Management of Swelling Post-Catheterization
Initial Assessment and Differential Diagnosis
- The American Heart Association recommends immediately assessing for arterial thrombosis with pulse loss and limb ischemia, venous thrombosis with congestion, or septic thrombosis with systemic signs, and treating accordingly 1
- Arterial thrombosis presents with pulse loss, cool extremity, and evidence of limb ischemia, and should be assessed with pedal pulses bilaterally and comparison of systolic Doppler blood pressure between affected and unaffected limbs 2, 1
- A systolic blood pressure less than two-thirds that of the unaffected leg suggests significant arterial compromise 3
Management Algorithm
- The American College of Cardiology recommends initial treatment of arterial thrombosis with intravenous unfractionated heparin (UFH) for patients with lower-extremity arterial pulse loss and evidence of limb ischemia 2, 1
- UFH should be started immediately and continued for 24-48 hours, with monitoring of activated clotting time (ACT) to maintain >200 seconds 3, 10
- If pulse does not return after 24 hours of heparinization, fibrinolytic therapy with tissue plasminogen activator (tPA) at 0.5 mg/kg/hour for 6 hours should be considered 2, 3
- The American College of Cardiology also recommends consideration of anticoagulation with intravenous UFH for clinical signs of venous thrombosis 1, 4
- For septic thrombosis, the Infectious Diseases Society of America recommends immediate catheter removal and initiation of empirical antibiotic therapy covering gram-positive and gram-negative organisms 5, 6, 8