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Quality Practice
Volume 12 No 3
I
June 2016
29
Anyone working in medical imaging can
enter a near miss or adverse event by
following the link from the website. It
only takes 5 to 10 minutes and will help
to inform practice and improve patient
safety in medical imaging. Enter a report
and help make a difference (www.raer.
org.au).
Although this report is of a complication
of a coronary angiogram, the lessons are
relevant to radiologists as radiologists
also perform femoral artery punctures
and our patients are at risk of the same
complications.
Coronary angiography and cardiac
catheterisation are invaluable tests for
the detection and quantification of
coronary artery disease, identification
of valvular and other structural
abnormalities, and measurement of
haemodynamic parameters
1
. Likewise
catheter angiography and catheter-
guided treatment by radiologists
provides patients with safe, effective
care via a minimally invasive approach.
The degree of risk and potential
complications can be associated with
the patient’s co-morbidities and the
skill and knowledge of the radiologist
or other proceduralist (a cardiologist in
our case report). Bleeding complications
after angiography are associated with
prolonged hospitalisation, increased
hospital costs, patient dissatisfaction,
morbidity, and increased one-year
mortality
2
, so ‘getting it right’ is vital.
Major bleeding complications among
patients undergoing percutaneous
coronary intervention (PCI) have
decreased over time. Bleeding,
haematoma or false aneurysm occur
in <5 per cent of angiograms; 1 in
100 people having angiograms will
require observation in the hospital
overnight, and fewer than 1 in 500–
1000 will require another procedure,
surgery or blood transfusion to correct
the bleeding
3
. Although there are
no absolute contraindications to
performing angiography in older age,
renal insufficiency, uncontrolled diabetes
mellitus, morbid obesity and underlying
cardiovascular problems (for example,
coronary artery disease, congestive
heart failure with low ejection fraction,
recent stroke or myocardial infarction,
bleeding propensity) can all contribute
to increasing the risk of complications
1
.
The procedure being performed, be it
a diagnostic coronary angiogram or a
PCI, also affects the risk to the patient.
The use of iso-osmolar contrast media,
lower gauge catheters, measures to
reduce the incidence of bleeding,
such as, extensive operator experience
reduce the already low incidence of
complications
1
. Major complications are
uncommon, and these procedures can
be performed in critically ill patients with
relatively low risk
1
.
Complications range from minor
problems with rapid resolution to life
threatening situations, if urgent care
is not provided
1
. Major complications
are uncommon occurring in less than 2
per cent of the treated population, with
mortality of less than 0.08 per cent
1
.
Vascular access site complications are
among the most common complications
and are the most significant contributor
to morbidity and mortality of the
procedure
1
. In the earlier days of cardiac
angiography, the incidence of vascular
complications was reported to be
between 0.7-11.7 per cent
4
. Bleeding/
bruising at the groin puncture occurs
in approximately 3–5 per cent of cases.
This can be a problem requiring further
treatment to either stop the bleeding or,
less commonly, to repair an injury to the
vessel wall (e.g. a pseudoaneurysm or
fistula)
5
. Worsening stenosis of the
Reducing Puncture Site
Complications Following
Angiography
The following adverse event reported to RaER
(www.raer.org.au) has been
edited by Australian Patient Safety Foundation staff so as to remove potential
identifiers. All data in RaER has had any potentially identifying information
removed so that it is anonymous at the point of analysis. RaER has statutory
immunity which protects cases reported to RaER: they cannot be used in
litigation. Errors or misconceptions in the original report are retained, but
once commented on may further inform readers. RaER is not able to follow
up cases to obtain more detail.
Presentation:
angina: had a diagnostic catheter coronary angiogram via
femoral artery approach
Incident Description:
3 days after the angiogram we were asked to
investigate a groin lump and haematoma with ultrasound: this demonstrated
a large pseudo-aneurysm. We were then asked to treat the patient for the
cardiologists by using our US machine and probe to compress the neck of
the pseudo-aneurysm
Contributing Factors:
cardiologist did not compress the puncture for very
long and relied on a sandbag to finish the compression
Action Taken:
nil: it was too late to do anything
Prevention:
proper compression of the puncture site
Factors that reduced the outcome:
otherwise well and healthy
Consequence/Outcome:
none long term but this sort of haematoma is
avoidable
Reporter:
Specialist Radiologist
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