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21 Closure Devices Leslie Cho and Debabrata Mukherjee Questions 1 The potential benefits of vascular closure devices include all of the following, except: (A) Reduction in time to hemostasis (B) Earlier ambulation of patients (C) Lower incidence of hematoma and pseudoaneurysm (D) Increased patient comfort (E) Earlier discharge for some patients 2 Which of the following is a patented product that enhances the natural method of achieving hemostasis by delivering collagen extravascularly to the surface of the femoral artery? (A) Angio-Seal (B) Duett (C) FemoStop (D) Perclose (E) Syvek (F) VasoSeal 3 Which of the following is an arch with a pneumatic pressure dome, connection tubing, and a two-way stopcock, a belt, and a pump for inflation? (A) Angio-Seal (B) Duett (C) FemoStop (D) Perclose (E) Syvek (F) VasoSeal 4 Which of the following is a device that creates a mechanical seal by sandwiching the arteriotomy between a bioabsorbable anchor and the collagen sponge, which dissolves within 8 to 12 weeks? (A) Angio-Seal (B) Duett 164 (C) FemoStop (D) Perclose (E) Syvek (F) VasoSeal 5 Which of the following is a suture-mediated closure device that can be used in anticoagulant patients? (A) Angio-Seal (B) Duett (C) FemoStop (D) Perclose (E) Syvek (F) VasoSeal 6 Which of the following is a balloon catheter that initiates hemostasis and ensures the precise placement of procoagulant (a flowable mixture of thrombin, collagen, and diluent) at the puncture site in the entire tissue tract? (A) Angio-Seal (B) Duett (C) FemoStop (D) Perclose (E) Syvek (F) VasoSeal 7 Which of the following is made of a soft, white, sterile, nonwoven pad of cellulosic polymer, and poly-Nacetyl glucosamine isolated from a microalgae? (A) Angio-Seal (B) Duett (C) FemoStop (D) Perclose (E) Syvek (F) VasoSeal Closure Devices 8 Clinical studies have suggested increased vascular complications with which of the following devices? (A) Angio-Seal (B) Duett (C) FemoStop (D) Perclose (E) Syvek (F) VasoSeal 9 The incidence of which complication is higher with vascular closure devices than with concomitant use of glycoprotein (GP) IIb/IIIa inhibitors: (A) (B) (C) (D) (E) Local hematoma Arteriovenous fistula Pseudoaneurysm Retroperitoneal hematoma Femoral vein thrombosis 10 The most common infectious complication associated with percutaneous vascular closure devices is: (A) (B) (C) (D) (E) Generalized sepsis Infective endocarditis Mycotic pseudoaneurysm Carbuncle Femoral endarteritis 11 A 45-year-old woman undergoes a diagnostic catheterization after having a positive stress test for atypical chest pain. She is found to have mild luminal irregularities, and the cardiologist decides to use an Angio-Seal device to close her groin. She responds well and is sent to the recovery room with instructions to return home in 2 hours. An hour after the procedure, she is found to be pulseless and have pain, pallor, and paresthesia of her right leg. What should you do next? (A) (B) (C) (D) Give pain pills for relief IV heparin and GPIIb/IIIa inhibitor IV fibrinolytic therapy Urgent surgery consult or urgent percutaneous peripheral vascular intervention 12 The patient mentioned in the preceding text responds well to the treatment and is discharged after 2 weeks in the hospital. She returns to your office demanding to know what had happened. She is convinced that the closure device is unsafe and should have never been used on her. She wants to know whether manual pressure would have been safer to use. Is she correct? (A) Yes, in a large analysis, manual pressure was safer compared with vascular closure devices regardless of the type of case 165 (B) No, in a large analysis, manual pressure was safer only in diagnostic cases, but not in percutaneous coronary intervention (PCI) cases (C) No, in a large analysis, both manual pressure and vascular closure devices had similar major complication rates (D) No, in a large analysis, manual pressure was safer only in PCI cases, but not in diagnostic cases 13 The same patient wants to know why she had femoral artery thrombosis. All of the following are risk factors for femoral artery thrombosis, except: (A) (B) (C) (D) (E) Small femoral artery size Peripheral vascular disease Diabetes Female gender Obesity 14 A 67-year-old woman presents to your office for a second opinion. She underwent PCI 3 months ago and did well. On a routine physical examination she was found to have a pulsatile