Which of the images A, B, or C in Figure 8.1 depicts the correct anatomic placement of the Kelly to identify the site of sheath entry for transfemoral access?

Where should be the ideal location of sheath entry in transfemoral access during cardiac catheterization?

1. Above the inferior epigastric artery to stay as far away from the common femoral bifurcation as possible
   
2. In the mid common femoral artery above the bifurcation
   
3. In the proximal profunda femoris
   
4. In the superficial femoral artery

What are the possible complications associated with the access depicted in Figure 8.3?

1. No complications as the access appears appropriate
   
2. Pseudoaneurysm and arteriovenous malformations
   
3. Retroperitoneal hemorrhage
   
4. Intracranial hemorrhage

What physical sign would be expected if a complication occurred from a “low” stick?

1. A continuous bruit over the access site
   
2. Bruising over the skin
   
3. A sudden and severe drop in blood pressure
   
4. Angina chest discomfort

A 70-year-old man underwent a diagnostic cardiac catheterization via the right transfemoral approach prior to aortic valve replacement. Approximately 1 h later the nurse reports to you that he appears agitated and is complaining of lower abdominal discomfort. His systolic blood pressure is now 90 mmHg. The blood pressure prior to the procedure was 150 mmHg systolic. What is the next best step?

1. Immediately start intravenous fluid and blood transfusion and obtain a noncontrast computed tomography (CT) of the abdomen and pelvis.
   
2. Immediately start intravenous fluid and monitor blood pressure response
   
3. Reassure the nurse that his is likely a vagal response and request that she monitor the blood pressure closely
   
4. Immediately take the patient back to the catheterization laboratory to reevaluate his femoral anatomy.

Which of the femoral angiograms A or B in Figure 8.6 is most likely to be associated with the patient in Question 8.5?

A 68-year old man underwent an uncomplicated percutaneous coronary intervention of the mid left anterior descending (LAD) artery. You are called about 30 min after the procedure that there is a large hematoma over the femoral access site. Manual pressure is applied for 40 min but the hematoma quickly reforms. What is the next best step?

1. Immediately start intravenous fluid and blood transfusion and obtain a noncontrast CT of the abdomen and pelvis
   
2. Immediately start intravenous fluid, apply a clamp for compression, and monitor blood pressure response
   
3. Reassure the nurse that his is likely a vagal response and request that she monitor the blood pressure closely
   
4. Immediately take the patient back to the catheterization laboratory to reevaluate his femoral anatomy

A 56-year-old man presents to the emergency department complaining of discomfort in the right groin. He underwent a diagnostic cardiac catheterization about 3 days ago. Examination reveals a loud, continuous bruit over the femoral artery. What test should be ordered next?

1. A complete lower extremity angiogram, as this patient likely has concomitant peripheral vascular disease
   
2. A CT scan of the pelvis
   
3. An ultrasound evaluation of the right groin
   
4. No work-up is needed as he likely has chronic peripheral vascular disease and the discomfort is normal in this time frame

A patient is being evaluated and consented prior to an outpatient cardiac catheterization. He reports that he had a CT angiogram about 2 years ago. After the procedure he developed hives and pruritus. His physician prescribed a medication for a week at that time, the name of which he cannot recall. How should he be managed?

1. Given that the procedure was remote, this is likely an idiosyncratic reaction; proceed with the planned procedure without addition evaluation or medication
   
2. He may have had a mild contrast reaction, which is unlikely to recur; proceed as planned without addition evaluation or medication
   
3. He may have had a mild contrast reaction; administer an antihistamine prior to the planned procedure
   
4. He may have had a mild contrast reaction; administer an antihistamine and a short course of oral steroids prior to the procedure

You are in the midst of completing a diagnostic cardiac catheterization on a patient. His coronary anatomy is angiographically normal and the left ventricular function is normal. He suddenly becomes profoundly hypotensive. He is fully alert and able to answer questions. A repeat angiography again demonstrates angiographically normal coronary arteries. A stat echocardiogram demonstrates that the left ventricular function is normal and there is no evidence of pericardial effusion. What is the next best step in his management?

1. Reverse the sedation and monitor hemodynamics
   
2. Administer a bolus of normal saline and monitor hemodynamic response
   
3. Start intravenous normal saline bolus followed by continued infusion and administer intravenous glucocorticoids
   
4. Start dopamine infusion immediately and admit to the intensive care unit. Consult cardiothoracic surgery

Which of the following statement is correct regarding sedation during transradial access?

1. No sedation is required as this is a minimal painful and quick access
   
2. Moderate sedation to achieve a completely comfortable response
   
3. Deep sedation, making sure that airway is protected but no response to painful stimuli
   
4. General anesthesia, as multiple sticks are often required and significant pain may occur