Complications of Cardiac Catheterization

Grossman’s cardiac catheterization, angiography, and intervention

CV CV R5 R5 陳儒逸陳儒逸醫師醫師Supervisor: Supervisor: 劉秉彥醫師劉秉彥醫師

Introduction (1)

• “ less than 1 % “

• risk-benefit ratio• The risk of sustaining a complication varies widely, depending

on:

1. Demographics (age, gender)

2. The cardiac anatomy (left main CAD, AS, LV dysfunction)

3. The clinical situation (ACS, shock, ARF)

4. The type of procedure being performed (diagnosis, PCI)

Introduction (2)

• Familiarity with those risks can be of immeasurable value in the following:

1. Anticipating increased risk of complication

2. Taking extra precautions to avoid them (TPM for PCI)

3. Promptly recognizing complications when they occur

4. Taking corrective and potentially life-saving action

Introduction (3)

• “ planned procedures “

• “ informed consent “

• “ documented all of them in the charts “

• “ early recognized “

• “ early treatment”

• “ closely follow-up visit after procedures “

Introduction (4)

Specific Complications

• Death : diagnostic cath; interventional cath

• MI : diagnostic cath; interventional cath

• Cerebrovascular events• Local vascular complications : diagnostic cath (brachial v.

s femoral); interventional cath

• Arrhythmias or conduction disturbance• Perforation of the heart or great vessels• Infections and pyrogen reactions• Allergic and anaphylactoid reactions• Renal dysfunction

Death – Diagnostic CathDeath – Diagnostic Cath

1960s1960s : the first Society for Cardiac Angiograph : the first Society for Cardiac Angiography registry of 53581 y registry of 53581 (0.14%)(0.14%)

1980s1980s : the second registry of 222553, more pa : the second registry of 222553, more patients at higher risk tients at higher risk (0.1%)(0.1%)

1990s1990s : : the third registry of 58332 the third registry of 58332 (0.08%)(0.08%) major complications (1.5%)major complications (1.5%)

NYHA class; multivessele disease;NYHA class; multivessele disease; CHF; renal insufficiency (0.3% => 2.5CHF; renal insufficiency (0.3% => 2.5%)%)

Important Risk Factors

PCWP>25mmHgSBP<100mmHgPCWP>30mmHgMBP<65mmHg (inotropic) >65mmHg ( iv diuretics)

LOCMIABPCPS (percutaneous cardiopulmonary bypass)

Improvement in catheter design : Improvement in catheter design : less traumatic “soft” tipsless traumatic “soft” tips

Imaging systemsImaging systems Contrast agents (LOCM non-ionic)Contrast agents (LOCM non-ionic) High annual procedure volume (>High annual procedure volume (>

1.5 million/year)1.5 million/year) Shorter procedure durationShorter procedure duration Routine heparinization??Routine heparinization?? Femoral vs radial?? Femoral vs radial??

Death – Interventional Cath

• 1979~1982 : NHLBI the elective angioplasty (1.1%)

• 1984~1987 : the second NHLBI (more high risk) (1.0%)

• Mid-1980s : 0.1%~0.3%

• It is fair to say that:

“ 1% vs 0.1% “

“ somewhat higher “

MI – Diagnostic Cath

• Transient “ischemic” episodes : drug or deflation

• Late 1970s : CASS (0.25%); the first, second, and third registries by Society for Cardiac Angiography (0.07%, 0.06%, 0.05%)

“patient-related” : “adequate preparation”

vs.

“technique-related” : “experienced”• “Angioplasty stand-by”

MI – Interventional Cath (1)

“ Dissection, abrupt vessel closure, snow-plow occlusion of side branches, spasm, no-reflow, thrombosis, distal embolization”• First NHLBI : 4.8% vs. Second NHLBI : 3.6%

• “elevated cardiac enzyme in 5~10% : PTCA”

vs.

“15~20% : directional, rotational, laser atherectomy”

MI – Interventional Cath (2)• Low order (1~3 times the upper limit of normal) appear

s to have no short- or long-term consequences and that only elevation above 5 times normal (CK-MB > 50 IU/L) tends to adversely impact late survival.

• Even low-level elevation of post-procedural CK have been found to have greater incidences of long-term adverse outcomes, including late death, late MI, late repeat revascularization.

• “cause-and-effect” ???