mass in her right groin. She then has a duplex ultrasound, which shows a 3.8 cm pseudoaneurysm. She was seen by a vascular surgeon and was given thrombin injection. However, her pseudoaneurysm is unchanged. She has been told that she will need surgery. She is convinced that this is because her groin was sealed with vascular closure device. Is the incidence of pseudoaneurysm higher with vascular closure devices? (A) No, it is the same with manual and vascular closure devices (B) Yes, it is higher with vascular closure devices (C) No, it is higher with manual pressure 15 The patient mentioned in the previous question would like your opinion regarding treatment options. What are her other options? (A) Surgery is the only option because she has failed thrombin injection (B) Manual compression is another option and if that fails, then surgery (C) Another round of thrombin injection should be tried (D) Conservative management should be tried with blood pressure control (E) Surgery is not needed at this time because she is asymptomatic 16 What are the distinguishing features on the physical examination of a groin hematoma from femoral artery pseudoaneurysm? (A) Groin mass (B) Pain and audible bruit 166 900 Questions: An Interventional Cardiology Board Review (C) Continuous groin pain and neuralgia (D) Pulsatile groin mass and bruit 17 Your hospital administrator contacts you regarding the catheterization laboratory revenue. He states that with drug-eluting stent usage, the margin for profit has decreased significantly. He is convinced that you can save money by not using vascular closure devices. He asks you about the disadvantages of not using vascular closure devices. You reply: (A) There will be more hematoma with manual pressure (B) Prolong bed rest with manual pressure (C) There will be more atrioventricular (AV) fistulas 18 An 81-year-old patient undergoes an urgent catheterization for acute myocardial infarction (MI). She is found on angiogram to have 100% occlusion of left anterior descending (LAD) artery. She has a successful PCI to LAD with 3.0/33 drug-eluting stent and 3.0/28 drug-eluting stent with heparin and GPIIb/IIIa inhibitor, abciximab. She is allergic to latex. She is unable to keep her leg still. Can you use Angio-Seal? (A) Yes, Angio-Seal can be used in patients with latex allergy (B) No, Angio-Seal cannot be used in patients with latex allergy (C) Only manual pressure should be applied to patients with latex allergy (D) No, only Perclose can be used in patients with latex allergy 19 A 78-year-old man undergoes PCI to the right coronary artery (RCA) with bivalirudin. He responds well and is sealed with Perclose without any complication. He is discharged home. He returns to your office within a month, complaining of severe right leg pain with minimal exertion. You examine him, and he is found to have slightly decreased right lower extremity pulse, but otherwise unremarkable. He undergoes duplex and is found to have Percloseinduced right femoral artery stenosis. What are the treatment options? (A) No treatment is required; it will go away within 2 to 3 weeks (B) There is no such thing as subacute limb ischemia from vascular closure device; therefore, he has peripheral arterial diseases (PAD) (C) Access from contralateral femoral artery and balloon angioplasty of the affected side (D) Surgical intervention 20 An 80-year-old woman undergoes an elective PCI to dominant circumflex (CX). Her right femoral artery is sealed with new generation Angio-Seal. Three days later she presents with chest pain, ST elevation, and hypotension in the emergency room (ER). She is taken back to catheterization laboratory. Can you reaccess the same site? (A) Yes, as long as it is 1 cm proximal to the previously accessed site (B) No, right femoral artery cannot be accessed for 90 days (C) No, the same site cannot be accessed for 30 days (D) No, the same site cannot be accessed for 7 days Answers and Explanations 1 Answer C. Vascular closure devices have some obvious advantages. The time spent by catheterization laboratory staff in manually compressing the puncture site is reduced, which in turn improves the patient flow throughput in busy catheterization laboratories. Other potential benefits include the reduction in time to hemostasis, earlier ambulation of patients, increased patient comfort and earlier discharge for some patients. A rigorously performed systematic review and meta-analysis suggested that vascular closure