What imaging should be ordered to rule out bleeding from the thrombectomy (thrombus removal) site in a patient with bruising on the right groin and severe anemia (hemoglobin level of 4)?

From the Guidelines

To rule out bleeding from a thrombectomy site in a patient with right groin bruising and severe anemia (hemoglobin of 4), a CT angiogram of the pelvis and right groin should be ordered immediately. This imaging modality provides detailed visualization of vascular structures and can identify active extravasation, pseudoaneurysm formation, or hematoma at the access site, as supported by the study published in the Journal of the American College of Radiology 1. Ultrasound with Doppler is an alternative that can be performed at bedside for initial assessment, but CT angiography offers superior sensitivity for detecting active bleeding.

While awaiting imaging, the patient should receive blood transfusions to address the critical hemoglobin level of 4, and direct pressure should be applied to the groin site if active external bleeding is observed, as recommended in the management of massive haemorrhage 1. The severe anemia in conjunction with localized bruising strongly suggests a post-procedural vascular complication, which requires prompt diagnosis as these complications can rapidly progress to hemodynamic instability. Early identification of bleeding allows for timely intervention, which may include endovascular repair or surgical exploration depending on the nature and extent of the vascular injury.

Some key points to consider in the management of this patient include:

• Control of obvious bleeding points through pressure or other means
• Administration of high flow oxygen and IV access for potential transfusions
• Baseline blood tests including full blood count, prothrombin time, and activated partial thromboplastin time
• Consideration of near-patient testing such as thromboelastography or thromboelastometry if available
• Rapid access to imaging, with CT angiogram being the preferred initial imaging modality for its sensitivity in detecting vascular complications, as noted in the study on pelvic trauma and guidelines 1.

From the Research

Imaging Options to Rule Out Bleeding from Thrombectomy Site

To determine the best imaging option for ruling out bleeding from the thrombectomy site in a patient with bruising on the right groin and severe anemia (hemoglobin level of 4), consider the following:

• CT Angiography (CTA): CTA has been shown to be useful in evaluating acute gastrointestinal bleeding 2. Although the study focused on GI bleeding, the principle of using CTA to detect active bleeding can be applied to other situations, including potential bleeding from a thrombectomy site.
• MRI vs. CT: A study comparing MRI and CT as initial imaging modalities for mechanical thrombectomy found that CT-based selection was associated with increased rates of futile recanalizations compared to MRI selection 3. However, this study does not directly address the issue of bleeding from the thrombectomy site.
• Imaging for Thrombectomy Complications: While there are studies on the outcomes of mechanical thrombectomy and the importance of collateral circulation 4, there is limited direct evidence on the best imaging modality for detecting bleeding from the thrombectomy site itself.

Considerations for Patient Condition

Given the patient's severe anemia (Hb of 4) and bruising on the right groin, it is crucial to quickly identify any source of bleeding. Anemia has been associated with poor clinical outcomes in patients undergoing mechanical thrombectomy, especially those with fair or good collateral circulation 4.

Potential Imaging Approach

Based on the available evidence, CTA might be considered as an initial imaging modality to quickly assess for any signs of active bleeding, given its rapidity and sensitivity for detecting vascular issues. However, the choice of imaging should be tailored to the patient's specific clinical situation, considering factors such as the severity of anemia, the presence of bruising, and the potential for bleeding from the thrombectomy site.

Key Points

• Severe anemia (Hb of 4) and bruising on the right groin necessitate urgent evaluation for a source of bleeding.
• CTA is a rapid and sensitive tool for detecting active bleeding and may be useful in this context.
• The choice of imaging modality should be individualized based on the patient's clinical presentation and potential sources of bleeding.