• “Gp IIb/IIIa antagonist agent”

• “ADP receptor blocker”

Cerebrovascular Complications(1)• Adams (1973) 0.23% == > SCA (1987) 0.07%

• Always embolic origin or hemorrhage• Avoid “catching” in aortic surface

• Avoid “prolonged wire dwell times > 3-min”

• Dislodgeable mural thrombus

• Avoid transseptal catheterization or mitral valvuloplasty in patients with left atrial thrombus, which may increase the incidence of stroke

• Paradoxical embolization (PFO, RVI, right to left shunt) == > flushing cath and sheaths during left or right cath studies

• Active left side endocarditis (AV or MV) : left side cath does not increase the incidence of embolic events (0/35)

AJC 1979;44:1306.

Local Vascular Complications

• The most common problems

• Vessel thrombosis

• Distal embolization

• Dissection

• Poorly controlled bleeding at the punctual site

• Ongoing bleeding == > poorly placed puncture, vessel laceration, excessive anticoagulation, poor technique in either suture closure or groin compression

Local Vascular ComplicationsDiagnostic Catheterization (1)

• SCA registry : 0.5~0.6% (brachial vs. femoral approach)

• Brachial (thrombotic) vs. femoral (hemorrhage)

• Femoral Approach:

1. femoral artery thrombosis is extremely rare (except for

PAOD, DM, female, IABP, long duration of catheter)

2. flow-obstructing dissection or thrombus == > urgent

vascular surgery == > within 2 to 6 hours!!

3. femoral venous thrombosis or pulmonary embolism

(EPS or compression by large arterial hematoma etc.)

up to 10% asymptomatic positive lung perfusion scan

4. endomyocardial biopsy

Local Vascular ComplicationsDiagnostic Catheterization (2)

• Femoral Approach:

5. poorly controlled bleeding == > laceration of F.A. == >

prolonged compression (30 to 60 mins) or surgery

6. hematoma formation == > usually resolve over 1 to 2

weeks == > femoral nerve compression == > quadriceps

weakness == > surgical repair is not required generally

== > above inguinal ligament (retroperitoneal hematoma)

(unexplained hypotension, decreased Hct, ipsilateral flank

pain) == > best prevention!!

Local Vascular ComplicationsDiagnostic Catheterization (3)

• Femoral Approach:

7. pseudoaneurysm (pulsation, audible bruit) == > duplex == > surgical repair or transducer compress the neck for 30 to 60 minutes == > procoagulant solutions or embolization coils @ <2cm in diameter == 2-week follow-up == persistent or symptomatic == surgical repair! @ accurate puncture of the common femoral artery @ effective initial control of bleeding 8. arteriovenous fistula (to-and-fro continuous bruit) superficial or profunda femoral arteries

Local Vascular ComplicationsInterventional Catheterization

• 10% == > 1~2%

• 15 minutes of manual compression is usually adequate

• Collagen plugging or percutaneous suture-mediated closure of the femoral puncture site ??

Arrhythmias or Conduction Disturbance

• Closely monitor the surface EKG and pressure tracings

• Immediately accessible treatment:

1. defibrillator

2. temporary pacemaker leads and generator

3. full array of antiarrhythmic drugs

4. ventilatory and circulatory support

Arrhythmias or Conduction DisturbanceVF (1)

• VPC or brief (3~5-beats) runs of VT are not uncommon

• Excess catheter or guidewire manipulation and intracoronary contrast injection (HOCM into RCA; damping; prolonged injection)

• Right heart cath :

1. brief runs of VT : up to 30%

2. sustained VT : 3%

3. VF : 0.7%

• Catheter or guidewire position and smooth passage

• Catheter or guidewire reposition

• 1973(1.28%) == 1974(0.77%) == 1991(<0.4%)

Arrhythmias or Conduction DisturbanceVF (2)

• Prolongation of the QT interval

• Therapy :

1. iv lidocaine (1.5 mg/kg over 1 minute, with a second bolus

of 0.75 mg/kg 7 minutes later)

2. procainamide (15 mg/kg over 20 minutes,↓BP ,↑QRS or QT)

3. iv amiodarone (5 mg/kg over 20 minutes, 1 gm/24 hours)

Atrial Arrhythmias• Atrial fibrillation is generally benign but may cause clinical sequelae if VR is

rapid (>100 bpm)

• If no significant hemodynamic dysfunction occurs:

1. heart rate control:

@ iv beta blockers (inderal : 1mg ; esmolol : loading 500μg/

kg/min for 30 sec, followed by 50~250 μg/kg/min)

@ iv CCB (verapamil 5mg)

2. convert rhythm:

@ iv procainamide (15 mg/kg for 20 min)

@ ibutilide (on other QT-prolonging drugs; ↓K or Mg;

bradycardia; QTc > 440 ms)

> 60 kg : 1mg over 10 min ; within 4 hours, no other class

III agents!!

@ synchronized cardioversion!!