devices may actually increase the risk of hematoma and pseudoaneurysm (JAMA. 2004;291:350–357). puncture site, minimizing the pain and discomfort associated with excessive pressure. Although the dome is made of a soft latex-free material occupying the smallest area necessary to achieve hemostasis, it minimizes the risk of venous congestion or pain associated with ligament and nerve compression. Its inflatable transparent dome facilitates accurate placement of pressure and allows clear visibility of the puncture site. The other advantages over manual compression are that FemoStop allows hands-free operation and compression, potentially less discomfort and more freedom of movement for patients, accurate manometer-controlled pressure, and less contact with blood. 2 Answer F. VasoSeal (see following figure) enhances the body’s natural method of achieving hemostasis by delivering collagen extravascularly to the surface of the femoral artery. Type 1 collagen produced from bovine tendons activates platelets in the arterial puncture, forming a clot on the surface of the artery, resulting in a seal at the arterial puncture site for immediate sheath removal after angioplasty and stent procedures. VasoSeal devices do not require leaving a foreign body inside the artery, do not increase the size of the arterial puncture, and do not require the user to leave a clip on the patient or surgical suturing after the procedure. In addition, the collagen reabsorbs over a 6-week period and no fluoroscopy is needed before use. Latex-free product 3 Answer C. The FemoStop Femoral Compression System (see following figure) provides an alternative to manual pressure and other methods of manually achieving femoral artery hemostasis. The FemoStop dome applies a focused, controlled pressure to the 4 Answer A. The Angio-Seal Vascular Closure Device quickly seals femoral artery punctures following catheterization procedures, allowing for early ambulation and hospital discharge. The device creates a mechanical seal by sandwiching the arteriotomy between a bioabsorbable anchor and collagen sponge, which dissolve within 60 to 90 days (see following figure). The Angio-Seal STS PLUS platform is composed of an absorbable collagen sponge and a specially designed absorbable polymer anchor connected by an absorbable self-tightening suture. The device seals and sandwiches the arteriotomy between its two primary components, the anchor and the collagen sponge. Hemostasis is achieved primarily through mechanical means and is supplemented by the platelet-inducing properties of the collagen. 167 168 900 Questions: An Interventional Cardiology Board Review 5 Answer D. The Perclose system (see following figure) uses percutaneous delivery of suture for closing the common femoral artery access site of patients who have undergone diagnostic or interventional catheterization procedures using 5 to 8 F sheaths. The modified Perclose A-T (Auto-Tie) is intended to simplify the complex knot-tying step that many physicians consider the most difficult step of the procedure. This innovation adds convenience, increases ease of use, and reduces the vessel closure procedure time. Device numbered with deployment sequence Quickcut mechanism 6 Answer B. The Duett sealing device (see following figure) is used to seal the arterial puncture site following percutaneous procedures such as angiography, angioplasty, and stent placement. Using a dual approach (a balloon catheter and procoagulant), the Duett sealing device is designed to rapidly and safely stop bleeding. The Duett sealing device can quickly seal the entire puncture site with a onesize-fits-all device that leaves nothing rigid behind that could interfere with reaccess or potentiate an infection. 7 Answer E. The Syvek patch (see following figure) is made of a soft, white, sterile, nonwoven pad of cellulosic polymer and poly-N-acetyl glucosamine isolated from a microalgae. It leaves no subcutaneous foreign matter, is nonallergenic, and does not restrict immediate same site reentry. Although there are no known contraindications, it does not eliminate manual compression, but may shorten the duration of compression needed. 8 Answer B. The pooled analyses by Vaitkus et al. (J Invasive Cardiol. 2004;16:243–246) demonstrated that the Angio-Seal and Perclose devices might be superior to or at least equivalent to manual compression for both interventional and diagnostic cases. The results of controlled clinical trials with VasoSeal, however, indicated a potentially increased risk of complications. Another analysis by Nikolsky et al. (J Am Coll Cardiol. 