty procedure. It will help to reduce cardiovascular morbidity and mortality for Mrs. Green (Tadros et al. 2015).

The above mentioned care plan is effectively in identifying bleeding complication and determining best intervention to reduce complications for patient. The initial process of assessment is necessary to understand procedural and individual risk factor of bleeding. In addition, strategies like bleeding avoidance strategy and dosage of anti-coagulant agent is considered (Zeymer, Rao and Montalescot 2016). Individualizing and stratifying bleeding risk before the procedure would also helped to minimize complications post angioplasty. The plan of care is evidence based strategy as modification of catheters, usage of closure devices and considerations related to anticoagulant doses and regimens have lowered bleeding rates following coronary angioplasty (Singh 2015).

Blood Transfusion and Major Femoral Bleeding Complications

The above mentioned care plan is a comprehensive and patient-centered strategy to promote health and reduce complication for Mrs. Green post angioplasty procedure. The care plan is in compliance with the NMBA Registered Nurse Standards 7 of evaluating outcomes to inform nursing practice (Nursing and Midwifery Board of Australia 2017). The goal of care has been planned for Mrs. Green after evaluation of the outcome of each action. The process of assessment of vital sites, puncture sites and other complications has helped in the evaluation of each outcome and engaging in critical thinking to identify best care for Mrs. Green. The care plans has also considered revisions in care plan based on identification of specific risk or complication in patient. Adapting the above mentioned process to evaluate outcome will promote achieving positive outcome for Mrs. Green.

References:

Bhatty, S., Cooke, R., Shetty, R. and Jovin, I.S., 2011. Femoral vascular access-site complications in the cardiac catheterization laboratory: diagnosis and management.

 Doyle, B.J., Ting, H.H., Bell, M.R., Lennon, R.J., Mathew, V., Singh, M., Holmes, D.R. and Rihal, C.S., 2008. Major femoral bleeding complications after percutaneous coronary intervention: incidence, predictors, and impact on long-term survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005. Jacc: Cardiovascular Interventions, 1(2), pp.202-209.

Ho, H.H. and Mok, K.H., 2016. Successful drug-coated balloon angioplasty and single anti-platelet therapy to treat an ischaemic stroke patient with haemorrhage and acute coronary syndrome. Acute cardiac care, 18(1), pp.28-30.

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Mattea, V., Salomon, C., Menck, N., Lauten, P., Malur, F.M., Schade, A., Steinborn, F., Costello-Boerrigter, L., Neumeister, A. and Lapp, H., 2017. Low rate of access site complications after transradial coronary catheterization: A prospective ultrasound study. IJC Heart & Vasculature, 14, pp.46-52.

Nardin, M., Verdoia, M., Barbieri, L., Schaffer, A., Suryapranata, H. and De Luca, G., 2018. Radial vs Femoral Approach in Acute Coronary Syndromes: A Meta-Analysis of Randomized Trials. Current vascular pharmacology, 16(1), pp.79-92.

Nathan, A.S., Sen, S. and Yeh, R.W., 2017. The risk of bleeding with the use of antiplatelet agents for the treatment of cardiovascular disease. Expert opinion on drug safety, 16(5), pp.561-572.

Numasawa, Y., Kohsaka, S., Ueda, I., Miyata, H., Sawano, M., Kawamura, A., Noma, S., Suzuki, M., Nakagawa, S., Momiyama, Y. and Fukuda, K., 2017. Incidence and predictors of bleeding complications after percutaneous coronary intervention. Journal of cardiology, 69(1), pp.272-279.

Nursing and Midwifery Board of Australia 2017. Registered nurse standards for practice. Retrieved from: https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx

Shanmugam, V.B., Wong, D.T., Rashid, H., Cameron, J.D., Malaiapan, Y. and Psaltis, P.J., 2017. Bleeding outcomes after non-emergency percutaneous coronary intervention in the very elderly. Journal of geriatric cardiology: JGC, 14(10), p.624.

Singh, M., 2015. Bleeding avoidance strategies during percutaneous coronary interventions. Journal of the American College of Cardiology, 65(20), pp.2225-2238.

Tadros, R.O., Vouyouka, A.G., Ting, W., Teodorescu, V., Kim, S.Y., Marin, M.L. and Faries, P.L., 2015. A review of superficial femoral artery angioplasty and stenting. Journal of Vascular Medicine & Surgery.

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Wu, P.J., Dai, Y.T., Kao, H.L., Chang, C.H. and Lou, M.F., 2015. Access site complications following transfemoral coronary procedures: comparison between traditional compression and angioseal vascular closure devices for haemostasis. BMC cardiovascular disorders, 15(1), p.34.

Zeymer, U., Rao, S.V. and Montalescot, G., 2016. Anticoagulation in coronary intervention. European heart journal, 37(45), pp.3376-3385.