CARDIAC CATHETERIZATION

COMPLICATIONS
MODULO 1
1/10/2021
 INTRODUCTION

Cardiac catheterization is one of the most widely performed

cardiac procedures.

As expected, in any invasive procedure, there are some patient-

related and procedure-related complications. With significant
advances in the equipment used for cardiac catheterization, the
improved skill of the operators, and newer techniques, the rates
of these complications have been reduced significantly.

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 PERSONNEL

A cardiac catheterization procedure is usually performed

in a cardiac catheterization laboratory with the help of
fluoroscopy to guide and position the catheters in the
appropriate position
.
Along with the experienced operator, support from
registered nurses and radiologic technologists is needed
for safely performing the procedure.

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 COMPLICATIONS

 The complications of a cardiac catheterization can be minor as discomfort at the

site of catheterization, to major ones like death.

• The risk of major complications during diagnostic cardiac catheterization

procedure is usually less than 1%, and the risk and the risk of mortality of 0.05%
for diagnostic procedures.

• For any patient, the complication rate is dependent on multiple factors and is
dependent on the demographics of the patient, vascular anatomy, co-morbid
conditions, clinical presentation, the procedure being performed, and the
experience of the operator.

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 COMPLICATIONS

 Death  Allergic reactions/Anaphylaxis

 Dysrhythmia  Air/clot embolism
 Stroke  Renal Failure
 Bleeding  Vagal reaction
 Hematoma  Local Vascular Complications
 Nephrotoxicity induced by  Radiation Injury
contrast
 Pulmonary Edema

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 MORTALITY
 Rare – less then 0.1%1 •
HIGHT RISK GROUP :

• Age >60 years and <1year

• Female
• NYHA IV heart failure
• Severe LMCA
• LVEF <30%
• Patient with valvular heart disease, CKD, DM requiring insulin therapy, peripheral arterial
disease, pul insufficiency, cerebrovascular disease

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 MYOCARDIAL INFARCTION

• Periprocedural myocardial infarction is

common but the risk of this event is < 0.1 %

• This is mostly influenced by patient-related

factors like the extent and severity of
underlying coronary artery disease, recent
acute coronary syndrome, diabetes requiring
insulin, and technique-related factor

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 STROKE

The overall risk of stroke in recently reported series is low at 0.05% to 0.1% in diagnostic
procedures and can increase to 0.18% to 0.4% in patients undergoing intervention.

RISKS FACTORS INCLUDE:

 Severity of coronary artery disease
 Diabetes
 Hypertension
 Prior stroke
 Renal failure

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 STROKE
The risk is higher in patients with extensive
atherosclerotic plaque in the aorta and aortic arch,
complex anatomy, procedures requiring multiple
catheter exchanges or excessive catheter
manipulation, or the need for large-bore catheters
and stiff wires.

Majority of periprocedural stroke patient have poor

outcome and in hosdpital mortality can be as hight as
32%

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 STROKE

Prevented by:

• The use of Normal Saline with heparin ( 1000 ml of Normal Saline + 5000 units of
heparin).
• Paying careful attention during the flushing and injection technique.
• Minimize dwell time of guidewire in the aortic root of patients who are not fully
anticoagulated.
• Carefully cleaning of the wipe and immerse guidewires in heparinized saline
before their reintroduction during left-sided heart catheterization .

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 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
 Pseudoaneurysm
 AV fistula

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 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

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 HEMATOMA /RETROPERITONEAL BLEEDING

• Hematomas are usually formed following poorly controlled hemostasis post sheath
removal. Most hematomas are self-limiting and benign, but large, rapidly expanding
hematomas can cause hemodynamic instability requiring resuscitation with fluids and
blood.

• In patients with transfemoral access, retroperitoneal bleeding should be suspected if there

is a sudden change in the patient's hemodynamic stability with or without back pain, as
there may not be any visible swelling in the groin for some of these patients.

• The incidence of this complication is less than 0.2%

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 HEMATOMA , RETROPERITONEAL BLEEDING

• Identification of the bleeding source is essential for patients with continued

hemodynamic deterioration.

• These life-threatening bleeds are more frequent when the artery is punctured
above the inguinal ligament. Most patients are managed with a reversal of
anticoagulation, application of manual compression and volume resuscitation, and
observation. Patients with continued deterioration with need coiling of the
bleeding source vessel, or balloon angioplasty, or covered stents for bleeding from
larger vessels.

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HEMATOMA RETROPERITONEAL

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 ARTERIOVENOUS FISTULA

Direct communication between the arterial and venous puncture sites with ongoing
bleeding from the arterial access site leads to the fistula formation and is associated
with a thrill or continuous bruit on examination.

Recognized by presence of thrill or continues bruit at the site of catheter insertion .

These usually will require surgical exploration as they are unlikely to heal
spontaneously and may expand with time.

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 ARTERIOVENOUS FISTULA

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

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 DISSECTION

• This infrequent complication occurs in patients with an increased atherosclerotic

burden, tortuous arteries, or traumatic sheath placement.

• Non-flow limiting dissections usually heal spontaneously following sheath removal.

• A flow limiting large dissections could lead to acute limb ischemia and should be

treated immediately with angioplasty and stenting.

• Vascular surgery is usually reserved for patients with failed percutaneous

techniques.
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DISSECTION

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DISSECTION

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 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

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 PSEUDOANEURYSM
RISKS FACTORS
 Too brief period of manual compression
 Large bore sheaths
 Postprocedural anticoagulation
 Antiplatelets therapy during procedure
 Age > 65 years
 Obesity
 Hypertension
 Peripheral arterial disease
 Hemodialysis

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 PSEUDOANEURYSM

• Small pseudoaneurysms of less than 2 to 3 cm in size may heal spontaneously

and can be followed by serial Doppler examinations.
• Large symptomatic pseudoaneurysms can be treated by either ultrasound-
guided compression of the neck of pseudoaneurysm or percutaneous injection
of the thrombin using ultrasound guidance or may need surgical intervention.

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PSEUDOANEURYSM

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 ARTERIAL THROMBOSIS

 Rare

PREDISPOSING FACTORS OF FEMORAL ARTERY THROMBOSIS :

 Small vessel lumen

 Peripheral arterial disease
 Diabetes
 Female
 Placement of large diameter catheter/sheath
 Prolong post procedure pressure

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 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

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ARTERIAL THROMBOSIS

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 RADIAL ARTERY ACCESS
• The most frequent complication after transradial access is about a 5% risk of radial
artery occlusion.

• Radial artery spasm is another frequent complication, and this can be avoided by
using local vasodilatory medications and systemic anxiolytics.

• Perforation of the radial artery is an extremely rare complication and is usually

managed with prolonged external compression and rarely requires vascular
surgery intervention.

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RADIAL ARTERY OCCLUSION

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RADIAL SPASM

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RADIAL ARTERY PERFORATION

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THANK YOU
‫شكرًا‬

Isabel Paulo

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