2004;44:1200–1209) showed that in interventional cases the rate of complications was also higher with VasoSeal. 9 Answer D. Cura et al. (Am J Cardiol. 2000;86:780– 782, A9) analyzed approximately 3,000 consecutive patients who underwent PCI and demonstrated that the use of femoral closure devices in a broad spectrum of patients was associated with an overall risk similar to manual compression. Even in patients treated with GPIIb/IIIa platelet inhibition, the incidence of access-site events between those receiving manual Closure Devices 169 compression and those treated with closure devices was quite comparable. However, in this cohort, the incidence of retroperitoneal hemorrhage was significantly increased among patients treated with closure devices compared with manual compression (0.9% vs. 0.1%, p = 0.01). compared with vascular closure devices (Catheter Cardiovasc Interv. 2006;67:556–562). However, in a meta-analysis by Koreny et al. (JAMA. 2004;291: 350–357) using only randomized studies, there appeared to be slightly higher hematoma and pseudoaneurysm incidence with vascular closure devices. 10 Answer C. Sohail MR et al. reviewed all cases of closure device–related infection seen in their institution and searched the English language medical literature for all previously published reports (Mayo Clin Proc. 2005;80:1011–1015). They identified 46 cases from the medical literature and 6 cases from their institutional database. Diabetes mellitus and obesity were the most common comorbidities. The median incubation period from device insertion to presentation with access-site infection was 8 days (with a range of 2 to 29 days). The most common presenting symptoms were pain, erythema, fever, swelling, and purulent drainage at the access site. Mycotic pseudoaneurysm was the most common complication (22 cases). Staphylococcus aureus was responsible for most of the infections (75%). The mortality rate was 6% (3 patients). This suggests that infection associated with closure device placement is uncommon, but is an extremely serious complication. Morbidity is high, and aggressive medical and surgical interventions are required to achieve cure. 13 Answer E. Obesity is not a risk factor for femoral artery thrombosis (UpToDate. 1997). 14 Answer C. In a large meta-analysis by Koreny et al. (JAMA. 2004;291:350–357) using only randomized studies of 4,000 patients, there appeared to be slightly higher hematoma and pseudoaneurysm incidence with vascular closure devices. 15 Answer A. She has a large pseudoaneurysm with failed injection. Her option is surgery (J Am Coll Cardiol. 2006;47:1239–1312). 16 Answer D. Pseudoaneurysm can be diagnosed on physical examination by pulsatile mass and audible bruit. Most are asymptomatic. 17 Answer B. The use of vascular closure devices reduces the time to hemostasis and the duration of bed rest (JAMA. 2004;291:350–357). 18 Answer A. Angio-Seal can be used in patients with latex allergy. 11 Answer D. She has acute femoral artery thrombosis. There is approximately 1% to 2% risk of major complication from vascular closure device. Acute femoral artery thrombosis requires urgent intervention (JAMA. 2004;291:350–357). 19 Answer C. Subacute limb ischemia has been reported from vascular closure devices. This may be treated with balloon angioplasty (Catheter Cardiovasc Interv. 2002;57:12–23). 12 Answer C. In a large propensity score analysis of 24,000 patients from a single-center retrospective study, the risk-adjusted occurrence of vascular complications was similar for manual pressure when 20 Answer A. Applegate RJ et al. studied the restick issue with Angio-Seal and found that restick can occur safely within 1 to 7 days of Angio-Seal (Catheter Cardiovasc Interv. 2003;58:181–184). 