1. Cardiac Catheterization
Complication

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 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.

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. • 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..

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 anticoagulated
– 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 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

16. • 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..

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. • 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

20. 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

21. 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

22. 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

23. 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

24. 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..

25. 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

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

27. 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

28. • 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

29. Complications includes
Ruptue
Distal embolization
Local pain
Neuropathy
Local skin ischemia
Pseudoaneurysm

30. 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

31. 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

32. 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

33. 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

34. • 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

35. 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

36. 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

37. 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

40. 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

41. 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

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

43. 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

44. 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..

45. 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

46. • 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..

47. 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

48. 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

49. 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.

50. 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

51. • 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..

53. 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

54. • 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..

55. 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

56. 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

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

58. 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

59. 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

60. 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

61. 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

62. 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

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

64. “Huh! Twice in
ONE day!”

65. 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