Cardiac Catheterization Complications

Abdelkader Almanfi, MD

Cath Lab Complications• Death• AMI• Dysrhythmia• Stroke• Bleeding• Hematoma• Vascular Injury• Contrast Induced

Nephrotoxicity• Allergic

reactions/Anaphylaxis• Pulmonary Edema• Air/clot embolism• Renal Failure (CIN)• Vagal reaction

“Huh; never seenTHAT before!”

AttendingFellow

“I thought you said never to say OOPS

in the Cath Lab”

Major Complications

• The risk of producing a major complication (death, myocardial infarction, or major embolization) during diagnostic cardiac catheterization is generally less than 1%

• Risk of adverse events depends upon– Demographic (age, gender)– Cardiovascular anatomy (left main coronary artery disease,

severe AS, diminished LV function)– Clinical situation (Unstable angina, Acute MI, cardiogenic shock)– Comorbids– Experience of operator– Peripheral arterial disease

Mortality• Rare – less then 0.1%1

• High risk group– Age >60 years and <1year– Female– NYHA IV heart failure (10 times increase risk than

Class I and II– Severe LMCA (20 times higher than SV-CAD)2

– LVEF <30%– Patient with valvular heart disease, CKD, DM

requiring insulin therapy, peripheral arterial disease, pul insufficiency, cerebrovascular disease

1. Noto TJ, Johnson LW, Krone R, et al. Cardiac catheterization 1990: a report of the registry of the Society for Cardiac Angiography and Interventions. Cathet Cardiovasc Diagn 1991;24:75.

2. Kennedy JW. Complications associated with cardiac catheterization and angiography. Cathet Cardiovasc Diagn 1982;8:5.

Myocardial infarction

• Periprocedural myocardial ischemia is common but risk of myocardial infarction is <0.1%

• Factor predispose patient for periprocedural MI are1:– Extent of disease (0.17% with LM disease vs

0.06% with SVCAD vs 0.08% for 3 VCAD)– Recent NSTEMI– DM requiring insulin therapy

1. Johnson LW, et al. Coronary angiography 1984-1987: a report of the registry of the Society for Cardiac Angiography and Interventions, I: results and complications. Cathet Cardiovasc Diagn 1989;17:5.

Akkerhuis KM, et al. Minor Myocardial Damage and Prognosis: Are Spontaneous and Percutaneous Coronary Intervention—Related Events Different? Circulation 2002;105: 554–556).

Stroke and Transient Ischemic Attack

• Rare but devastating complication• Incidence 0.07-0.1% but most are asymptomatic embolic

event• Risk factors includes:

– Severity of coronary artery disease– Length of fluoroscopy time– Diabetes– Hypertension– Prior stroke– Renal failure

• Mostly caused by disruption of atheromatous plaques on the wall of aorta - other sources can be- surface of valves and cardiac chambers

Stroke and Transient Ischemic Attack..

• Also result from injection of high osmolal contrast agent into carotids and vertebral arteries

• Risk is higher in patients with valvular aortic stenosis

• Majority of periprocedural stroke patient have poor outcome and in hospital mortality can be as high as 32%

Stroke and Transient Ischemic Attack..

• Prevented by– paying careful attention to flushing and injection

technique, minimize dwell time of guidewire in the aortic root of patients who are not fully anti-coagulated

– Carefully wipe and immerse guidewires in heparinized saline before their reintroduction during left-sided heart catheterization

Local Vascular Complications

• Local complications at the site of insertion are most common, include– Acute thrombosis– Distal embolization– Dissection– Poorly control bleeding ( free hemorrhage, femoral

hematoma, retroperitoneal hematoma– Pseudoanerysm– AV fistula

• Less frequent with radial artery access

• Data obtained from the American College of Cardiology National Cardiovascular Data Registry

• It included information from 59 institutions and 13,878 cardiac catheterizations performed during the last quarter of 2003

Risk of Local Adverse Events following Cardiac Catheterization by Hemostasis Device Use -- Phase IIDale R. Tavris

Local Vascular Complications..

