Treatment strategies for groin hematomas generally consist of observation along with correction of any underlying coagulopathy, stoppage of anticoagulation, and transfusion to maintain appropriate hemoglobin levels. Manual compression should be applied to hematomas that have been identified in the acute setting, with specific attention to focused digital pressure directly at the site of puncture. The placement of “sandbag” type pressure on the groin is generally ineffective because it will not place direct pressure on the bleeding femoral vessel but rather displace the force throughout the groin. Mechanical compression devices, such as the FemoStop and C-clamp, have demonstrated benefit in reducing bleeding complications.²⁰ The extremity in which the mechanical compression device is applied should be carefully monitored to ensure that it does not slip and become displaced off the femoral vessels or compress the femoral artery to the point of occlusion and thrombosis. Computed tomography (CT) is useful to gauge the extent and expansion of the hematoma and to assess for active bleeding as evidenced by a contrast-induced blush (Fig. 46-1). Patients should be placed on bed rest and undergo frequent physical examination to ensure that the size of the hematoma is stable. Continued hemodynamic instability without groin hematoma expansion could indicate expansion of the hematoma into the retroperitoneal space, and further CT scan or duplex ultrasound evaluation is indicated. Laboratory assessment of hemoglobin levels should be done every 4 to 6 hours until stabilization. Once the hematoma is stable, a duplex ultrasound assessment should be performed to rule out the development of a pseudoaneurysm.

Although most of these patients can avoid surgical exploration, the morbidity from a hematoma is significant and includes skin changes, ecchymosis, prolonged pain, and retroperitoneal bleeding. In addition, the time to ambulation is delayed and length of stay increases. Furthermore, patients receiving transfusion for groin hematoma have been shown to have significantly higher mortality rates than those who do not require transfusion.²¹

Groin exploration with evacuation of the hematoma is warranted in the setting of hemodynamic instability, persistent anemia despite ongoing transfusions, skin necrosis, nerve compression, or severe pain. Surgery is often challenging because tissue planes have been destroyed by a dissecting hematoma, and therefore postoperative care is fraught with wound complications. The femoral artery should be explored thoroughly and the arteriotomy inspected for active bleeding, including examination of the posterior wall of the common femoral artery (CFA) to ensure that no back wall injury has occurred.

The diagnostic test of choice for retroperitoneal hematoma is abdominopelvic CT (Fig. 46-3). If it is performed with the intravenous administration of contrast material, extravasation can be an indicator of active bleeding and may prompt earlier intervention. Retroperitoneal hematoma can often be distinguished from spontaneous retroperitoneal bleeding by communication of the retroperitoneal hematoma with the femoral vessels. Spontaneous retroperitoneal hematoma bleeding is often more centrally located and generally venous in etiology. Wire injuries to the vena cava or iliac veins can also result in retroperitoneal hematoma, but surgical intervention is required only for ongoing blood loss or abdominal compartment syndrome.

Therapy for retroperitoneal hematoma is tailored to the clinical status of the patient. In most cases, retroperitoneal hematomas can be managed conservatively with serial hematocrit determinations, correction of coagulopathy, and transfusions as needed. Similar to patients with groin hematomas, patients should be placed on bed rest in a monitored setting. Indications for intervention include neurologic deficits in the affected extremity, hemodynamic instability, ongoing blood loss, and severe pain.²² When it is necessary, decompression of a retroperitoneal hematoma can be performed either through a groin incision or through an incision above the inguinal ligament to gain direct access to the retroperitoneum and iliac vessels. Either way, the arteriotomy must be investigated and repaired for optimal therapy.

Symptomatic inguinal canal hematoma originating from a percutaneous CFA access and pseudoaneurysm formation can be treated by duplex ultrasound–directed compression, surgical exploration, or duplex ultrasound–directed thrombin injection into the pseudoaneurysm sac.

Etiology, Manifestations, and Incidence

An arteriovenous fistula (AVF) in the groin is a rare complication of percutaneous access and involves a communication between the femoral artery and vein. It can occur when a simultaneous right- and left-sided heart catheterization is performed to access the femoral artery and vein. It can also occur after inadvertent low puncture of the CFA bifurcation or between the profunda femoris artery and profunda femoral vein, which run near the superficial femoral artery (SFA). AVF may also develop after through-and-through puncture of the CFA or SFA into the common femoral vein. Groin AVFs are generally asymptomatic and detected on physical examination by the presence of a palpable thrill in the groin or auscultation of a continuous bruit. Rarely do AVFs result in cardiac failure because the shunt volume from these fistulae (average of 160 to 510 mL/min) falls far below that required to cause significant cardiac dysfunction.¹¹ Duplex ultrasound is the imaging study of choice and demonstrates the characteristic systolic-diastolic flow pattern with arterialization of the venous signal (Fig. 46-4).²³

The incidence of AVF after catheterization varies by study and is significantly influenced by the evaluation criteria as well as by the study cohort, inasmuch as many of these patients had been referred to vascular surgery for surgical repair. Kresowik et al²⁴ prospectively performed primary duplex scans on 144 patients undergoing PCI and found four AVFs (2.8%); all were asymptomatic. In contrast, Ricci et al²⁵ identified only four AVFs, all symptomatic, in 7690 catheterizations (0.05%). In one of the larger studies to date, Kelm et al¹¹ evaluated 10,271 consecutive patients undergoing PCI with a 3-year follow-up and reported a 0.88% incidence of AVF. In accordance with the work of Kent et al,²⁶ who described a 0.3% incidence of AVF, these investigators used an audible bruit in the groin as the trigger to prompt duplex ultrasound investigation. Risk factors for the development of AVF included female gender and hypertension, and procedure-related factors included puncture of the left groin and high-dose procedural anticoagulation.²⁷ The reason for the elevated risk for AVF with left groin puncture is believed to be the angle of approach because the physician generally stands on the contralateral side of the patient.²³

