Cardiac cath complications


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Cardiac cath complications

  1. 1. Cardiac Catheterization Complication
  2. 2. 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 seen THAT before!” AttendingFellow “I thought you said never to say OOPS in the Cath Lab”
  3. 3. 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
  4. 4. 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 SVCAD)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.
  5. 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.
  6. 6. Akkerhuis KM, et al. Minor Myocardial Damage and Prognosis: Are Spontaneous and Percutaneous Coronary Intervention—Related Events Different? Circulation 2002;105: 554–556).
  7. 7. 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
  8. 8. • 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..
  9. 9. 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 anticoagulated – Carefully wipe and immerse guidewires in heparinized saline before their reintroduction during left-sided heart catheterization
  10. 10. 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
  11. 11. • Data obtained from the American College of Cardiology National Cardiovascular Data Registr • 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 II Dale R. Tavris
  12. 12. • 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 Local Vascular Complications..
  13. 13. Femoral Artery Laceration • Uncontrollable free bleeding around the sheath Control by placement of upsized sheath If not control then manual pressure around the sheath until procedure is complete Then reverse anticoagulation and remove the sheath and prolong compression for 30-60 min or placement of closure device If bleeding continue the urgent vascular surgeon consult to be taken
  14. 14. Major Femoral Bleeding Complications After PCI • Consecutive patients who underwent transfemoral PCI from 1994to 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 sheathsize, intensity and duration of anticoagulation with heparin,and procedure time were observed (p < 0.001) – multivariateanalysis confirmed each as an independent predictor of complications(p < 0.001)
  15. 15. • Adverse outcomes of major femoral bleeding – prolonged hospital stay (mean 4.5 vs. 2.7 days (p < 0.0001) – increased requirement for blood transfusion (39% vs. 4.7%;p < 0.0001) • Major femoral bleeding and blood transfusion were both associated with decreased long-term survival, drivenby a significant increase in 30- day mortality (p < 0.001) Doyle et al. J Am Coll Cardiol Intv. 2008; 1: 202-209
  16. 16. Independent correlates of major bleeding: • Age>55 years • Female gender • GFR <60 mL/min/1.73 m2 • Pre-existing anemia • Administrationof low-molecular-weight heparin within 48 h pre-PCI • Use ofglycoprotein IIb/IIIa inhibitors • Intraaortic balloon pumpinsertion • The risk of major bleeding variedfrom 1.0 % in patients without risk factors to 5.4% in high-riskpatients 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
  17. 17. 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 resolve Surgical repair of hematoma usually not required Prevented by accurate puncture and puncture site compression or closure technique to minimize hematoma formation
  18. 18. 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
  19. 19. 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
  20. 20. Rx: usually conservative, usually bed rest and blood transfusion Reversal of anticoagulation if bleeding persists or hemodynamic compromise Catheter-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 Retroperitoneal Hematoma..
  21. 21. 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
  22. 22. Angiographic appearance of an arteriovenous fistula with simultaneous filling of the femoral artery (left) and vein (right)
  23. 23. 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
  24. 24. • 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
  25. 25. Complications includes Ruptue Distal embolization Local pain Neuropathy Local skin ischemia Pseudoaneurysm
  26. 26. 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
  27. 27. Pseudoaneurysm Expanding hematoma has propensity to rupture esp when pt is on anticoagulation Emerging alternative therapy is percutaneous polytetrafluoroethylene covered stent-graft deployment at the site of the pseudoaneurysm
  28. 28. 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
  29. 29. 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
  30. 30. • Suspected if white lower extremity with pain/paresthesia along with decreased or absent distal pulses not responding to catheter removal Urgent vascular surgery or thrombectomy may be required for the prevention of limb Can 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 Arterial Thrombosis
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. Premature Ventricular Contractions • Common • Induced by catheter introduction into right or left ventricle • Without any clinical significance
  37. 37. 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
  38. 38. 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 cardioversion Hemodynamically stable extrasystoles/VT can be treated pharmacologically with lidocaine, amiodarone or procainamide MgSO4 in patients with Torsades Ventricular Tachycardia and Ventricular Fibrillation..
  39. 39. 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
  40. 40. • 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..
  41. 41. 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
  42. 42. 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
  43. 43. 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.
  44. 44. 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
  45. 45. • Hemodynamic finding of temponade may develop If hemodynamically stable- portable echo to rule out blood in the pericardial space If hemodynamic instability- urgent pericardiocentesis under echo guidance Reversal of anticoagulation by protamine ( 1ml = 1mg for 1000 IU of heparin) Perforation of Heart and Great Vessels..
  46. 46. 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
  47. 47. • 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 restored I/V Fluids infused rapidly as overall fluid status warrents Consider vasopressors if hypotension do not responds I/V Hydrocortisone If bradycardia consider Atropine Allergic Reaction..
  48. 48. Allergic Reaction.. • Protamine: – Occasionally in diabetic patients using NPH insulin – Rapid injection can also provoke back pain of unknown etiology – Rarely used now a days
  49. 49. 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
  50. 50. Acute Renal Failure • Three major causes – Contrast induced acute renal failure – Renal atheroembolism – Hemodynamic instability with renal hypo perfusion
  51. 51. 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
  52. 52. 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
  53. 53. 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
  54. 54. 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 bleeding If low filling pressure along with inappropriate bradycardia then atropine can be given High filling pressure suggest primary cardiac dysfunction like ischemia, temponade, or sudden onset of valvular regurgitation – support empirically with inotropes, vasopressors and circulatory support devices
  55. 55. Volume overload • Predispose to volume overload owing to admistration 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
  56. 56. Prevention of Complications • Proper patient selection • Proper patient preparation • Attention to details • Experience • Skills
  57. 57. “Huh! Twice in ONE day!”
  58. 58. Summary • Although procedures may seem routine, there is no routine procedures • Careful with patients predisposed to risk • Assist the attending with extra eyes • The catheters need to fit the anatomy • Never force equipment