• Hemorrhage and hematoma usually evident within 12 hours– Local discomfort, hypotension, and decrease

hemoglobin– Conform by U/S and CT

• AV fistula and pseudo aneurysm may not apparent for days and weeks

Femoral Artery Laceration

• Uncontrollable free bleeding around the sheathControl by placement of upsized sheathIf not control then manual pressure around the sheath until procedure is completeThen reverse anticoagulation and remove the sheath and prolong compression for 30-60 min or placement of closure deviceIf bleeding continue the urgent vascular surgeon consult to be taken

Major Femoral Bleeding Complications After PCI

• Consecutive patients who underwent transfemoral PCI from 1994 to 2005 at the Mayo Clinic (n = 17,901) were studied

• 3 groups: – Group 1 (1994 to 1995, n = 2,441)– Group 2 (1996 to 1999, n = 6,207)– Group 3 (2000 to 2005, n = 9,253)

• Incidence of major femoral bleeding complications decreased (from 8.4% to 5.3% to 3.5%; p < 0.001)

• Reductions in sheath size, intensity and duration of anticoagulation with heparin, and procedure time were observed (p < 0.001)– multivariate analysis confirmed each as an independent predictor of

complications (p < 0.001)

Independent correlates of major bleeding:• Age >55 years• Female gender• GFR <60 mL/min/1.73 m2

• Pre-existing anemia • Administration of low-molecular-weight heparin within 48

h pre-PCI• Use of glycoprotein IIb/IIIa inhibitors• Intra-aortic balloon pump insertion

• The risk of major bleeding varied from 1.0 % in patients without risk factors to 5.4% in high-risk patients

Nikolsky et Al. Development and validation of a prognostic risk score for major bleeding in patients undergoing percutaneous coronary intervention via the femoral approach. European Heart Journal 2007

Hematoma Formation

• Common than free bleeding• Most common in the soft tissue of upper thigh• Mostly resolved over period of days as the blood

gradually spreads and is reabsorbed from the soft tissues

• Femoral or lateral cutaneous nerve compression can occur resulting in motor and sensory deficit, which may take weeks and months to resolveSurgical repair of hematoma usually not requiredPrevented by accurate puncture and puncture site compression or closure technique to minimize hematoma formation

Factors for Hematoma Generation

• Women• SBP>160 mm Hg• Artery puncture >1• Sheath time >16 min• ACT≥175 sec• Glycoprotein (GP) IIB/IIIa inhibitors• Low Molecular Weight Heparin before procedure • Personnel change during compression• Anti-coagulant-treatment before procedure

Andersen,Bregendahl ,Kaestel Et al.Haematoma after coronary angiography and percutaneous coronary intervention via the femoral artery frequency and risk factors.European Journal of Cardiovascular Nursing;4 : 123 - 127

Retroperitoneal Hematoma

• When the puncture occur above the inguinal ligament

• Usually go unnoticed as not evident on surface

• Causing unexplained hypotension, ipsilateral flank pain and fall in hematocrit

• U/S, CT scanning of abdomen can establish the diagnosis

Retroperitoneal Hematoma..

Rx: usually conservative, usually bed rest and blood transfusion

Reversal of anticoagulation if bleeding persists or hemodynamic compromiseCatheter-based intervention include an ipsilateral (or contralateral if the problem is low in the iliac) approach for localization and tamponade of the retroperitoneal bleeding site, using a peripheral angioplasty balloon followed by placement of a covered stents

Arteriovenous Fistula

• Ongoing bleeding from the arterial puncture site may decompress into the adjacent venous puncture site, leading to AV fistula

• Recognized by presence of thrill or continues bruit at the site of catheter insertion

• Surgical repair usually necessary as fistula tends to enlarge with time

• Most common surgical finding is the puncture site below the common femoral artery

Angiographic appearance of an arteriovenous fistula with simultaneous filling of the femoral artery (left) and vein (right)

Pseudoaneurysm

• Incidence is 0.1-0.2% following diagnostic angiograms and 0.8-2.2% following interventional procedures

• Develop if hematoma remains in continuity with the arterial lumen forming blood filled cavity

• Blood flows in and out of the hematoma cavity during systole and diastole

• Recognized by the pulsatile mass with the systolic bruit over catheter insertion site

