14.2 Recognition & Treatment of Procedure Complications

Recognition & Treatment of Procedure Complications

ARRT Focus of Questions 8 is Complications: recognition and treatment. This section is procedure-level — what the wire, balloon, stent, or device just did inside a vessel or chamber. It is not a rewrite of Patient Care emergency care. Anaphylaxis and contrast-induced nephropathy (CIN / CI-AKI) stay in 6.1. Retroperitoneal bleeding after a high femoral stick is summarized in 6.3: a quiet dressing with flank pain and falling pressure is still retroperitoneal hemorrhage, not a new Focus 8 invention.

Quick Answer: A new flap is dissection — keep the true-lumen wire and stent the entry. No-reflow is a closed microcirculation with an open epicardial vessel — give intracoronary (IC) vasodilators. Ellis III is a jet of contrast leaving the artery — prolonged balloon, covered stent, protamine as ordered, echo, pericardiocentesis. Lost devices get a snare. The technologist calls for echo, puts a covered stent on the table, opens the crash cart, notifies the surgeon, and documents fluoro, dose, and contrast.

Coronary dissection, intramural hematoma, acute closure

Dissection is a new false lumen. Guide-catheter trauma at an ostium, a wire in the wall, an oversized balloon, or a calcified plaque that splits can all start it. A spiral dissection propagates down the vessel and can shut TIMI flow. Recognition: a linear flap, contrast staining that persists after the injection, a new hazy lumen, ST elevation, and pain. Do not inject into the false lumen. If the wire is in the true lumen, leave it. The operator stents the entry (and enough length to pin the flap). A perfusion balloon can keep some distal flow while the stent is prepared. If the wire is lost to the false lumen, a second wire into the true lumen comes first — pulling everything out can close the vessel.

Intramural hematoma is blood in the media without a free flap on angiography; IVUS or optical coherence tomography (OCT) makes the diagnosis. Treatment is often a stent to tack the hematoma, not more high-pressure inflations that extend it.

Acute closure is sudden TIMI 0 in a vessel that was open: dissection, thrombus, spasm, hematoma, or a jailed side branch. Treat the cause — rewire, balloon, stent, thrombectomy, IC nitroglycerin for spasm — not a blind extra cine run while ST segments climb.

Side-branch occlusion after main-branch stenting is lost flow in a diagonal, obtuse marginal, or septal that was jailed. Recognition is a sudden ST shift in that territory and a stump on angiography. Rewire through struts, balloon, kissing inflations, or a provisional stent as the operator chooses.

No-reflow

No-reflow (and slow-flow) is TIMI 0–1 despite a patent epicardial lumen after balloon, stent, or thrombectomy. The microcirculation is obstructed by debris, spasm, and edema. Recognition: the stent looks fine, the myocardium does not blush, ST stays up, the patient hurts. First pharmacologic treatment is IC vasodilators — teaching agents include nitroprusside, nicardipine, verapamil, adenosine, and sometimes IC epinephrine in collapse. Another high-pressure stent into an already open lumen is not the first move. Maintain blood pressure; no-reflow can become hemodynamic collapse.

Perforation: Ellis I–III

Contrast leaving the coronary is perforation. Teaching Ellis grades:

Prolonged balloon inflation is the first mechanical seal. A covered (PTFE) stent treats a proximal or mid-vessel hole that will not stay dry. Distal wire perforations may need prolonged balloon, coils, or embolic material rather than a large covered stent jammed into a tiny vessel — that is an operator decision; your job is to have the covered stent in the room. Reverse heparin with protamine only on order, and not blindly if a fresh uncovered stent is the only thing keeping the artery open. Call for echo (transthoracic or ICE) early. Tamponade physiology as a shock state is in 6.2; Focus 8 is getting the hole closed and the pericardium assessed. Notify surgery while you still have a blood pressure.

Device embolization, stent loss, wire fracture

Device embolization (plug, valve leaflet, coil, filter) is a retrieval case. Keep a snare on the table for structural and foreign-body lists. Do not chase a device with an unshaped catheter that pushes it further downstream.

Stent loss (stripped from the balloon): if the wire is still through the stent, a low-profile balloon can be advanced, inflated, and withdrawn; a snare can grab the strut; crushing the lost stent against the wall with another stent is a bailout; surgery is last. Do not lose the wire.

Wire fracture or a retained fragment: stop yanking. Snare or balloon-trap the fragment. Document any retained hardware on the record and on fluoro.

Air embolism, stroke, access occlusion — pointers with procedure actions

Air embolism: never let the manifold run dry (6.3). Sudden ischemia or ventricular fibrillation after a dry line is air until proven otherwise — stop injecting, give 100% oxygen, support, and defibrillate VF.

Stroke during PCI, TAVR, or arch work is sudden aphasia or focal weakness (6.3). Stop unnecessary catheter movement, notify the operator, protect the airway, activate the stroke pathway, and document last known well.

Access occlusion (radial occlusion, femoral thrombosis) is a lost pulse versus the documented baseline. Check pulses before the patient leaves. This is not “the dressing looks pretty.”

CIN is a creatinine story prevented with hydration and less volume (6.1), not a Focus 8 steroid.

Hemodynamic collapse during PCI

Collapse during PCI is ischemia from closure or no-reflow, tamponade from perforation, vagal bradycardia, anaphylaxis (6.1), or bleeding (6.3). Pads should already be on. Call the rhythm and the arterial line in closed loop. Open the crash cart. Prepare IABP or Impella if the operator is going to mechanical support. Notify the surgeon — that call is cheaper than a late call. Stop shooting cine on a pulseless patient.

Technologist actions that the exam will score

1. Call for echo when perforation, tamponade, or unexplained hypotension appears.
2. Put a covered stent (and a snare, on device cases) on the table before they are a scavenger hunt.
3. Crash cart, defibrillator, airway, suction — unobstructed.
4. Notify the surgeon (the hybrid advantage is that they may already be there).
5. Document fluoro time, cumulative air kerma, dose-area product, contrast volume, activated clotting time, and a timed narrative of the complication.

Table: complication / first recognition / first treatment

Scenario and traps

During right-coronary PCI a distal wire produces a jet into the pericardium and the arterial line falls. That is Ellis III. Inflate a balloon, call for echo, open a covered stent, notify surgery — do not call it vasovagal because both can drop the blood pressure. After a thrombus-laden stent the lumen looks huge but the myocardial blush is gone: no-reflow, IC vasodilators, not protamine. A guide produces a spiral ostial flap with the wire still central: stent the entry, do not inject to “better see” the false lumen.

Traps: treating no-reflow as Ellis III. Treating Ellis III as CIN. Rewriting anaphylaxis here. Assuming a quiet groin excludes retroperitoneal bleeding (6.3). Losing the coronary wire after stent stripping. Documenting the pretty angiogram and not the fluoro dose or contrast tally after a complication.