Hello, everyone, I'm Saurabh Joshi, an interventional cardiologist, and we'll be talking about PCI complications. Major complications with PCI are infrequent, but when they happen, they can be life-threatening. With increasing patient and procedural complexities, there are more PCI complications, so one should be familiar with their management. The management requires preparation and awareness, early recognition of the complication, learning the broad differential diagnosis, having the knowledge and experience of effective techniques. It's usually a team-based strategy. Multidisciplinary collaboration, need to have other interventional cardiologists available to help scrub in during the time of emergency and complications, having CT surgery notified and available, may need a shock team to come and help as well. And more important is that all cath lab staff should be able to raise concern regarding potential or active complication. They should feel free to raise a concern. So all cath labs should have a cart or a kit, which can have equipment to take care of complications at times of emergency, so it should be easily located. Such a cart should include a pericardiocentesis tray, pericardiocentesis for tamponade, should have covered stents for perforation, if there's a distal vessel perforation, should have coils and micro catheters to deliver the coil, snares, thrombate, or microspheres. In the room or nearby, should have mechanical circulatory support devices, like intra-aortic balloon pump, impella, ACLS drugs and defibrillator should be available, and contact information for individuals providing emergency support or advice. And in the hospital or on call, should be available our CT surgery team, perfusion team, peripheral vascular specialist, echocardiography, and have experienced cardiac ICU care. In hospitals where the procedures are performed and they do not have CT surgery backup, they should have a plan in place where a patient can be emergently transferred to a hospital or facility where these resources and services are available. Important, again, that all staff should be aware of the location of this equipment and resources and their use. Once the complication is suspected, should have a rough algorithm that one should go through. If there's a complication, first thing to see is if the patient can perfuse, oxygenate, and ventilate without support for the next 60 seconds. If they are not able to do so, then one should act immediately to address that. If the patient is not being able to breathe, should be intubated. If they're not being able to perfuse, will require mechanical circulatory support devices. Should act on that and at the same time, start thinking about the etiology leading to this situation and taking care of it. Start asking for help and see who's available. Usually in these situations, if you have another set of hands helping you is of great help. If you do have some time, if the patient is stable in the beginning, then think first. Think of the differential diagnosis, see the reversible causes, and have a plan of the next few steps. Ask for help, see if someone can scrub in with you, and then start acting on it, taking care of the reversible causes and making sure the cardiac function is good, blood pressure is stable, and rhythm is good. Once the patient is stable, then check if you want to continue with the procedure. If it feels like the procedure at this time can be deferred, should do that. In that case, have the patient in transport to an intensive care unit and have a close monitoring and plan for optimal post-procedure support. Let's talk about acute drop in blood pressure during the procedure. If there's an acute drop in blood pressure, first thing to check is if it is real. At times, there can be an equipment malfunction that the co-pilot may not be working well or too is open, so correct those causes if that's the case. But if the blood pressure drop is real, first thing to do is check the pulse. If there is no pulse, then initiate CPR and ACLS. If there is a pulse, then assess for etiology, see what is leading to hypotension, and it can be divided into different categories. One is ischemia or infarct-related, that is because of thrombosis, dissection, air embolism in coronary artery, or no reflow, and we'll be talking about these individually. If there's a rhythm problem, say if there's bradyarrhythmia leading to hypotension, patient may require a pacemaker. If there's a cardiac performance issue, there's a low cardiac output, may require mechanical circulatory support device. If there's an acute AR or MR, that needs to be addressed. If there is bleeding, one needs to think about access site, make sure there's no bleeding from there, and accordingly act on it. Hypotension could also be because of vasodilatory or distributive shock, which could be because of anaphylaxis, sepsis, or due to anesthesia. Once an etiology is identified for drop in blood pressure, one should ask if this can be quickly reversible. Can you take care of it quickly? If yes, then work on it. With that, the blood pressure improves. If you anticipate that taking care of the underlying etiology will take long, then the patient needs to be first supported hemodynamically, and for that will need to be started on intravenous inotrope or vasopressor or mechanical circulatory support device. Let's talk about coronary dissection. If one identifies a coronary dissection, first question to ask is, is there a wire across the dissection? If wire is across, then the question arises, do you have an integrative flow in the vessel? Please note, one needs to avoid taking integrative injections as it can propagate the dissection. If the vessel is not open, first thing to do after that is to perform balloon angioplasty and establish integrative blood flow. Important thing is if there is a lot of intramural hematoma, in that case, a cutting balloon will help release the pressure and can pursue that. Once the artery is open, there is an integrative flow, the next step would be to deploy a stent and being mindful to cover the distal edge of the dissection first so that it does not propagate further down. If wire is not across the dissection, then one can attempt integrative wiring using non-polymer jacketed wire. If it is successful, then can go ahead with balloon angioplasty if needed, and then deployment of a stent. If wiring is not successful, then one can pursue CTO techniques, which includes integrated dissection re-entry or sub-intimal tracking and re-entry. It would be important to check if someone around is available who has expertise in these techniques to scrub in and help. Once the dissection is taken care of, then one can pursue and complete the rest of the procedure, complete the PCI. If dissection could not be taken care of because of inability to wire integrate or you lost wire position, then assess the patient's condition. If the patient is hemodynamically stable and not having angina, then one can choose to pursue conservative management and watch. If the patient is hemodynamically unstable, will require mechanical circulatory support device and CT surgery should be consulted and may even require urgent surgical revascularization for the dissected coronary artery. For main vessel perforation, first question is, is