• Confirm by Doppler U/S• Mostly occur within first 3 days after removal of arterial

sheath

Pseudoaneurysm

• Risk factors:– too brief period of manual compression– Large bore sheaths– Postprocedual anticoagulation– Antiplatelets therapy during intervention– Age >65yrs– Obesity– Hypertension– Peripheral arterial disease– Hemodialysis– Cannulation of superficial femoral or profunda femoral artery

(catheter insertion below the bifurcation of common femoral artery)- low calibre vessel and no bony structure underneath it

Pseudoaneurysm

Complications includesRuptureDistal embolizationLocal painNeuropathyLocal skin ischemia

Pseudoaneurysm

Rx: Surgical management when– At the site of vascular anastomosis– Very large – Threaten or causing skin necrosis– Expanding rapidly– Occurs spontaneously– Infected

Smaller pseudoaneurysms and be treated by either U/S guided compression or with U/S guided local injection of thrombin or collagen into the cavity<3 mm can be managed conservatively with serial imaging to confirm spontaneous resolution If beyond two weeks or expands, surgical repair or ultrasound compression are recommended to reduce the risk of rupture

Pseudoaneurysm

Expanding hematoma has propensity to rupture esp when pt is on anticoagulationEmerging alternative therapy is percutaneous polytetrafluoroethylene covered stent-graft deployment at the site of the pseudoaneurysm

Crossover angiography was performed from the right groin showing a large pseudoaneurysm over the left common femoral artery

An angioplasty balloon was positioned under the prior puncture site as a needle (arrow) was advanced to puncture the pseudoaneurysm cavity confirmed by contrast injection

After occlusion of the common femoral by inflation of the angioplasty balloon, thrombin was injected through the needle into the pseudoaneurysm cavity, causing it to clot, as shown by the absence of further contrast flow into it on the postprocedure angiogram

Arterial Thrombosis

• Rare• Predisposing factors of femoral artery

thrombosis:– Small vessel lumen– Peripheral arterial disease– DM– Female– Placement of large diameter catheter/sheath (IABP)– Longer catheter dwell time– Prolong post procedure pressure

Arterial Thrombosis

• Suspected if white lower extremity with pain/paresthesia along with decreased or absent distal pulses not responding to catheter removalUrgent vascular surgery or thrombectomy may be required for the prevention of limbCan be fixed percutaneously by puncturing contralateral femoral artery and crossing over the aortic bifurcation and address the common femoral artery occlusion

• Failure to restore limb flow with in 2-6 hours results in extension of thrombosis into distal branches and lead to muscle necrosis and need of limb amputation

Crossover from the contralateral side showed occlusion of the common femoral

After balloon dilation, there was a prominent filling defect consistent with thrombus

After thrombectomy, the filling defect has decreased in size

Femoral Venous Thrombosis

• Femoral venous thrombosis and pulmonary embolism are rare complications

• A small number of clinical cases have been reported, particularly in the setting of – venous compression by a large arterial hematoma– sustained mechanical compression– prolonged procedures with multiple venous lines (e.g., EP study)

• The actual incidence of thrombotic and pulmonary embolic complications may be substantially under-reported, since most are not evident clinically

• Asymptomatic lung scan abnormalities in up to 10% of patients after diagnostic catheterization

Gowda S, Bollis AM, Haikal AM, Salem BI. Incidence of new focal pulmonary emboli after routine cardiac catheterization comparing the brachial to the femoral approach. Cathet Cardiovasc Diagn 1984:10:157

Femoral, Iliac and Aortic Dissection

• Generally occurs during retrograde passing of wires and catheters through tortuous or stenotic arteries

• If these dissections are retrograde and small, usually the forward blood flow will seal down the dissection flap

• If persist or flow limiting, can be treated stenting

Radial Artery Access

• Less access site complications• Associated with 5-19% chance of radial artery

occlusion• Less clinical importance as hand is perfused by

both radial and ulnar arteries• If incomplete palmer arch then leading to hand

ischemia• Modified Allen’s test is used to identify patients

who are increased risk from radial artery cath• Pulse oximetry and plethysmigraphy are

alternatives

Arrhythmias

• Verity of arrhythmias and conduction disturbances– Premature ventricular contractions– VT and V Fib– Atrial arrhythmias– Bradycardia