22 Management of Intraprocedural and Postprocedural Complications Ferdinand Leya Questions 1 A 69-year-old man with hypertension (HTN) and renal insufficiency (glomerular filtration rate [GFR] 65) presents to your office for consult from an Internist. He has been experiencing chest pain with exertion and underwent stress thallium which showed anterior defect. He then had cardiac catheterization that showed severe three-vessel disease with ejection fraction (EF) of 45%. He refused coronary artery bypass grafting (CABG) and presents to your office for multivessel percutaneous coronary intervention (PCI). He is concerned about his risk. What is his risk of emergent CABG with percutaneous revascularization? (A) (B) (C) (D) 0.4% 1.5% 3.7% 5.0% 2 During the selective cannulation of the left main coronary ostium, the blood pressure (BP) waveform, as seen in the figure, was recorded. Which of the following is the most likely explanation for the waveform? (A) The pressure waveform indicates that the catheter tip prolapsed into the left ventricle (B) The pressure transducer contains air (C) There is catheter kink (D) The catheter is up against the wall (E) The catheter is engaged into a diseased left main artery 170 1000 ms ll v 200 180 Pl AO 131/53 64 160 140 142 134 139 141 136 136 120 100 100 80 60 40 63 55 57 55 9 154 154 20 0 11:02:20 AM 11:02:22 AM 11:02:24 AM 11:02:26 AM 11:02:28 AM Management of Intraprocedural and Postprocedural Complications 3 A 67-year-old retired lawyer with diabetes mellitus (DM), hyperlipidemia, and HTN presents to you for a second opinion. He underwent cardiac catheterization for increasing exertional chest pain and was found to have chronically occluded moderate-size right coronary artery (RCA) and 50% left anterior descending (LAD) artery, and circumflex (CX) lesions. He underwent PCI to RCA and had 2.5/28, 2.5/33, and 2.25/28 bare-metal stent. Drug-eluting stents were not used because of the patient’s history of ulcers. Immediately after the intervention, the patient started complaining of chest pain and had inferior ST elevation. He underwent immediate catheterization and was found to have occluded RCA. However, the artery could not be successfully opened. In the stent era, all factors have been correlated with abrupt vessel closure, except: (A) Stent length (B) Small vessel diameter (C) Poor distal run off (D) Excessive tortuosity (E) Unstable angina 4 A 51-year-old woman presents to you for second opinion. She underwent successful elective PCI to CX for exertional chest pain. Her hospitalization was uneventful until the time of discharge when she was told that her creatine kinase-MB (CK-MB) isoform was three times the normal limit. She was discharged home and has been doing well but cannot stop worrying. Which of the following statements is true regarding procedure-related enzyme release? (A) CK-MB elevation does not occur after angiographically successful uncomplicated coronary interventions (B) Routine monitoring of cardiac enzymes is not necessary to detect patients who suffer from myocardial injury after coronary intervention (C) The incidence of CK-MB enzyme elevation after angiographically successful percutaneous intervention is >50% (D) Elevation of CK-MB after PCI predicts increased long-term cardiac mortality and morbidity 5 A 45-year-old patient with diabetes who was hypercholesterolemic, hypertensive, and a heavy (two-packs-a-day) smoker underwent a successful angioplasty and stent placement to mid-LAD lesion. Before angioplasty, the patient received acetylsalicylic acid (ASA) 325, and glycoprotein (GP) IIb/IIIa inhibitor treatment. The angioplasty procedure was uneventful. The Cypher 3.0 × 28-mm stent was deployed at 16 atm. The final angiogram showed a well-expanded vessel with thrombolysis in 171 myocardial infarction (TIMI) 3 flow. The following morning, a routine troponin was 1.5 ng/mL. The patient remained asymptomatic and his cardiac examination was normal. His electrocardiogram (EKG) showed nonspecific ST–T-wave changes, which were unchanged from the admitting EKG. The best course of action for this patient now is as follows: (A) Discharge the patient immediately with β-blockers, nitrates, statin, ASA, Plavix, and an angiotensin-converting enzyme (ACE) inhibitor (B) Bring the patient back to the catheterization laboratory for a repeat angiogram (C) Transfer the patient to a coronary care unit (CCU) (D) Continue to monitor the patient in telemetry for 48 hours (E) Check another set of troponin in 8 hours. If the trend is down then discharge him on Plavix, ASA, β-blockers, statins, and an ACE inhibitor 6 A 75-year-old patient traveled 4 hours by car to get to the hospital for a 7:00 am, first case, elective, complex, multilesion, multivessel coronary intervention. Although the angioplasty procedure was difficult to perform because of lack of adequate guide support, finally after trying several guide catheters, an Amplatz no. 3 guide catheter was found to give a good guide support to deliver three long Taxus stents. At the end of the procedure, the operator