COMPLICATIONS OF

PERCUTANEOUS CORONARY
INTERVENTIONS AND
MANAGEMENT
 VASCULAR ACCESS

• The first part of any PCI begins with vascular access.

• Using the femoral access, the major complications are femoral artery
dissections, pseudoaneurysm, arteriovenous (AV) fistula, and retroperitoneal
bleeding.
• All arterial complications are markedly reduced (but are not eliminated) using
the radial artery access.
 FEMORAL ACCESS COMPLICATIONS
PSEUDO-ANEURYSM
• A femoral artery pseudoaneurysm represents a failure of sealing of the initial
arterial puncture site, allowing arterial blood to flow into the surrounding
tissue.
• Pseudoaneurysms are late appearing, associated with local pain and swelling,
and diagnosed with femoral ultrasound
• The two most common treatment methods are ultrasound-guided
compression or thrombin injection.
• Thrombin injection can be performed by diluting 1000 u thrombin in a
1-ml syringe with normal saline (final concentration of 100 u per 0.1
ml) and injecting with direct ultrasound visualization through a long
22-gauge needle until thrombus is formed in the pseudoaneurysm
cavity and doppler-detected flow is abolished
ARTERIOVENOUS FISTULA
• This is recognized on physical examination by a palpable thrill or an audible continuous bruit.
• The main risk factor for development of an AV fistula is a low arterial puncture
• Most persistent AV fistulae are asymptomatic and do not require repair.

INFECTION
• A RARE COMPLICATION OF GROIN ACCESS IS SYSTEMIC INFECTION.
• PROPER STERILE TECHNIQUE, INCLUDING HAND-WASHING AND USE OF HATS,
MASKS, GOWN, AND GLOVES,
BLEEDING
• Most dangerous complication of groin access is major femoral bleeding.
• Significant risk factor: old age, use of Heparin, severe renal impairment,
closure device use, larger sheath, GP IIb/IIIa use, longer procedure
• The bleeding complication of most concern is a retroperitoneal hematoma
because large amounts of blood can fill the pelvic cavity, and shock can
develop rapidly
• Classical signs and symptoms of retroperitoneal bleed
• Hypotension, bradycardia, back/flank pain, groin pain, abdominal pain,
transient response to fluid loading, grey turner sign (bruising along flank)
[late appearing], Cullen sign (bruising around umbilicus) [late appearing.
COMPLICATIONS OF RADIAL ACCESS
Radial artery occlusion (2%–10%)
• Factors believed to be associated with radial occlusion include lack of adequate anticoagulation, too large a sheath
size compared to the vessel size (e.G., Consider 5F sheaths for smaller patients and women), prolonged and
aggressive postprocedure compression without maintenance of forward flow, and repeat cannulations of the same
radial artery.
• Allen test prior to the procedure

Radial artery spasm (12%–22%)

• spasm of the vessel can occur and is frequently due to significant alpha1 adenoreceptors within the medial layer
of the vessel; it is overcome and minimized by the use of vasodilators (e.G., Intra-arterial verapamil and/or
nitroglycerin).
• Occasionally, it has been reported that a severe spasm entraps the catheter or long sheath so that it cannot be
withdrawn.
• This diffuse and severe spasm has been managed by increased sedation, sometimes requiring a local nerve block
or induction of general anesthesia.
COMPLICATIONS RELATED TO GUIDE CATHETERS, BALLOONS, STENTS, AND
INTRAVASCULAR DEVICES
• CORONARY DISSECTION

• CONTRAST MEDIA COMPLICATIONS

• Air embolization

Another potential complication of coronary angiography and contrast media injection is air embolization This is
always an iatrogenic complication due to failure to clear the air from the injection manifold system. Automatic
contrast injection systems have a much lower rate of air embolism because of built-in air detection sensors.
However, these systems do not fully eliminate the incidence of air embolism despite their inherent safety
mechanisms and are not a replacement for a good manifold technique of aspiration and visual inspection for
bubbles.
Treatment of coronary air embolism consists of immediate initiation of 100% oxygen by facemask. The oxygen
helps to minimize ischemia and produces a diffusion gradient favoring reabsorption of the air. If large bubbles
persist, the air can be aspirated by various aspiration catheters
• Arrhythmias
• Another general complication of PCI that might occur at any time during the procedure is
arrhythmia (either tachycardia or bradycardia). Unstable tachycardias like ventricular tachycardia
or ventricular fibrillation are more commonly seen in the setting of an acute MI. Bradycardia is
most often seen in RCA occlusions; use of rotational atherectomy, especially in the RCA; or use
of rheolytic thrombectomy catheters.
• Treatment of arrhythmias should follow standard advanced cardiovascular life support (ACLS)
protocols.
• NO REFLOW
• An acute cessation of coronary flow during PCI can occur as a result of abrupt occlusion or a
consequence of distal failure of outflow.
• This observation, termed the no reflow phenomenon is used by some authors only in conjunction
with microembolization, whereas others reserve the term for myocardial blush grades of 0 or 1
(regardless of coronary thrombolysis in myocardial infarction [TIMI] flow) in the setting of a
primary PCI.