• Varying clinical consequences depending upon severity of coronary artery disease, valvular heart disease, LV dysfunction, LVEDP

Premature Ventricular Contractions

• Common• Induced by catheter introduction into right or left

ventricle• Without any clinical significance

Ventricular Tachycardia and Ventricular Fibrillation

• Rare, 0.4% case• Results from excess catheter manipulation and

intracoronary contrast injection (ionic high osmolar contrast esp. in RCA)

• Still occur with nonionic low osmolar contrast media if prolong injection or performed with partially damped pressures

• Incidence is higher in patients with baseline prolonged QT interval

• Refractory ventricular ectopy is seen in the setting of profound transmural ischemia or early myocardial infarction

Ventricular Tachycardia and Ventricular Fibrillation..

If run of ventricular tachycardia initiated, the offending catheter must be repositioned immediately so that baseline cardiac rhythm is restored Ventricular fibrillation or unstable ventricular tachycardia should be treated with prompt electrical cardioversionHemodynamically stable extrasystoles/VT can be treated pharmacologically with lidocaine, amiodarone or procainamideMgSO4 in patients with Torsades

Atrial Arrhythmias

• Atrial extrasystole in response to catheter placement in or out of right atrium

• Subsided when catheter is repositioned• May progress to atrial flutter and AFib in

sensitive patients• Atrial flutter usually well tolerated• Usually do not require immediate treatment

unless produce hemodynamic instability– In patients with mitral stenosis, hypertrophic

cardiomyopathy and diastolic LV dysfunction

Atrial Arrhythmias..

• Treated with burst atrial pacing, electrical or pharmacological cardioversion ( Beta blocker, calcium channel blockers)– Care must be taken as catheter advancement

into the ventricle can trigger VF• Atrial fibrillation- can results in rapid ventricular

response and loss of atrial systole- results in hypotension– Synchronized cardioversion immediately if

hemodynamic instability

Atrial Arrhythmias..

• Other narrow complex tachycardia e.g., paroxysmal supraventricular tachycardia can be treated with vagal maneuver (carotid sinus message), i.v adenosine, beta blocker, verapamil, or amiodarone

• Synchronized DCCV if prolong episode or producing hemodynamic instability

Bradycardia

• Most often secondary to injection of high osmolor ionic contrast into the right coronary artery

• Forceful coughing helps clear the contrast, support perfusion, and restore normal cardiac rhythm

Vasovagal Reaction

• Vasovagal reactions- include bradycardia, hypotension, yawing and/or sweating– Suspected when bradycardia is prolonged– Seen in 3% of patients especially if they have pain or anxious in

setting of hypovolemia – Can be the early sign of cardiac perforation– Landau et al. quoted as more than 80% of such reactions

occurred as vascular access was being obtained, with 16% occurring during sheath removal

– Prevented by preprocedural sedation and admistration of adequate local anesthetic before catheter insertion

• Rx: volume admistration, atropine and removal of painful stimulus

Landau C, Lange RA, Glamann DB, Willard JE, Hillis LD. Vasovagal reactions in the cardiac catheterization laboratory. Am J Cardiol 1993;73:95.

Perforation of Heart and Great Vessels

• Extremely rare• High risk procedure are

– Involving stiffer catheters– Transseptal catheterization– Endomyocardial biopsy– Balloon valvoplasty– Needle pericardiocentesis– Placement of pacing catheter

• Heralded by bradycardia and hypotension secondary to vagal stimulation secondary to the accumulation of blood in the pericardial sac

• Cardiac silhouette may enlarge and the normal pulsation of the heart borders on fluoroscopy will become blunted

Perforation of Heart and Great Vessels..

• Hemodynamic finding of temponade may develop If hemodynamically stable- portable echo to rule out blood in the pericardial spaceIf hemodynamic instability- urgent pericardiocentesis under echo guidanceReversal of anticoagulation by protamine ( 1ml = 1mg for 1000 IU of heparin)

Allergic Reaction

• Can be precipitated by– Local anesthetic– Contrast agent– Protamine sulfate

• Local anesthetic: – In patients with previous reaction- use

preservative free agents e.g., bupivicane, mepivicaine

Allergic Reaction..

