Back and Flank Pain After Femoral Sheath Removal
Mr. D is 62 and returns to the step-down unit five hours after elective PCI via the right femoral artery with a 6F sheath, removed two hours ago after manual compression. He received bivalirudin during the procedure and is on aspirin 325 mg and ticagrelor 90 mg twice daily. He now reports severe low back and right flank pain, is pale and diaphoretic, and has vomited once. Blood pressure 84/52, heart rate 120, respirations 24. The right groin is dry and flat with no swelling, bruit, or ecchymosis, and the abdomen is soft and nontender. Hemoglobin has fallen from 13.4 to 10.1 g/dL. Earlier he had a similar episode of hypotension that resolved with 500 mL of saline and was labeled a vasovagal reaction.
1. What is the most likely explanation, and why is the absence of groin swelling misleading rather than reassuring?
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Retroperitoneal hemorrhage from the femoral access site.
The decisive combination is back and flank pain with hypotension, tachycardia, vomiting, and a hemoglobin drop of 3.3 g/dL, in a patient anticoagulated during PCI.
Why no groin swelling: the common femoral artery above the inguinal ligament lies in the retroperitoneum. A puncture that is too high, or a tract that opens above the ligament, bleeds into a large potential space rather than into the subcutaneous tissue. Blood can therefore accumulate to a liter or more with a flat, dry, nontender groin and a soft abdomen - the physical exam is normal because the bleeding is hidden, not because it has stopped.
Why it was not vasovagal: vasovagal reactions produce bradycardia (not 120), resolve promptly and completely with recumbency and fluids, and do not drop hemoglobin. The earlier 'vasovagal' episode was most likely the first, unrecognized bleed. Treat prior unexplained hypotension after femoral access as bleeding until proven otherwise.
2. List the actions you would take in the next 30 minutes and what the diagnostic priority is.
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Next 30 minutes:
- Call rapid response and the interventional cardiologist now; obtain provider orders for type and crossmatch of at least 2 units.
- Two large-bore IVs; crystalloid bolus; keep the patient supine - do not sit him up or ambulate him.
- Stat CBC with repeat hemoglobin, coagulation studies, fibrinogen, renal panel, lactate.
- Hold any further anticoagulation; review exactly what he received and when.
- Continuous monitoring, hourly urine output, distal pulses and access site checks.
- Prepare for CT abdomen and pelvis with contrast to confirm and localize the hematoma.
- Anticipate blood products and definitive control: interventional radiology coil embolization or covered stent, or vascular surgery.
Diagnostic priority: CT is confirmatory, but resuscitation proceeds in parallel with it. Do not let the scan delay blood products in a hypotensive patient.
Communication: hand off directly to the receiving team, state the words 'suspected retroperitoneal hemorrhage' with a documented hemoglobin trend, and correct the earlier 'vasovagal' entry so the next clinician does not repeat the same assumption.
3. How would you manage his antithrombotic regimen while he is actively bleeding, given the recent stent?
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Do not reflexively stop all antithrombotic therapy.
- Bivalirudin is short-acting and already stopped; its effect will have largely resolved, so no reversal agent is indicated for it.
- Dual antiplatelet therapy protects a freshly deployed coronary stent. Stopping both drugs in the first weeks after PCI risks stent thrombosis, which carries a mortality comparable to the bleed. The correct approach is to control the bleeding source (fluid, blood products, embolization) while continuing antiplatelet therapy in most cases.
- Aspirin 325 mg is a higher-than-maintenance dose; after stabilization, discuss reducing to 81 mg with cardiology rather than eliminating it.
- Ticagrelor should generally continue; in uncontrolled, life-threatening hemorrhage, platelet transfusion and temporary interruption are decisions made jointly by cardiology, interventional radiology, and the intensivist - not unilaterally at the bedside.
Frame the trade-off explicitly in handoff: the risk of stent thrombosis versus ongoing hemorrhage, and which is currently dominant. Reassess with every unit of blood given.