HPI

77 y.o F PMHx CAD, AF on Eliquis presents with R thigh hematoma. 

• Cardiac cath 10 days prior (access through R femoral)
• Also states fall few days prior, hitting R leg against book shelf
• Progressively worsening x6 days

PHYSICAL EXAM

BP 104/53  | Pulse 70 | Temp 97.9 °F | Resp 18  | SpO2 100%  

• R thigh with large bruise extending from knee to hip, with extension to RLQ abdomen.
• Baseball sized area of swelling medial thigh with small bullae. 
• Thigh and lower leg compartments soft. 
• Motor/sensory intact. 
• Palpable distal pulses. 
• R femoral signal on doppler.  

DDx

• Pseudoaneurysm (recent cath), expanding hematoma (recent trauma), active arterial bleed, acute blood loss anemia (in setting of AC)

WORK UP

• Labs: CBC, BMP, coags, type & screen
• Imaging: US groin pseu protocol, CTA RLE

RESULTS / MANAGEMENT

• HGB 6.4 from 9.6 five days prior
• US: Evolving R groin subcutaneous hematoma, 12.6 cm. No pseudoaneurysm or AV fistula.
• CTA: large hematoma with small active extravasation from inferior aspect of hematoma
• 1U pRBCs, Kcentra (later also given plasma)
• IR - successful coil embolization

TAKE HOME POINTS

•  Cardiac cath complications - femoral artery pseudoaneurysm → may require surgical intervention
• Reversing NOACs (‘xabans’) - Eliquis, Xarelto
• Andexanet alfa (Andexxa): preferred reversal agent for patients with life threatening CNS, epidural, or ocular bleed or acute hemorrhage 
• 4F PCC aka Kcentra: bleeding from other sites
• Contains Factors II, VII, IX, X, proteins C and S
• Second line: FFP
• Any concern for arterial bleeding or compromise requires CTA