Leg Pain

70yo M presenting with R groin and RLE pain x2days. Patient had a cardiac cath 5days ago, access via R groin. States the pain started shortly post cath but intensified 2days ago after he had a vigorous cough. Now with difficulty ambulating. No other associated symptoms. 

PMHx: DM, HTN, CAD, arthritis SgHx -prior cardiac cath with stents

SHx, FHx non-contributory

PE(pertinent): +femoral and distal pulses in both lower extremities. R groin with 10cm area of old bruising, palpable induration and pain on palpation over the artery, 1+ non-pitting edema in RLE. 

No other significant PE finding.

US groin - 3.8cm partially thrombosed pseudo-aneurysm in R femoral artery with small AV fistula between the  R femoral artery and vein

 Outcome: Pt sent to IR, sent back without intervention secondary to AV fistula. Sg consulted, Pt admitted for observation, serial H/H and repeat US in AM. 

Teaching Point: Access site related complications. 
DDX: pseudo-aneurysm, hematoma, DVT, acute vessel occlusion, AV fistula, Neurogenic


1. Pseudo-aneurysm(PSA): Most common access site complication. It is an arterial rupture of one or more layers of its walls, contained by overlying fibromuscular tissue, which communicates with an artery by a neck or sinus tract. 7.5%-8% of femoral artery catheterizations and can result in distal embolization, extrinsic compression on neurovascular structures, rupture and hemorrhage.
Clinically patient presents with groin pain. +/-pulsatile groin mass +/-audible bruit
Plan
Workup: US groin - looking for extra-arterial flow or 'to and fro' doppler waveform via neck of PSA. Large PSA (>3 cm) that are symptomatic, expanding or those associated with large hematomas are generally thought the most prone to rupture.
Consults: IR or Vascular Surgery consult.
Rx:  Ultrasound-guided thrombin injection for PSA. Potential complications of thrombin injection include leakage of thrombin causing thrombosis of the femoral artery and distal embolization.Contraindication for thrombin injection includes PSA with a wide, short neck, and associated arteriovenous fistula. 


2. Acute vessel occlusion: the patient may complain of pain, pallor, parenthesis or decreased movement in the respective limb. Clinical examination may reveal a cold ischemic limb with absent pulses
Consults: Surgery ASAP
Rx: percutaneous vs surgical 


3. Hematoma:
a. Local: Duplex ultrasound of the groin should be performed if the hematoma is pulsatile, expansile, has a bruit or exquisitely tender to exclude a PSA or arteriovenous fistula.
b. Retroperitoneal: Clinical signs that may point toward the diagnosis of a retroperitoneal hemorrhage include hypotension, lower abdominal or flank pain, acute drop in hematocrit and a high puncture at the site of arterial access (typically above the inguinal ligament) which predispose to a higher risk of retroperitoneal bleeding.
Workup: H/H, CT abd/pelvis
Plan: 
If stable, Admit for serial H/H, close monitoring, transfusion and anticoag reversal if indicated
If unstable, Volume resuscitation, Vascular Sg consult and urgent angiography 


4. AV fistula 
Clinically: high index of suspicion is warranted in patients with a new femoral bruit, thrill, fresh hematoma or pain in the lower limbs on the following day after sheath removal. Suspected clinical femoral AVF can be confirmed by color Doppler ultrasonography demonstrating an AVF with continuous systolic and diastolic flow
Plan: Conservative VS surgical management. 
Simple observation and ultrasound guided compression have been suggested as first line therapies in the management of post-catheterization femoral AVF because of their noninvasive nature
Contraindications for conservative management include associated large PSA, hemorrhage, expanding mass, compromised cardiac output, arterial or venous occlusion, and leg edema. 


5. DVT - need i say more?!
6. Neurogenic - due to the proximity of the femoral nerve and the more laterally located lateral cutaneous nerve of the thigh to the common femoral artery. Clinically: hypoesthesia, dysesthesia and hypalgesia of the thigh can be caused by compression of either of the above two nerves as a result of hematoma from the femoral artery access site. Symptoms usually subside over a number of days but symptoms have been reported up to 6 months.