informed the patient that he was successful in opening all the blockages. The catheterization laboratory staff moved the patient to the recovery room. The patient was asymptomatic without any complaint and had normal vital signs. Later, the recovery room registered nurse (RN) noticed that the patient became progressively lethargic and less responsive to her. The physician in charge was notified. After obtaining the vital signs, which were noted to be unchanged, the most appropriate action at this time should be: (A) Have the RN check the patient’s EKG and his vital signs again (B) Give him naloxone (Narcan) (C) Perform a screening neurologic examination or obtain an urgent neurology consult (D) Check the patient’s complete blood count (CBC), blood sugar, blood urea nitrogen (BUN), and creatinine level 7 The patient mentioned in the preceding text recovers and is discharged without any residual deficits. He has filed a formal complaint against you to the hospital. The Chief of Staff’s office would like to know about 172 900 Questions: An Interventional Cardiology Board Review periprocedural stroke during coronary interventions. Which of the following statements is correct? (A) Periprocedural stroke occurs approximately 0.5% (B) Patients who suffer a stroke have an increased in-hospital mortality of 37% (C) Patients who suffer a stroke have an increased 1-year mortality of 56% (D) It is mostly embolic and not hemorrhagic stroke (E) A, B, and C are true (F) B, C, and D are true (G) C and D are true (H) A, B, C, and D are true 8 You are asked to examine a 65-year-old heavy smoker with a strong family history of coronary artery disease (CAD), status post (s/p) multivessel PCI in the past with left-sided stroke for cardiology evaluation. His past medical history is notable for PCI to heavily calcified ostial LAD and mid-CX 8 months ago. Recently, he has been under treatment for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia following his right below-knee amputation for gangrene. At baseline, he has an abnormal EKG with nonspecific ST changes in the precordial leads. The two-dimensional (2D) echo demonstrated moderate aortic insufficiency (AI) with multiple large vegetations on the aortic valve. He is examined by the cardiothoracic surgeons who would like to operate on him. They would like to visualize his coronary anatomy first and then ask for your opinion. The most appropriate action at this time is: (A) Because of high risk of embolization with left heart catheterization, he should undergo cardiac computed tomography (CT) to assess patency of ostial LAD and mid-CX stents (B) Send the patient for emergency heart surgery without cardiac angiogram (C) Perform left-sided cardiac catheterization to visualize coronary anatomy (D) Transfer the patient to neuro intensive care unit (ICU) for stroke management and treat endocarditis medically 9 A 75-year-old morbidly obese patient (378 pounds, 5 ft. 5 in. tall) is referred from an outside hospital for angioplasty and stenting of a large proximal dominant RCA lesion. The patient has an infected skin lesion in the right groin beneath a large abdominal pannus. The operator decides to cannulate the left groin instead, and after multiple sticks he is finally able to cannulate the left leg artery and to place a 7 F arterial introducer. The angioplasty procedure is successful using a 3.5/33 mm Cypher stent to RCA with heparin and GPIIb/IIIa inhibitor eptifibatide (Integrilin). Following the angioplasty procedure, all equipment is removed from the patient’s heart. At the end of the procedure the activated clotting time (ACT) is measured at 287 seconds. The operator decides to close the left groin artery entry site with an 8 F Angio-Seal device. Before doing so, he performs a peripheral angiogram using the introducing sheath to inject dye. The angiogram shows that the introducer was placed in the proximal profunda femoris artery too close to its bifurcation. The operator elects to place the Fem Stop instead. The Fem Stop is successfully applied and the patient is moved to the recovery room. In the recovery room, the RN notices that the patient’s BP has dropped from 130/90 to 96/70, and her pulse has increased from 68 to 78 bpm. The physician is notified, and he orders an increase in intravenous fluids to 200 mL/hour for 1 hour. The patient’s BP normalizes, but an hour later it drops again. This time it measures 90/68, with a pulse of 90 bpm. Soon after that, the patient starts