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Most complications occur within the first 2 hours after sheath removal. Frequent monitoring of the arterial and/or venous puncture sites for adequate or pre-procedure peripheral circulation. This includes temperature, color, capillary refill, and pulse checks of the limb(s). At the puncture site, checking for pulsatile masses with or without bruit and thrill, excessive bruising. Other signs and symptoms to assess for include unexplained hypotension, ipsilateral flank pain, vague abdominal or back pain, and/or abdominal distention. Ultrasound is generally used to verify more serious complications, including:

• Hematoma and pseudoaneurysm: A collection of blood that forms in the soft tissues. Usually, this hematoma solidifies into a jellylike consistency, and eventually the body reabsorbs the clot, and the hole in the artery heals completely. If, however, the hematoma liquefies, and the hole in the artery doesn’t close up and heal, there can be a persistent flow of blood from the artery through the puncture hole in the artery and into the hematoma cavity. This pouch or sac coming off the artery looks like an aneurysm. It is called a “pseudoaneurysm,” however, because the lining of this sac is not made up of the normal layers of the artery wall but is rather just a fibrous lining that forms around the hematoma. For this reason, the sac is not a “true” aneurysm but is rather called a false (“pseudo”) aneurysm. An ultrasound exam is usually performed to distinguish between a hematoma and a pseudoaneurysm. It is important to make this distinction because a hematoma will usually resolve without treatment, whereas a pseudoaneurysm requires treatment to seal the aneurysm and prevent rupture. If the pseudoanerysm is <2 cm, it may be observed and monitored until it is healed. If larger than 2 cm, it may require surgical intervention, thrombin injection, or ultrasound-guided compression.
• Retroperitoneal bleeding: Abnormal bleeding in the retroperitoneal cavity from a hematoma or pseudoaneurysm rupture. A late development of retroperitoneal bleeding would be Grey Turner’s sign or bruising of the flanks, the part of the body between the last rib and the top of the hip. The bruising appears as a blue discoloration and is a sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum. Grey Turner’s sign takes 24 to 48 hours to develop.
• Arteriovenous fistula: An abnormal connection between a vein and artery, usually from vascular injury. Most AV fistulas close spontaneously.
• Impaired distal circulation: Loss of pulses due to injury to artery.
• Nerve damage: Due to swelling and nerve compression. This can lead to weakness in quadriceps that can take weeks to improve.
• Stroke: Is almost always embolic due to dislodged plaque. Any changes in neurological functioning of the patient should be documented and communicated immediately. A CT scan may be indicated. Intracranial hemorrhage is a complication of aggressive anticoagulation; therefore, frequent neurological assessments should be done.
• Cardiac tamponade: A ruptured or perforated coronary artery will have muffled heart sounds, hypotension, tachycardia, tachypnea, and distended neck veins. Treatment includes pericardiocentesis.
• Vaso-vagal reaction: Administer fluids and atropine per protocol, elevating legs in a Trendelenburg position.
• Contrast-induced nephropathy: Diabetic patients are at risk; renal dysfunction may be permanent or return to baseline in a week. Hydration and prudent use of contrast will reduce the risk of renal impairment from cardiac catheterization. Diabetics who take metformin should be told to hold this drug 24 to 28 hours prior to the use of contrast dye and 48 hours after dye is injected.

Nursing care for complications: hemodynamic assessment and system review with constant monitoring and documentation. The recovery nurse is responsible for maintaining bed rest, providing hydration, positioning for comfort, drawing serial blood counts and giving prescribed medications, and providing communication with providers when needed.