Presentation about the hazards and potential complications that could happen in any cardiac or peripheral catheterization procedure and how to avoid them

1. Cardiac Catheterization Complications
Abdelkader Almanfi, MD

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. 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

6. 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.

7. 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.

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

9. 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

10. 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%

11. 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

12. 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

13. • 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 II
Dale R. Tavris

16. 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

17. 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

18. 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)

19. 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
• Intra-aortic 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
2007

20. 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

21. 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

22. 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

23. Retroperitoneal Hematoma..
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

24. 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

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

26. 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

27. 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

28. Pseudoaneurysm
Complications includes
Rupture
Distal embolization
Local pain
Neuropathy
Local skin ischemia

29. 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

30. 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

31. 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

32. 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

33. Arterial Thrombosis
• 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Premature Ventricular Contractions
• Common
• Induced by catheter introduction into right or left
ventricle
• Without any clinical significance

40. 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

41. 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 cardioversion
Hemodynamically stable extrasystoles/VT can
be treated pharmacologically with lidocaine,
amiodarone or procainamide
MgSO4 in patients with Torsades

42. 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

43. 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

44. 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

45. 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

46. 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.

47. 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

48. Perforation of Heart and Great Vessels..
• 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)

49. 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

50. 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 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

51. Allergic Reaction..
• Protamine:
– Occasionally in diabetic patients using NPH
insulin
– Rapid injection can also provoke back pain of
unknown etiology
– Rarely used nowadays

52. 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

53. Acute Renal Failure
• Three major causes
– Contrast induced acute renal failure
– Renal atheroembolism
– Hemodynamic instability with renal hypo
perfusion

54. 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

55. 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

56. 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

57. 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

58. 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

59. Prevention of Complications
• Proper patient selection
• Proper patient preparation
• Attention to details
• Experience
• Skills

60. “Huh! Twice in
ONE day!”

61. 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

62. Thank you
With my two
mentors at Texas
Heart organizing
Interventional
meeting in Dubai