Management

Because of the rarity of this phenomenon, the natural history of femoral AVFs is somewhat unclear, and therefore the treatment algorithm is controversial. Treatment options include observation alone, surgical repair, and endovascular repair. Ultrasound-guided compression has been reported to treat groin AVF; however, low success rates have prompted abandonment of this therapy.²⁸ Kelm et al¹¹ showed that 38% of AVF patients underwent spontaneous closure of their fistula within 1 year and that more than two thirds of these fistulae closed within 4 months. Of the remaining fistulae that persisted, the authors reported no adverse outcomes, including right-sided heart failure or limb swelling. Similarly, Toursarkissian et al²⁹ monitored 81 AVFs, 81% of which closed spontaneously, prompting the authors to recommend that carefully selected patients can be managed without surgery or intervention. If conservative management is implemented, patients require close duplex ultrasound surveillance and frequent physical examination evaluating for signs of congestive heart failure or limb swelling. If symptoms do arise or the fistula increases in size, surgical treatment is indicated.

Groin exploration can in most cases be performed with local anesthesia. AVF ligation consists of standard proximal and distal control of the artery, followed by division of the fistula and primary closure of the defect in both vessels with interrupted polypropylene sutures. Depending on chronicity, there is always the potential for large-volume scar tissue to have developed, which can at times make this procedure more complex.

Endovascular management of femoral AVFs has been reported with balloon-expandable stent-grafts.^30–32 Coverage of the arterial component of the fistula with a covered stent-graft results in immediate abolishment of the AVF without the need for surgery and therefore is optimal for high-risk candidates who may have failed to respond to conservative management. Onal et al³³ were clinically successful in abolishing 9 of 10 AVFs originating from the profunda femoris artery, and all stents were patent at 18 months of follow-up. However, caution must be exercised in deployment of these stents, especially in the distal CFA or the proximal profunda femoris, where the graft could impinge on the origin of the SFA or profunda femoris artery. In addition, the long-term durability of covered stents in this anatomic location remains to be determined. Another endovascular option is embolization of long fistula tracks with n-butyl cyanoacrylate, but there is a risk of distal embolization of the agent.³⁴ The decision whether to treat an AVF with open, endovascular, or conservative measures is still under debate and should be driven by the surgeon’s experience and the patient’s overall symptoms and comorbid conditions.

Etiology and Manifestations

A pseudoaneurysm (PSA) develops after endovascular procedures if the arteriotomy has not adequately sealed once the sheath is removed or if the occluding clot in the arteriotomy is dislodged in the postprocedure period. There is communication with the arterial lumen, and blood extravasates into the surrounding soft tissue. It is a “pseudo” aneurysm in that no elements of the arterial wall are incorporated in the aneurysm sac; the wall of the PSA consists solely of compressed thrombus and surrounding soft tissue. PSAs can be differentiated from hematomas in that there is arterial flow into the PSA with a defined neck that tracks to the arteriotomy through the femoral sheath. The incidence of PSA formation after percutaneous procedures varies widely from 0.05% to 8.0%, with heterogeneity of study characteristics being the main cause of this variability.^24,35,36 Factors that increase the risk for PSA are listed in Box 46-1 and are similar to those for other postcatheterization vascular complications.

The cause of a PSA is often related to an inability to adequately compress the vessel after removal of the sheath. This occurs most frequently with SFA or low CFA puncture because the femoral head sits more cephalic and compression is inadequate. To decrease the potential for PSA, it is important to identify the femoral head fluoroscopically before puncture so that the arteriotomy site will be placed over the bone. In a large meta-analysis by Koreny et al³⁷ involving more than 4000 patients, use of a vascular closure device was also associated with a slightly higher risk for PSA formation than was manual compression alone.

PSAs are characterized by a pulsatile mass at the puncture site, usually within 24 to 48 hours after the procedure. They are often associated with groin tenderness and can be difficult to differentiate from hematomas. Large PSAs can cause local compression symptoms on the femoral nerve, leading to a neuropathy, or on the femoral vein, leading to thrombosis. Large PSAs can also cause local skin ischemia with eventual necrosis. On physical examination, a systolic bruit can be auscultated and is associated with the pulsatile groin mass.

When there is clinical suspicion of a PSA, groin arterial duplex ultrasound examination should be performed. Duplex ultrasound examination provides a determination of the size and location of the PSA relative to the bifurcation of the CFA to the profunda and SFA and also allows differentiation between hematoma and PSA, the latter having arterial flow characteristics outside the vessel. The typical ultrasound appearance of a PSA is an echolucent sac that is pulsatile, and with the addition of color Doppler study, a swirling flow pattern is noted within this sac (Fig. 46-5). On spectral waveform analysis, the characteristic “to-and-fro” flow pattern can be discerned and is pathognomonic for PSA.³⁸ Adjacent structures can also be visualized with B-mode imaging, and after the artery is localized, the neck of the aneurysm can be found as it communicates with the sac. The sensitivity of duplex ultrasound for the identification of PSA is 94% with a specificity of 97%.³⁹ If the PSA has significant extension into the retroperitoneum, abdominopelvic contrast-enhanced CT may be of benefit to evaluate its size as well as to identify additional arterial injury sites.