Procedural Complications, Safety, and Radiation Management
Core concepts
Know access-site complications: hematoma, pseudoaneurysm, arteriovenous fistula, retroperitoneal hemorrhage, and radial artery occlusion. Understand contrast-induced acute kidney injury (CI-AKI) prevention: hydration, minimize contrast volume, avoid nephrotoxins. Master radiation safety: ALARA, collimation, pulsed fluoroscopy, lead shielding, and dose monitoring. Know coronary complications: dissection (NHLBI classification), perforation (Ellis classification), no-reflow, air embolism, and stent loss. Understand management of perforation (balloon tamponade, covered stent, coil embolization, surgery) and no-reflow (vasodilators, aspiration).
Traps
- Missing retroperitoneal hemorrhage after femoral access (hypotension, back pain, falling hematocrit).
- Forgetting radial artery occlusion is usually asymptomatic but can limit future access.
- Underestimating CI-AKI risk in diabetics and CKD patients.
- Overlooking that no-reflow may be due to distal embolization or vasospasm.
- Ignoring radiation dose to the operator and patient.
Rule of thumb
For coronary perforation, inflate a balloon proximal to the perforation for tamponade, then deploy a covered stent. For CI-AKI, hydrate and keep contrast volume low, especially in CKD.
Worked example
During PCI, a wire perforates a distal branch causing rapid hypotension. Inflate a balloon across the perforation for tamponade, give protamine if heparinized, and deploy a covered stent or coil.