How to Overcome The

Complication
Budi Baktijasa

Overview
All individuals performing coronary
angiography should be intimately
knowledgeable about the potential
complications of the procedures they
perform

William
Grossman

Overview
And,
they should know
how to overcome
those complications !
Budi
Baktijasa

The Complications During Angiography

Please Remember.
There is NO SUCH
SIMPLE CASE.

Nobody is another case of.

You HAVE NO CASES.

You have patients who are
human
beings
with
feelings and emotions who
often have a greater
dignity and self-respect
than
you
possess
yourself.

-Wiiliam Osler, Father

of Modern Medicine-

High Risk Patient Mortality

Age : the elderly (>65 years old)
Functional Class : class IV > 10 times
Severity of Coronary Lession : left main > 10 times than
one or two vessel disease
Valvular Heart Disease : severe aortic stenosis
LV Dysfunction : EF ejection fraction <30% > 10 times
Severe Noncardiac Disease : diabetes , severe pulmonary
disease, advanced cerebrovascular or peripheral vascular
disease, renal insufficiency

Preparation. Prevention. Again.

To prevent is easier than to treat, isnit ?

But it takes time .
Unfortunately, muddle through the complication
is costly and need much more time,
than just prevent .

If The Complication Does Occur

The patient and family should be informed as soon as
possible.
The discussion should describe :
- The nature (without placing blame on anyone)
- Whether any long-term consequences are expected
- What corrective actions have been and will continue to be
pursued
Malpractice
suit?

Vasovagal Reactions
Commonly during the painful period (arterial
access)
Or after the procedure (arterial sheath removal
and application of pressure to the groin area).
Bradycardia ,hypotension , pallor, nausea, or
diaphoresis
- Atropine, 0.5 to 1 mg IV up to
3 mg.
- Fluids

Allergic and Anaphylactoid Reactions(5 %)

Allergic and Anaphylactoid Reactions(5 %)

Prevention

Treatment

Patients reporting allergic

reactions should be premedicated
with prednisone and
diphenhydramine.
Common dosages include 60 mg
prednisone the night, and 60 mg
of prednisone the morning of,
along with 50 mg oral
diphenhydramine and H2 blocker
(cimetidine or ranitidine)

Dexamethasone inj
Diphenhydramin inj
Ranitidine inj
If needed : intravenous
injection of dilute epinephrine
1 mL of 1:10,000 epinephrine
(i.e., 0.1 mg of epinephrine per
mL)

Dissection (0.1%)
Prevention
Never advance guidewire or
catheter against resistance
Confirmed catheter tip location
by gentle contrast injection
Do not manipulate catheter in
coronary ostium, monitoring
pressure of catheter tip
Do not inject with damped
pressure

Dissection
NHLBI classification
for coronary artery
dissection types.
Types A and B
generally benign,
whereas types C
through F portend
significant morbidity
and mortality if
untreated.

Left anterior oblique view of right coronary artery demonstrating complete dissection with
minimal distal flow.

Dissection (0.1%)

Hobelmann, A et al. Emerg Med J 2006;23:580-581

Copyright 2006 BMJ Publishing Group Ltd.

More dangerous : Perforation

Perforation
Ellis classification
coronary artery
perforations. Types I
and II are "contained"
perforations, whereas
Type III is a "free"
perforation with
continuous
extravasation of
contrast

If it happens?

Balloon and Stenting !

Consider CABG if
needed

Balloon and Stenting for LAD Perforation

Acute Coronary Occlusion

The mechanism :
- Thrombosis at atherosclerotic plaque
- Catheter induced thromboembolism

Thrombus
Aspiration

Prevent
Myocardial
Infarction

Myocardial Infarction

Intracoronary nitroglycerin (rule out spasm)

Intracoronary thrombectomy or aspiration
Balloon angioplasty
Stenting
CABG

Ventricular Tachycardia/Fibrillation, or
Asystole (0.6 %)
Prevention
Use nonionic contrast agents in high-risk pt
Do not wedge the catheter, contrast material
washout should be brisk. ECG and BP should be
normal before next injection
DO NOT inject if damped !
Limit contrast, avoid prolonged injections

Ventricular Tachycardia/Fibrillation, or
Asystole (0.6 %)

Treatment

Remove catheter from

ostium or LV
ACLS procedure
Emergency PCI or
CABG

Acute Pulmonary Edema

Prevention
Treat preexisting CHF optimally
Limit contrast medium
Avoid LV angiography in severe AS, marked CHF, or
pulmonary hypertension
Use nonionic or low-osmolar contrast media agents
Avoid hypotension
Limit flush solution volume
Monitor LV filling pressure (PCW)

Acute Pulmonary Edema

Treatment

Elevate patient's trunk 30 to 45

degrees
Oxygen, morphine (2 to 5 mg IV),
nitrates (100 to 200 IC), furosemide
(20 to 100 mg IV): vasodilator for
afterload reduction; inotropic
support with dopamine or
dobutamine
Intraaortic balloon pumping

Cardiogenic Shock
Prevention

Careful patient selection

Prophylactic IABP for high-risk left main
Minimize number of injections
Treat hypotension
Atropin, adequate volume expansion, vasopressor

Cardiogenic Shock

Treatment

If caused by coronary occlusion

PCI or CABG
Vasopressor support
IABP
Intubation and mechanical
ventilation
Pacemaker as needed.

Cerebrovascular Complication (usually

embolic stroke, 0.1 %)
Prevention

Systemic heparinization
Cleaning of guidewires before use
Limit guidewire-blood exposure (<2 min)
Use guidewire to cross aortic arch (especially in
atherosclerotic aortas)
Aspirate and flush catheters frequently
Remove air bubbles
Ensure all tubing and catheter connections are tight

Cerebrovascular Complication (usually

embolic stroke)
If the patient is less alert, has slurred
speech, and either visual, sensory, or motor
symptoms during or after procedure
CT scan urgent carotid angiogram
neurovascular rescue

Hematoma in Femoral Artery

Prevention
Precise puncture
location
Attention to
compression
Prolonged compression
if patient coughing, AR,
hypertension

Treatment
Evacuation rarely
needed
Surgical consult for
enlarging hematoma,
compartment
syndrome, or cool
extremity

Femoral Complication
Aneurysm

Pseudoaneurysm
AV fistula

Retroperitoneal Bleeding
Prevention
Avoid high puncture
Watch for hypotension,
low abdominal or frank
pain within 2-12 hr
Aware with low
hematocrit, tachycardia

Treatment
Reverse anticoagulants
Volume replacement
Transfussion
CT scan
Surgical consultation

Retroperitoneal Bleeding

Contrast Agent Nephrotoxicity

Prevention and Treatment

Hypotension
May occure before, during or after
procedure
Several condition : hypovolemic caused by
fasting, vasovagal reaction, hypovolemic
caused by contrast induced diuresis,
anaphylactoid reaction, myocardial
ischemia, myocardial infarction, malignant
arrhytmia, bleeding, cardiac tamponade, etc

Management of Hypotension
Most important : early recognition and
adequate treatment for the cause of
hypotension
AND,
Fluid iv saline solution, vasopressor when
needed.

Thank you..