Management of Bilateral Leg Pain Post-TAVR
Patients with bilateral leg pain after transfemoral TAVR must be immediately evaluated for lower extremity vascular insufficiency, groin hematoma, retroperitoneal bleeding, and femoral artery pseudoaneurysm formation, as these are recognized post-procedural complications that require urgent assessment and intervention. 1
Immediate Assessment and Monitoring
Critical Vascular Complications to Exclude
Evaluate for lower extremity vascular insufficiency in the instrumented limb(s), which can manifest as bilateral leg pain if both femoral arteries were accessed or if there is compromised distal perfusion 1
Assess for groin hematoma at the access site(s), which can cause pain radiating to both legs if large enough or if bilateral access was used 1
Rule out retroperitoneal bleeding, a potentially life-threatening complication that can present with bilateral leg pain, back pain, and hemodynamic instability 1
Screen for femoral artery pseudoaneurysm formation, which may cause localized pain and can compromise distal perfusion 1
Diagnostic Approach
Monitor the access site carefully to ensure adequate hemostasis with normal distal blood flow, as this allows early detection and intervention for bleeding, hematoma, or pseudoaneurysm 1
Perform ultrasound of the groin site if there is concern for pseudoaneurysm or vascular complications 1
Assess distal pulses, capillary refill, and limb temperature bilaterally to evaluate for vascular insufficiency 1
Monitor vital signs and hemodynamic stability as retroperitoneal bleeding can present with hypotension and tachycardia before overt signs appear 1
Management Strategy
For Vascular Complications
Large-vessel aortoiliac injury can be managed in most cases by introduction of a covered stent if identified 1
Readiness for vessel rupture with occlusion balloon is critical, and preparation for this complication should have been established during the procedure 1
Groin hematomas may require surgical evacuation if large, expanding, or causing vascular compromise 1
Pain Management Protocol
Initiate a pain management regimen immediately if necessary after operation in the postprocedural unit, which may consist of local anesthetics, narcotics, or non-narcotic analgesics 1
Appropriate pain management is especially important post-TAVR, as patients are often elderly with a high burden of comorbidities 1
Avoid premature mobilization until femoral vascular access sheaths are removed and hemostasis has been achieved, as transfemoral TAVR patients require supine positioning during this period 1
Monitoring and Follow-Up
Continue telemetry and vital signs monitoring per hospital protocol, with particular attention to signs of ongoing bleeding or vascular compromise 1
Monitor intake and output and maintain adequate hydration, as avoidance of early diuretic administration is important to minimize renal failure 1
Assess laboratory results including complete blood count to evaluate for ongoing bleeding 1
Early mobilization should be encouraged only after access site stability is confirmed and vascular complications are excluded 1
Common Pitfalls to Avoid
Do not attribute bilateral leg pain solely to positioning or benign causes without first excluding serious vascular complications, as these can be life-threatening if missed 1
Do not delay imaging if clinical suspicion exists for retroperitoneal bleeding or pseudoaneurysm, as early detection improves outcomes 1
Avoid premature discharge in patients with unexplained bilateral leg pain, as vascular complications may evolve over the first 24-72 hours post-procedure 1