Abstract & Commentary
With Comment by Michael H. Crawford, MD, Professor of Medicine, Chief of Clinical Cardiology, University of California, San Francisco, Editor, Clinical Cardiology Alert.
Synopsis: Small individuals and women are at risk for RPH and high femoral artery sticks are associated with this complication.
Source: Farougue HMO, et al. J Am Coll Cardiol. 2005;45: 363-368.
Retroperitoneal hematoma (RPH) is a dangerous complication of percutaneous coronary interventions (PCIs), which may be more prevalent in this era of multiple antiplatelet drug therapy. Hence, this group from Stanford University Hospital reviewed 3508 consecutive PCIs done over 4 years (2000-2004) to determine the incidence, clinical features, and outcomes of this complication. There were 26 cases of RPH (0.7%) which were compared to 50 randomly selected controls without RPH. RPH was confirmed by CT scans or autopsy (1 case). Anemia occurred in all RPH patients, with the mean drop in hematocrit of 11.5 vs 2.3 in control patients. Blood transfusions were given in 92% of RPH cases. Only 3 patients required surgery because of hypotension. One patient (4%) died in the RPH group vs 1 death in the control group (2%).
Predictors of RPH included high femoral artery puncture site, female sex, and small size (BSA < 1.7 m2). Use of IIb/IIIa agents and vascular closure devices did not increase the risk. Farougue and colleagues concluded that small individuals and women are at risk for RPH. Also, high femoral artery sticks are associated with this complication.
Comment
RPH is uncommon, but a serious complication of PCI that increases hospital stay. The incidence in this large series was 0.7%, similar to other reports of 0.5-1.0%. Recognition of this complication is straightforward, since 96% of the patients with RPH had at least 1 symptom; usually lower abdominal pain and diaphoresis, but back and groin pain also occurred. Also, 92% developed hypotension, and many had lower abdominal tenderness. With these symptoms and signs, a significant drop in hematocrit is usually diagnostic. Clinical signs of RPH occur within 3 hours in 75%, and by 6 hours in 96%. Thus, observing the post PCI patient for at least 3 hours makes sense.
Despite concerns that modern antiplatelet therapy, including aspirin, IIb/IIIa agents, thienopyridines, and heparin leads to spontaneous RPH, there was no evidence for a superanticoagulation theory in this series. In fact, all the RPH patients’ hematoma was ipsilateral to the femoral stick, and the sticks were often high—at or above the proximal third of the femoral head on fluoroscopy. Also, the anti-coagulation agents and the femoral closure device used were not related to RPH. However, few patients received bivalirudin or high-dose clopidogrel alone, which some believe are safer than IIb/III agents.
The major limitations to this study are that it is a one institution observational series, with case controls and the number of RPH episodes being small. However, it is a large series, and the incidence data are similar to smaller series. Thus, the clinical data are probably useful. In the absence of a randomized trial demonstrating the best anticoagulation regimen, focus on the procedure seems warranted.
Many cath labs now routinely cine-document the femoral stick to facilitate quality assurance. Perhaps women or smaller individuals should be observed longer than 3 hours. Clearly, meticulous attention to the techniques of catheter insertion is key to preventing RPH.
Small individuals and women are at risk for RPH and high femoral artery sticks are associated with this complication.
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