the patient stable? Because if there is a perforation, it can lead to tamponade. If the patient is unstable, call for echocardiogram, look for tamponade, and pursue pericardiocentesis. Stabilize the patient, give IV fluid boluses, blood transfusion. Once the patient is stable or if you have another set of hands at the time, one needs to again check if you have a wire across the perforation. It's important to seal the site of perforation. Once you have a wire across, advance a balloon and perform a balloon tamponade. If you have two people working in a situation of perforation leading to tamponade, one can work on pericardiocentesis, others should work on inflating the balloon at the site of the perforation for balloon tamponading. After that, the plan should be to check if you are able to seal the perforation. If not, it will require a covered stent. If you do need a covered stent to seal the area of the site of perforation, one can use a ping-pong technique where another exercise is obtained, go with a second guide and wire across the site and advance the covered stent. At this time, deflate the balloon that's tamponading, position the covered stent, and deploy it. If one is unable to wire across the perforation site or lost wire position or unable to advance a covered stent and the patient continues to bleed and is unstable, CT surgery should be notified urgently and will require urgent surgical intervention. If there's a distal vessel perforation, it's that distal that you cannot advance a balloon to that site or a covered stent. So again, it starts with the same thing, that distal vessel perforation can lead to hemodynamic instability and to lead to cardiac tamponade. So first question to ask is, is the patient stable? And if it is again unstable, give fluid boluses, blood transfusion, pursue pericardial synthesis. Once the patient becomes stable, advance a balloon proximal to the site of perforation and blow the balloon up, keep it inflated to prevent blood flow distally. One may have to leave it for a long time to achieve hemostasis with this balloon tamponade. Once a balloon is deflated and you perform an angiogram and identify that there's no further bleeding, then we can stop the procedure. You can decide if you still want to give a protamine to reverse anticoagulation or not. But if the bleeding has not stopped after balloon tamponade, one can pursue interventions like coil embolization, can inject thrombin or microspheres. No reflow. So no reflow phenomena, when that happens, one needs to ask a question, is there an epicardial obstruction? Epicardial obstruction includes dissection, the management of that we recently reviewed. It could be because of air embolism. If that is the case, the patient should be placed on 100% inhaled oxygen, can try to aspirate the air embolism or can take a second wire and try to poke into it to make the air bubble burst. If there's a proximal thrombus, one would need to perform aspiration thrombectomy, can pursue balloon angioplasty, but there's a risk of distal embolization with this. Also at the same time, should check ECT and make sure it's therapeutic. May have to give GP2V3A inhibitors. Once epicardial obstruction is excluded, then one is left with microvascular dysfunction or embolic obstruction as a cause for no flow phenomena. And in that situation, one should pursue pharmacologic management of no reflow. For that, there are various medications that can be administered distally in the epicardial vessels, including adenosine, calcium channel blockers like verapamil, nicardipine, can also give nitroprusside or GP2V3A inhibitor, epifibatide, if spatially thrombotic embolization was the suspected cause for no reflow. If in this situation, a patient is hypotensive, then a very good choice is to administer epinephrine for no reflow. After that, if the no reflow phenomena is resolved, you can go ahead and complete your If it continues, then additional pharmacologic treatment can be considered to improve the perfusion pressure. With diuretics, you can repeat the same procedure for a few weeks, and then you can go ahead to improve the perfusion pressure. With diuretics, you can repeat these medications again, can have the patient on intra-aortic balloon pump or hemodynamic circulatory support. Next, we'll talk about allergic reactions. All allergies should be reviewed prior to the procedure. If a patient has an allergy to a medication, that should be avoided. But if a medication or a class is indicated for the use during the procedure, then one needs to find an alternative. For example, if a patient has a heparin allergy, can use bivalirudine for anticoagulation. A medication like aspirin, which is needed for dual antiplatelet therapy, and a patient is undergoing percutaneous coronary intervention, then will benefit from desensitization. If a patient has allergy to iodinated contrast media, then it should be premedicated. Let's talk about iodinated contrast media allergic reaction, that's anaphylactoid or hypersensitivity reaction. When the patient has a reaction to this contrast media, they can have symptoms including skin rash or itching, can have breathing difficulty, or can have hemodynamic instability with hypotensive. There's a wide range. These symptoms overlap with other etiologies. So when this situation is identified, any symptoms or complaint, the other etiology should be entertained, should run through the differential diagnosis. For example, if there's urticaria, other drug allergies should be entertained. If a patient is having difficulty breathing, should check for flash pulmonary edema. If patient becomes hypotensive, should also look for other PCI complications or excess site bleeding. Once the patient is diagnosed with iodinated contrast media, that the symptom is because of the allergic reaction to contrast media, then treatment should be pursued and treatment is based on the severity of reaction. So reaction can be divided into mild, moderate, or severe. Mild includes skin reactions, itching, and for this frequent observation should be started looking for progression. Sure, patient should be given intravenous diphenhydramine, and if does not respond to that, can pursue subcutaneous epinephrine. When it comes to epinephrine in this situation, one should be very clear about the dose, the dilution, and the route of administration. If there is moderate reaction, which includes bronchospasm, facial, or laryngeal edema, patient should be placed on supplemental oxygen by face mask, should be given inhaled beta agonist, and subcutaneous epinephrine should be administered. If the patient does not respond to this, then intravenous epinephrine starting with the bolus should be initiated. In this situation, one should also consider administering intravenous steroids, diphenhydramine, and optional H2 receptor blocker like famotidine. Severe reactions, which includes hypotension, respiratory failure, or cardiac respiratory arrest, patient should be started with epinephrine intravenous, and if having respiratory failure may require intubation. Other medications including IV steroids and diphenhydramine should be considered as well. Thank you.

interventional cardiologist

percutaneous coronary intervention

complications management

team-based approach

cath lab equipment