to complain that the Fem Stop causes her to have left groin pain. The physician comes and adjusts the Fem Stop. He examines the groin and it appears normal. The intravenous fluids are increased and the systolic BP returns to 102/70 mm Hg. After a while, the patient again starts complaining of being uncomfortable in bed with the Fem Stop compressing her groin, and she becomes diaphoretic, her BP drops to 75/50, and her heart rate (HR) slows down to 45 bpm. The physician is notified. The most appropriate initial response at this time should be: (A) Loosen or reposition the Fem Stop and give the patient a pain medication with sedation for comfort (B) Send the patient for CT scan (C) Send the patient to vascular laboratory for ultrasound (D) Order patient’s CBC, and type and cross (E) Remove Fem Stop and apply direct manual pressure on the artery entry site (F) Continue rapid fluid infusion to expand the volume (G) Stop GPIIb/IIIa inhibitors (H) Consult a vascular surgeon to consider surgery (I) A, B, and C are correct (J) D, E, F, and G are correct (K) A–H are correct 10 The patient mentioned in the preceding text does well with manual pressure and goes upstairs to the telemetry floor. In 3 hours, you are called to see the patient because she has developed pulselessness, Management of Intraprocedural and Postprocedural Complications pain, pallor, and paresthesia of her left leg. What is the best way to treat this patient at this time? (A) Start intravenous heparin and careful clinical monitoring (B) Start intravenous heparin, GPIIb/IIIa inhibitor, and careful monitoring (C) Intravenous fibrinolytic therapy (D) Urgent peripheral vascular (PV) surgery consultation or urgent percutaneous PV intervention 173 bleeding and hematoma. Bowel sounds were weak but present. He reassured the patient and returned to the catheterization laboratory. Fifteen minutes later, her BP dropped again to 76 mm Hg with a pulse of 60 bpm. The patient became slightly diaphoretic and restless, complaining of increasing abdominal discomfort. Soon thereafter, her BP dropped to 60/40, HR was 45 bpm, the patient began to retch, but could not vomit. The most likely diagnostic explanation of this patient’s problem is: 11 Complication of groin hematoma may lead to sensory or motor neurologic deficit by compressing the surrounding nerves. Which nerves are most commonly affected by groin hematoma? (A) Femoral and sciatic nerves (B) Sciatic, femoral, and lateral cutaneous nerves (C) Femoral and lateral cutaneous nerves 12 The most common cause of procedurally related retroperitoneal hematoma includes: (A) Spontaneous retroperitoneal venous bleeding triggered by aggressive anticoagulant therapy (B) Arterial bleed caused by a back wall puncture of the femoral artery distal to the origin of the superficial CX iliac artery (C) Arterial bleeding caused by a back wall puncture of the femoral artery proximal to the origin of the deep CX iliac artery 13 A 54-year-old woman is transferred to the medical center from an outside hospital for an elective angioplasty of the RCA artery lesion. Three days before admission, the patient suffered an acute inferior wall myocardial infarction (MI), which was successfully treated with IV tPA. On the day of the procedure, the patient was asymptomatic, but she was quite anxious about the upcoming coronary angioplasty. The 80% lesion in the proximal RCA was opened with a 3.5 × 23 mm Cypher stent. The final angiogram showed a widely patent RCA, normal left coronary system, and EF of 50% with moderate inferior wall hypokinesia. The right groin entry site was successfully closed with a Perclose device after angiogram was taken (see following figure). The patient was transferred to the recovery unit, and within 45 minutes she began to complain of right groin and right flank pain, which improved when she adjusted her position. Thirty minutes later, her BP and pulse, which previously read 130/70 and 70 respectively, measured 100/60 and 80. Fluids were administered, and her BP improved, but she continued to complain about the right lower abdominal quadrant pain. The physician was called. He examined the groin and found no evidence of (A) Patient is allergic to intravenous pyelogram (IVP) dye (B) Patient has femoral artery dissection (C) Patient has spontaneous RP bleed (D) Patient has adverse reaction to midazolam (Versed) and fentanyl (E) Patient has arterial external iliac artery perforation with retroperitoneal dye extravasation