What are the potential complications of groin access for procedures?

Complications of Groin Access for Procedures

The most common complications of groin access for vascular procedures include hematoma, bleeding, pseudoaneurysm, arteriovenous fistula, infection, and thrombosis, with overall complication rates of approximately 6% and surgical repair required in about 2.3% of cases. 1

Major Complications

Vascular Complications

• Bleeding complications:
  • Minor and major hematoma (most common)
  • Retroperitoneal bleeding (potentially life-threatening)
  • Pseudoaneurysm formation (occurs in up to 6% of cases)
  • Arteriovenous fistula (occurs in about 12% of cases requiring repair)
  • Femoral artery laceration or perforation

Infectious Complications

• Groin wound infections:
  • Occur in approximately 8.6% of cases with surgical groin incisions 2
  • Superficial infections (4.6%) and deeper infections
  • Associated with significantly longer hospital stays and higher rates of postoperative acute kidney injury

Thrombotic Complications

• Arterial thrombosis:
  • Can lead to acute limb ischemia requiring urgent intervention
  • Higher risk in smaller vessels, prolonged procedures, and in patients with peripheral arterial disease

Risk Factors

Patient-Related Factors

• Female gender (43% vs 26% in patients without complications) 1
• Advanced age (66.8 vs 62.1 years) 1
• Obesity (BMI ≥30 kg/m²) 2
• Peripheral vascular disease
• Ischemic heart disease 2
• Hypertension (higher systolic blood pressure) 1
• Coexisting renal insufficiency

Procedure-Related Factors

• Anticoagulation therapy (especially post-procedural heparin administration) 1
• Larger sheath sizes
• Multiple catheter exchanges
• Prolonged procedure time 2
• Use of certain devices (e.g., stents have 14.9% vs 3.5% complication rate) 1
• Aqueous betadine skin preparation (associated with higher infection rates) 2
• Bypass/patch use (vein, xenograft, or prosthetic) 2

Prevention Strategies

Access Technique

• Ultrasound guidance:
  • The American College of Cardiology recommends using ultrasound guidance for access to reduce complications 3
  • Target the common femoral artery (avoid high or low punctures) 3

Alternative Access Considerations

• Consider radial access when appropriate:
  • Radial access is preferred in patients with:
    • Previous bilateral femoral artery surgery
    • Obesity
    • Non-palpable femoral pulses
    • Pelvic trauma
    • High-dose anticoagulation requirements
    • Previous major femoral access site complications
    • "Hostile groin" (scarring, infection, skin breakdown) 4

Anticoagulation Management

• For patients receiving unfractionated heparin, aim for:
  • ACT of 200-250 seconds when using GP IIb/IIIa inhibitors
  • ACT of 250-300 seconds without GP IIb/IIIa inhibitors 3
• Remove sheaths when ACT approaches normal levels 3

Incision Technique

• Consider oblique groin incision rather than vertical incision when surgical access is required
  • Associated with lower rates of lymphocele, lymph fistulae and infections 5

Management of Complications

General Approach

• The American College of Cardiology notes that >80% of complications can be managed conservatively 3
• Conservative management includes:
  • CT confirmation of diagnosis
  • Volume resuscitation
  • Blood transfusion if needed

Specific Complications Management

• Pseudoaneurysm:

  • Ultrasound-guided compression for small pseudoaneurysms
  • Thrombin injection for larger pseudoaneurysms 3

• Hematoma:

  • Manual compression
  • Reversal of anticoagulation if appropriate
  • Surgical evacuation for expanding hematomas causing neurovascular compromise

• Infections:

  • Appropriate antibiotic therapy
  • Surgical debridement for deep infections
  • Removal of infected prosthetic material if present

Special Considerations

High-Risk Patients

• Patients undergoing interventional (rather than diagnostic) procedures require more intensive monitoring 3
• Consider longer bed rest for high-risk patients 3
• In patients with "hostile groin," direct superficial femoral artery access under ultrasound guidance may be safer than common femoral artery access 6

Post-Procedure Monitoring

• Monitor for signs of complications including:
  • Hypotension
  • Suprainguinal tenderness
  • Severe back or lower abdominal pain 3
  • Expanding groin hematoma
  • Fever or other signs of infection

By understanding these complications and implementing appropriate preventive strategies, clinicians can minimize the risks associated with groin access procedures and improve patient outcomes.