37220-78-RT
+37222-RT
37244-80-RT

PROCEDURES PERFORMED:
1. Right lower extremity angiography.
2. Balloon inflation of the right external iliac artery with an Armada 4 mm x 40 mm balloon, balloon inflation of the right common iliac artery with an Armada 7 mm x 40 mm balloon, coiling of the right inferior epigastric artery with Interlock 2×3 mm, 2×4 mm and 3×6 mm coils.

INDICATIONS FOR PROCEDURE: Patient is a 34-year-old Caucasian female that presented earlier today for an outpatient atrial septal defect closure via right and left femoral venous access. Post procedure, she had a right groin hematoma and complained of extensive pain. She was hypotensive and continued to be unstable, so the patient was brought back to the Cath Lab emergently for lower extremity angiography.

FLUOROSCOPY TIME: 17.5 minutes.

RADIATION EXPOSURE: 578 milligray.

CONTRAST: 100 mL of Omnipaque.

PROCEDURE IN DETAIL: The patient was brought to the Cardiac Cath Lab in an emergent fashion. The bilateral groins were prepped and draped in the usual sterile fashion. The skin overlying the left common femoral artery was anesthetized with 1% lidocaine. A Cook needle was used to access the left common femoral artery under direct ultrasound visual guidance and a 6-French short sheath was placed. At that time, a Contra catheter was advanced over a J-tipped wire and used to engage the right common iliac artery. The J-tipped wire was then advanced down into the right common femoral artery. The Contra catheter was removed and a 4-French Glidecath was advanced over the wire into the right external iliac artery. At that time, selective right lower extremity angiography was performed with hand injection of contrast. We noted that there was extensive extravasation of contrast from the inferior epigastric artery on the right. The Glidecath was removed over a wire and then the 6F short sheath was exchanged out for a 6F Destination sheath which was placed in the right common iliac artery. An Armada 4 mm x 40 mm balloon was advanced over the J-tipped wire into the proximal portion of the right external iliac artery. That balloon was inflated to 2 atmospheres for 5 minutes. We then performed another angiogram and noted that there was still extravasation, so it was inflated for another 5 minutes. We then performed another angiogram and noted that there was extravasation from the same vessel from branches coming from the internal iliac artery as well, so that balloon was removed and an Armada 7 mm x 40 mm balloon was placed in the distal right common iliac artery just proximal to the bifurcation. Balloon occlusion was performed for 10 minutes and we repeated angiography and noted that there was still extravasation. Another balloon inflation was performed at 6 atmospheres for 10 minutes and we were still unable to control the bleeding despite already giving protamine and having multiple balloon inflations.

At that time, I asked Dr. _______ for assistance and he joined the procedure to help with coil embolization of the bleeding artery. The balloon was removed and a 6-French IMA guide catheter was advanced through the 6-French Destination sheath. The IMA guide was directed towards the ostium of the inferior epigastric artery and then a BMW wire was advanced up the inferior epigastric artery. We then placed a microcatheter over the BMW guidewire up into the inferior epigastric artery and removed the BMW wire. At that point, we were able to deploy 2 coils in the more superior aspect of the inferior epigastric artery, distal to where the bleeding was noted, and then pulled the microcatheter down and place 1 more coil proximal to the bleeding site in the inferior epigastric artery. A repeat angiogram was performed and we noted that we had achieved hemostasis of the inferior epigastric artery with the coils. The microcatheter was removed and the multipurpose guide catheter was removed. We again repeated right lower extremity angiography through the Destination sheath and noted that the common iliac, internal iliac, external iliac, femoral, and profunda arteries were all patent, although severely vasospastic, and there was no longer any signs of extravasation from the inferior epigastric artery. At that time, the Destination sheath was removed from the left groin over a wire and a 6 French short sheath was placed. An angiogram was performed noting that the left femoral artery was acceptable for a closure device. The 6-French Angio-Seal was deployed successfully.

FINDINGS:
1. Right lower extremity angiography.
2. Severe vasospasm in all the lower extremity arteries.
3. Widely patent right common iliac, right external iliac, and right internal iliac arteries.
4. Extravasation of contrast from the right inferior epigastric artery near the takeoff from the common femoral artery.
5. Post procedure there was no longer any extravasation noted from the inferior epigastric artery.

ASSESSMENT AND PLAN:
1. Extravasation of contrast from the right inferior epigastric artery.
2. Successful coiling of the right inferior epigastric artery with 3 Interlock coils both proximal and distal to the site of extravasation.
3. We will admit the patient to the CCU and monitor closely. The patient received 2 units of PRBCs during the procedure. We will wean the phenylephrine drip off as soon as possible.

I administered moderate sedation throughout this 118-minute procedure. An independent trained observer pushed medication at my direction and monitored the patient’s level of consciousness and physiologic status throughout.