The Case Files

Abstract

A patient presented after a cardiac cath with a football-sized mass in her groinFigure 1.: Axial CT angiography demonstrating right anterior thigh hematoma measuring 11.9 cm by 15.4 cm by 21 cm with active arterial extravasation (arrow).FigureFigureFigureA 56-year-old woman presented with shortness of breath and a cough she had had for a month. She also had associated orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion. A workup revealed an NSTEMI and new systolic heart failure, dilated cardiomyopathy (estimated ejection fraction 18%), and a sizable left ventricular apical thrombus on echocardiogram. Cardiac catheterization was performed and complicated by stable focal dissection of the right femoral artery and external iliac artery. She was discharged home on warfarin and enoxaparin for the LV thrombus. The patient returned to the ED one week later with symptoms of right groin pain and generalized lethargy, and she was in hypovolemic shock and had a massive right groin mass. Bedside ultrasound of the mass revealed a large hyperechoic fluid collection prompting resuscitation with two units of packed red blood cells to treat suspected hemorrhagic shock. She was also started on norepinephrine infusion for blood pressure and MAP support. Anticoagulation reversal was administered with 10 mg of vitamin K and one unit of FFP. CT angiography of the mass was obtained (Figures 1 and 2), and the patient was immediately taken to the OR for right femoral groin exploration for suspected right femoral artery injury with active arterial extravasation.Figure 2.: Coronal CT angiography demonstrating right anterior thigh hematoma with active arterial extravasation (arrow).Massive Hematoma The patient was diagnosed with post-catheterization femoral artery dissection with massive hematoma and active hemorrhage. She presented with hypotension, progressing to hypovolemic shock requiring aggressive fluid resuscitation, blood transfusion, vasopressors, and anticoagulation reversal. CT angiography showed a mixed density hematoma measuring 11.9 cm by 15.4 cm by 21 cm, and a small central focus of contrast blush. The patient was taken to the OR, where the surgeon found a hematoma the size of a football, which is roughly 17 cm in diameter and roughly 28 cm long. The hematoma was evacuated, and the femoral artery and external iliac arteries were repaired. Hematomas are the most common complication after cardiac catheterization. One review found that the incidence of femoral hematomas was 2.8 percent while active femoral and retroperitoneal bleeds were even lower at 0.6 percent and 0.3 percent, respectively. Dissection of the femoral or iliac arteries is also extremely rare, with an incidence of 0.46 percent. (Glob J Health Sci. 2012;4[1]:65; https://bit.ly/42TUAv5.) A large multicenter cohort study investigating vascular complications following endovascular cardiac procedures found that the incidence of major vascular complications was only 1.6 percent, defined as major hematoma (>10 cm), unstable bleeding, retroperitoneal hematoma, pseudoaneurysm, and arteriovenous fistula within a 48-hour periprocedural window. (Rev Lat Am Enfermagem. 2018;26:e3060; https://bit.ly/3lXFhRx.) The study also found that most vascular complications took place within six hours of surgery, making this patient's prolonged presentation even more unexpected. Most hematomas are self-limited, but larger ones with bleeding can cause hemodynamic instability. This patient was on anticoagulation for an LV thrombus, which likely complicated the bleeding. This case highlighted the importance of physician awareness of an emergent, rare presentation of a common hospital procedure—the cardiac cath. Clinical suspicion, especially in the periprocedural setting, rapid identification of the bleeding source, and immediate imaging make the diagnosis. Patients who continue to deteriorate despite resuscitative efforts require operative management. (StatPearls. Jan. 16, 2023; http://bit.ly/3nnkmaL.) Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].