Bradyarrhythmias (1)

• HOCM and RCA

• Forceful coughing :

1. clear contrast from the coronaries

2. support aortic pressure and cerebral perfusion during asystole

3. restore normal cardiac rhythm• Vasovagal reaction (3%): (80% : vascular access; 16% : sheath removal)

bradycardia with hypotension, nausea, yawning, and sweating

triggered by pain and anxiety especially in hypovolemic status!

adequate preprocedure sedation and local anesthetic!!

elderly and early perforation of heart with irritated pericardium

Bradyarrhythmias (2)

• Atropine is rarely helpful but should be given anyway since it has few adverse effects

• Prophylactic right-sided pacing catheters:

1. balloon valvuloplasties

2. rotational atherectomy (RCA and LCX)

Perforation of the Heart or Great Vessels (1)

• 1968 : 0.8% ; RA-RV-LA-LV

• Stiffer catheters and elderly women (>65y/o)

• Hypotension and bradycardia due to vagal stimulation

• Signs : enlarged cardiac silhouette; blunted pulsation of the heart

borders on fluoroscopy; arterial paradox; elevation of RA

pressure with loss of y descent.

• TTE

• Immediate subxyphoid pericardiocentesis!! (18-gauge needle

J-tip guidewire, tapered catheter with multiple side holes)

• Most perforations will seal so that surgery is unnecessary!!

• 0.08% in 18-year review from the Mayo Clinic

• 1.9% : valvuloplasties

• 0.23% : EPS

• 0.08% : PCI

• 0.006% : diagnostic catheterizations

• The majority (57%) were in frank collapse (SBP<60 mmHg) at

the time of pericardiocentesis

• 18% surgical therapy ; 82% pericardiocentesis

Perforation of the Heart or Great Vessels (2)

• Aorta or pulmonary trunk and branches : rare

• Tamponade of the proximal pulmonary artery, embolization of the bleeding branch, double-lumen endotracheal intubation, or even emergency lobectomy or pneumonectomy

• 1% : aggressive new technologies for PCI era

• Perfusion balloon catheter

• Coil embolization if a small distal branches

• Covered stent if a larger proximal vessels

• Emergent surgical repair if free perforation with ongoing leakage!

Perforation of the Heart or Great Vessels (3)

• Brachial vs. femoral (0.62% vs. 0.06%)

• Recommended technique:

1. shaving and cleaning the puncture site with povidone-iodine,

use of nonporous drape, and adequate operator clothing

2. cephalosporin 1 gm on call and q8h for 48 hours if delayed

intervention by exchanging sheaths that were placed in an

earlier diagnostic procedure or when any break in sterile

technique is suspected

3. within 2 weeks, contra-lateral site!!

4. avoid the multiuse drug vials and clean the room

Infections and Pyrogen Reactions

• Local anesthetic; iodinated contrast agent; protamine suflate

• IgE (true anaphylactic reactions) and direct complement activation (anaphylactoid reaction)

• 15%~35% rate (prior allergy to contrast)

• 5%~10% (pre-procedure: prednisone 20mg tid x 24~48 hours and H1 antihistamine or H2 blocker)

• Cross-reaction

Allergic and Anaphylactoid Reactions

• Protamine allergy : IDDM under NPH therapy (protamine-contained)

• Slowly (>5 min) push : rapid push induced severe back pain

• HIT (heparin induced thrombocytopenia) : ↓50% platelet count and positive serologic test (IgG Ab)

• IgG Ab-platelet factor 4 complex bind to platelet Fc receptor

• Mechanism : vasomotor instability, increased glomerular permeability to protein, direct tubular injury, tubular obstruction

• 5% to 50% if patients with:

1. DM

2. M.M.

3. volume depletion

4. preexisting renal failure

5. nephrotoxicity drugs (aminoglycoside, ACEI, ARB, NSAID)

• Nonoliguric, peak within 1 to 2 days, return to baseline by 7 days

• <1% requires chronic dialysis.

Renal Dysfunction (1)

• Defense : total contrast volume (3 ml/kg or 5 ml/kg divided by serum creatinine, in patients with elevated baseline creatinine

• 1990 SCA&I registry : mean volume 130ml in diagnostic cath and 191ml in angioplasty

• Adequate prehydration and fluimucil 1200 mg

• 26% with a mean Cr of 2.1 mg/dL : ↑>0.5 mg/dL

• Hydration with HS or NS for 12 hours before and after procedure : the best protection

• JACC 1999 : 98 patients with a baseline Cr of > 1.8 mg/dL (mean 2.5 mg/dL) received mean 160 mL contrast had a mean change in Cr of 0.6 mg/dL, 15% peak Cr>5 mg/dL at 48 hours and 7% dialysis

Renal Dysfunction (2)