• Iodinated contrast agents:– Upto 1% of patients– Risk is highest in patients with prior history of reaction– Risk is also in patients with asthma, atopy, history of sea food

allergy (contain iodine)– Risk reduced by premedication with steroids, H1 blocker and H2

blocker– Use of non-ionic dye

If anaphylactic reaction then use epinephrine 1:10,000 (1ml = 0.1mg) admistered I/V every minute until pulse restoredI/V Fluids infused rapidly as overall fluid status warrentsConsider vasopressors if hypotension do not respondsI/V Hydrocortisone If bradycardia consider Atropine

Allergic Reaction..

• Protamine:– Occasionally in diabetic patients using NPH

insulin– Rapid injection can also provoke back pain of

unknown etiology– Rarely used nowadays

Atheroembolism

• Incidence in 0.6 – 0.9%• During cath athromatous debris

may scrap off from the wall of the aorta and causes systemic embolization (cutaneous, renal, retinal, cerebral, gastrointestinal)

• To prevent this catheter exchange best performed over a wire in the descending aorta at the level of diaphragm

• Increased eosinophilic counts• Treatment supportive

Acute Renal Failure

• Three major causes– Contrast induced acute renal failure– Renal atheroembolism– Hemodynamic instability with renal hypo

perfusion

Contrast Nephropathy

• 5% patients undergo cardiac cath experienced transient rise in the plasma Cr >1.0mg/dl due contrast induced renal dysfunction

• Highest risk in patients with moderate to severe renal insufficiency and diabetes

• Plasma Cr usually return to baseline within 7 days• Less then 1% of patients require chronic dialysis, usually

diabetic patients with severe renal insufficiency• Nonionic low osmolal and iso-osmolal contrast agents

has decreased risk of hypersentivity

Renal Atheroembolism

• Seen in 0.15% patients • Kidneys are one important organ that can effect from the

systemic embolism• Greatest risk in patients with

– diffuse atherosclerosis– abdominal aortic aneurysm

• Findings differentiate from contrast nephropathy– Presence of other signs of embolism e.g. blue toes, livedo

reticularis, Hollenhorst plaque in the retina, abdominal pain– Transient eosinphilia and hypocomplimentemia– Persistent renal failure after 7 days– 50% patients require chronic dialysis

Treatment is usually supportive

Infection

• Rare as sterile technique• Local infection and bacteremia is rare• Endocarditic prophylaxis during cardiac cath not

recommended for patients with valvular heart disease

• Importance of hand washing, caps, gloves, gown, and mask to protect patient for bacterial infection and eye wear and vaccination for Hip B to protect lab personal

Hypotension

• Commonest finding in cardiac cath seen in variety of conditions– Hypovolemia 20 blood loss, inadequate prehydration, excessive contrast

induced diuresis– Reduced cardiac output 20 to ischemia, temponade, arrhythmia, valvular

regurgitation– Inappropriate systemic arteriolar vasodilatation 20 Vasovagal, nitrates,

contrast, vasodilator response of inotropes• Treatment according to the cause

If low filling pressure volume expansion in hypovolumic state, look for the source of bleedingIf low filling pressure along with inappropriate bradycardia then atropine can be givenHigh filling pressure suggest primary cardiac dysfunction like ischemia, temponade, or sudden onset of valvular regurgitation – support empirically with inotropes, vasopressors and circulatory support devices

Volume overload

• Predispose to volume overload owing to administration of hypertonic contrast agents, myocardial depression or ischemia 20 contrast agent, baseline LV dysfunction and prophylactic volume load to prevent contrast induced nephropathy

• Support the patient with diuretics, morphine, nitrates if frank pulmonary edema and respiratory failure imminent then early anesthesia support and intubation

Prevention of Complications

• Proper patient selection• Proper patient preparation• Attention to details• Experience• Skills

“Huh! Twice in ONE day!”

Summary

• Although procedures may seem routine, there is no routine procedures

• Careful with patients predisposed to risk• Assist the attending/fellow with extra eyes and

hands • The catheters need to fit the anatomy • Never force equipment

Thank you

With my two mentors at Texas Heart organizing Interventional meeting in Dubai