What are the complications at the access site after Percutaneous Coronary Intervention (PCI)?

Access Site Complications After Percutaneous Coronary Intervention

Vascular access site complications are the most common type of complications after PCI, occurring in 2-6% of cases, with higher rates in patients receiving aggressive anticoagulation therapy. 1 These complications can significantly impact patient morbidity, mortality, and quality of life.

Types of Access Site Complications

Bleeding Complications

• Hematoma: Most common complication (8.5-15.5% of cases) 2
  • Small (1-5 cm): Generally self-limiting
  • Large (>5 cm): May require intervention
• Retroperitoneal bleeding: Serious complication with high mortality risk
  • Signs: Hypotension, suprainguinal tenderness, severe back/lower abdominal pain, unexplained hemoglobin drop (>5-6%) 1
  • Diagnosis: CT scan of abdomen/pelvis
  • Management: 80% can be treated conservatively with transfusions; some require surgical intervention 1

Vascular Complications

• Pseudoaneurysm: False aneurysm at puncture site
  • Management: Ultrasound-directed compression effective for most patients not requiring continued anticoagulation 1
• Arteriovenous fistula: Abnormal connection between artery and vein
  • Detection: Continuous murmur over puncture site
  • Complication: Rarely associated with high-output heart failure 1
• Arterial occlusion/thrombosis: Blockage of femoral artery
• Femoral artery dissection: Tear in arterial wall

Risk Factors for Access Site Complications

Patient-Related Factors

• Advanced age (>70 years)
• Female sex
• Low body weight/small body surface area (<1.6 m²)
• Peripheral arterial disease
• Renal failure (creatinine >2 mg/dL)
• Coagulopathy or bleeding disorders
• Hypertension at presentation 1

Procedure-Related Factors

• Emergent procedures
• Use of glycoprotein IIb/IIIa inhibitors
• Larger sheath size
• Prolonged heparin use with delayed sheath removal
• Improper puncture site (too high or too low)
• Higher activated clotting times
• Use of intra-aortic balloon pump 1

Prevention Strategies

Access Site Selection

• Radial artery access: Significantly reduces vascular complications compared to femoral access
  • Consider for all patients when feasible, especially high-risk patients 1
  • Operator experience is important for success

Femoral Access Techniques

• Proper identification of common femoral artery (below inguinal ligament, above bifurcation)
• Fluoroscopic or ultrasound guidance for arterial puncture
• Use of smaller sheath sizes when possible (5F-6F)

Hemostasis Methods

• Manual compression: Traditional method, effective but requires longer bed rest
• Vascular closure devices (VCDs): Associated with more rapid hemostasis and shorter bed rest
  • Not consistently proven to reduce vascular complications compared to manual compression 1
  • May be beneficial in specific patient populations
• Procoagulant pads with manual compression: Can reduce time to hemostasis 3

Management of Specific Complications

Hematoma

• Small hematomas: Observation, compression if enlarging
• Large hematomas: Extended compression, close monitoring for expansion

Retroperitoneal Bleeding

1. Immediate recognition of signs (hypotension, pain, dropping hematocrit)
2. CT imaging for confirmation
3. Conservative management in 80% of cases (fluid resuscitation, transfusion)
4. Early vascular surgical or interventional consultation 1
5. Surgical intervention if hemodynamically unstable

Pseudoaneurysm

• Ultrasound-guided compression
• Thrombin injection for larger pseudoaneurysms
• Surgical repair if other methods fail

Arteriovenous Fistula

• Small fistulas may close spontaneously
• Larger or persistent fistulas may require surgical repair
• Avoid repeat use of the same access site 1

Post-Procedure Monitoring

• Regular assessment of access site for bleeding, hematoma, or bruit
• Monitor vital signs for hypotension
• Check hematocrit if suspicion of bleeding (drop >5-6% warrants investigation)
• Extended observation for high-risk patients
• Careful timing of anticoagulant resumption after PCI (typically within 24 hours) 1

Special Considerations

• For patients on oral anticoagulants, radial access is strongly preferred to minimize bleeding risk 1
• In patients requiring large-bore access (TAVR, mechanical support devices), careful planning and specialized closure techniques are essential
• Patients with peripheral arterial disease require extra caution and may benefit from alternative access sites

Vigilant monitoring and early recognition of access site complications are essential to prevent progression to more serious conditions that could impact patient outcomes and quality of life.