Prevention of hematoma and thrombus after CAG/PTCA

Ishwarya1, Sakthivel2, Yashoda K3

1Staff Nurse, Kauvery Hospital, Salem, Tamil Nadu

2Staff Nurse, Kauvery Hospital, Salem, Tamil Nadu

3DNS, Kauvery Hospital, Salem, Tamil Nadu

Abstract

Coronary angiography (CAG) and Percutaneous Transluminal Coronary Angioplasty (PTCA) are common interventional procedures for diagnosis and treatment of coronary artery disease. Sometimes vascular complications such as hematoma / thrombus formation at the access site remain a significant concern, leading to pain, prolonged hospitalization, increased healthcare costs and , rarely a fatality.

Background

Prevention of hematoma and thrombus formation requires a multidisciplinary approach & key preventive measures. Here we are going to discusst meticulous techniques during sheath removal and effective use of closure devices. Nurses play a pivotal role in early detection and timely interventions.

Case Presentation

A 59 years aged female presented with complaints of back pain and left shoulder pain for four days She was known to have Type 2 Diabetes Mellitus for 10 years. The patient was initially evaluated at an outside hospital and diagnosed as ACS, and loading dose was given.

Coronary angiogram + PTCA to LAD was done on 09.07.2025 in our hospital and Approach was through Radial artery puncture (Right hand).

Post procedure patient developed hematoma.

On examination

Pain, swelling, hardness and skin discoloration presented in right upper limb

Vital Signs

Temperature: 98.8 ° F. Pulse Rate 112 beats/min, Blood Pressure 100/60 mmHg

Respiratory Rate: 24 breath/min, SpO2: 98% in RA

GCS: 15/15

Investigation

ParametersValues
Hemoglobin13.0 g/dL
Total WBC9160 cells/µL
HIV RapidNon-reactive
HCV RapidNon-reactive
HBsAG RapidNon-reactive
Platelets1.69L cells/µL
Urea38mg/dL
Creatinine0.53
Sodium132 mmol/L
Potassium4.3 mmol/L

USG Doppler right upper limb

Diffuse subcutaneous edema present

ECG

  • Sinus rhythm, rate 100/mit
  • Normal QRS axis, ST elevation in V2-V5
  • ST depression in III

ECHO

  • Aknetic anterior, distal 2/3rd ef IVS apex
  • Mild LV dysfunction EF(45%)
  • Moderate MR and moderate AR

Immediate Management

  • Reduced anticoagulant dose Inj: Heparin
  • Minimize activities using hand
  • Check frequently radial pulse of the affected arm.
  • For radial or ulnar hematoma apply BP cuff or Tourniquet to prevent further spread of hematoma.
  • Later apply crepe bandage with tight compression
  • Chymoral forte BD
  • Paracetamol 1gm IV Stat
  • Ceftriaxone 1gm IV BD

Nursing management

Post Procedure Care

  • Post procedure check APTT and ACT (Activated clotting time) value 250 sec.
  • Flush the sheath every half an hour once with using of Heparinated saline (500 ml NS and 500 unit of unfractnated Heparin)

Femoral Access

  • Apply Manual compression for 15-20 minutes (or until hemostasis is achieved)
  • Use closure device if prescribed
  • Keep limb straight and immobilized for 4 – 6 hours
  • Avoid hip flexion, coughing or straining
  • After sheath removal apply sandbag for 4 hours
  • After sheath removal check hourly hematoma status

Radial Access

  • Ice application 10 – 15 min several time a day to be applied.
  • Elastic bandage was also applied
  • Limb elevation given
  • Magnesium sulphate dressing was applied
  • Watch for increase size of hematoma
  • Apply compression band / device to radial site
  • Maintain wrist immobilization for 2-3 hr

Monitoring & Observation

  • Check puncture site for swelling, bleeding or hematoma every 15 min x 1 hr, every 30 min x 2 hr, then hourly x 4 hr
  • Palpate for tenderness, induration or expanding hematoma
  • Assess distal pulses, temperature and sensation
  • Monitor vital signs for hypotension / tachycardia (May indicate bleeding)
  • Documentation
  • Record site condition, hemostasis time and observations
  • Note patient’s complaints (Pain, swelling, numbness)
  • Document interventions and notify consultant of abnormalities

Day-3

On the day of discharge her swelling reduced drastically and she had a gradual recovery. She was discharged as per doctor’s advice.

  • Patient Education
  • Instruct the patient not to bend, lift or strain for at least 24 hours
  • Educate on signs of bleeding / hematoma to report immediately
  • Advise adequate oral fluids to flush out contrast (If not contraindicated)

Discharge Advice

DrugDoseFrequencyDuration
Tab. Augmentin625 mg1-0-15 days
Tab. Brilinta90 mg1-0-15 days
Tab. Ecospirn75 mg1-0-05 days
Tab. Aztor20 mg0-0-15 days
Tab. Ivabradine5 mg1-0-15 days
Tab. Pantocid 40 mg1-0-15 days
Tab. Volix-M0.3/500 mg1-0-05 days
Tab. Carvidon MR35 mg1-0-15 days
Tab. Dolo 650 mgSOS5 days
Tab. Zolfresh5 mg0-0-15 days

Conclusion

  • Every angiogram and stenting patient after procedure closely monitoring for hematoma, properly educate the patient. Do not use to activities this hand (Puncture hand).
  • Monitor the size of hematoma and proper treatment give and proper follow up.

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