Complications in the cath lab. Coronary perforation and dissection

1. PCI COMPLICAIONSPCI COMPLICAIONS
BY
DR Mohamed Ramadan, PhD
Consultant Intervention Cardiologist

2. STATISTICSSTATISTICS
 Over 2 million PCI procedures worldwide

 Angiographic success rate of 90-95%

 Overall complication rate 1-5%

3. Successful PCISuccessful PCI
 PCI performance is defined in terms of
procedural success which identifies
anatomical (or angiographic) success,
(the enlargement of an epicardial vessel
to a minimum luminal diameter of <10%
stenosis or as near to 0% as possible,
and TIMI 3 flow), without clinical
complications

4.  The assessment that takes place in
order to judge the feasibility for PCI
is essentially one based on a
combination of individualized
risk/benefit analysis, lesion/technical
and patient/co-morbid characteristics
 Aim: to identify those at highest risk

5. Patient clinical characteristics,Patient clinical characteristics,
carrying increased riskcarrying increased risk
 Advanced age
 Urgent or unscheduled intervention
 Hemodynamic instability
 Heart failure
 Renal insufficiency
 Diabetes mellitus
 Electrolyte imbalance
 Arrhythmia


6. Procedure complication categoryProcedure complication category
1. Death (related to the procedure, regardless
of mechanism)
2. Stroke
3. MI (related to the procedure, regardless of
mechanism)
4. Ischemia requiring emergency CABG
5. Vascular access site complication
6. Contrast agent nephropathy
7. Excessive bleeding, requiring treatment
8. Other (such as coronary perforation and
tamponade)


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10. Complications from femoralComplications from femoral
access for PCIaccess for PCI
 Retroperitoneal hemorrhage
 Pseudo aneurysm
 AV fistula
 Infection
 Hematoma
 Neuropraxia
 Lower limb ischemia (thrombosis or
embolism)
 Dissection


11. Predictors of complicationsPredictors of complications
relating to vascular accessrelating to vascular access
 Female gender
 Advanced age
 Small body surface area
 Prior instrumentation
 Anticoagulation
 Peripheral vascular disease
 Diabetes Mellitus
 Suboptimal technique (puncture and closure)


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The aim should be to puncture the common femoral artery within a
target zone , 5 mm to 14 mm inferior to the centre of the femoral head

13. LESION (ANGIOGRAPHIC)LESION (ANGIOGRAPHIC)
CHARACTERISTICSCHARACTERISTICS
 Calcification, tortuosity (angulation >45
degrees), left main, bifurcation subsets,
degenerated saphenous vein graft, chronic
total occlusion and multivessel disease all
feature prominently in the diminished
technical success of a procedure and the
ability to be associated with complications

15. Coronary DissectionCoronary Dissection
Coronary dissection involves plaque fracture,
intimal splitting and localized tear which may
extend to the media for varying distance

17. Left main artery dissection

20. Perforation is an anatomical breach in the
integrity of the tunica adventitia of an epicardial
artery leading to extravasation of blood, either
into the myocardium, pericardium or a cardiac
chamber
Coronary Perforation

31. After Balloon Inflation For more than 10 mins

35. Indications for emergencyIndications for emergency
cardiac surgery following PCIcardiac surgery following PCI
 Extensive coronary dissection (54%)
 Perforation/tamponade (20%)
 Recurrent acute vessel closure (20%)
 Hemodynamic instability (3%)
 Aortic dissection (2%)
 Guide wire fracture (1%)


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How can you minimize PCI complications?