Post-Cath Complications
Arun Kalyanasundaram
Mehdi H. Shishehbor
Although a relatively safe procedure, cardiac catheterization carries a low but significant risk of both major and minor complications. The combined complication of contrast media reaction, cardiogenic shock, cerebrovascular accident, congestive heart failure, cardiac tamponade, and renal failure following a diagnostic catheterization is <2%, and the risk of mortality is 0.1% (0.6 in a 1,000).
A brief history should be elicited to detect any symptoms suggestive of potential complications (Table 10-1).
The post-catheterization examination accordingly needs to focus on likely complications and should be directed by the history. The vital signs should be reviewed and blood pressure and pulse checked in supine and erect position if possible. The presence of tachycardia after cardiac catheterization should always prompt a search for the underlying cause. It may be a manifestation of intravascular depletion secondary to diuresis or bleeding or a sign of decompensated heart failure. It may also be a marker of pericardial irritation. Fever immediately after catheterization is not normal and may be a pyrogen reaction to fluids or medications. Any fever should prompt a search for an infective focus.
A brief neurologic examination should routinely be performed, and special attention should be paid to the patient’s speech and gait. Importantly, patients may not note neurologic deficits until they ambulate; these may include focal paresis or paralysis, visual symptoms, sensory deficits, and ataxia.
The jugular venous pressure should be assessed as an index of intravascular status, while cardiac auscultation should focus on the presence of any pericardial rub. All patients who have had subclavian or jugular cannulation need to be examined for signs of pneumothorax, as it may not manifest during the procedure.
Table 10-1 Symptoms Suggestive of Cardiac Catheterization Complications | ||||||||||||||||||||||||||||||
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Local Complications
The most important part of the examination that is unique to the postcath check is the assessment of the catheterization site. The site of catheterization should be checked for evidence of bleeding, pseudoaneurysm, arteriovenous fistula (a new onset bruit), or vascular compromise (absent distal pulses). Factors associated with high risk of local bleeding include advanced age, female gender, low body mass index (BMI), and use of anticoagulants or platelet glycoprotein IIb/IIIa inhibitors. Fluoroscopy prior to obtaining access routinely has been shown to reduce the complication rate significantly. Bleeding has been recognized increasingly as an important predictor of increased mortality. Due to their associated morbidity and mortality, we will discuss post-catheterization bleeding, pseudoaneurysm, and infection in greater detail.
Hematoma:
Bleeding after cardiac catheterization may be external or may manifest as a hematoma. Clinically, hematomas present as pain or local discomfort, focal discoloration or bruising, hemodynamic compromise, and rarely as femoral nerve compression and quadriceps weakness.
Meticulous detail to puncture technique by using external and internal landmarks and avoidance of multiple or posterior wall puncture will reduce the incidence of local bleeding. When using fluoroscopy, attention
should be given to the presence of calcium. In general, the femoral puncture should be above or below any calcification if possible. Other measures to reduce the frequency and severity of groin bleeding include careful monitoring of anticoagulation and careful attention to hemostasis during sheath removal. Adequate hemostasis must be achieved with manual pressure or a closure device before leaving the patient’s bedside (Figure 10-1).
should be given to the presence of calcium. In general, the femoral puncture should be above or below any calcification if possible. Other measures to reduce the frequency and severity of groin bleeding include careful monitoring of anticoagulation and careful attention to hemostasis during sheath removal. Adequate hemostasis must be achieved with manual pressure or a closure device before leaving the patient’s bedside (Figure 10-1).
Retroperitoneal Hematoma:
Retroperitoneal hematoma is usually associated with arterial puncture above the inguinal ligament. Hence, routine angiography of the common femoral artery might be reasonable even in diagnostic procedures to determine the risk of this complication. Since all the bleeding may be internal, the patient often presents with unexplained hypotension and tachycardia (occasionally bradycardia) without any external signs. Flank pain and bruising may be seen in some patients. An unexplained falling hematocrit may be the only finding in others. Dysuria might also be a presenting symptom as the hematoma presses on the bladder.
The best modality for detection of a retroperitoneal hematoma is a computed tomography (CT) scan. Ultrasound may be used if CT is not available. Since the therapy of retroperitoneal hematoma is based on its clinical implications, and directed toward correcting those, some physicians do not routinely obtain radiologic imaging studies. Unstable patients should not be sent for a CT scan. A conservative strategy of reserving these tests for patients where a definitive diagnosis is required to guide therapy, such as determining the need for withholding anticoagulant or antiplatelet therapy in stable patients might be reasonable.
Pseudoaneurysm:
Pseudoaneurysm is defined as arterial wall disruption with resultant extraluminal flow into a chamber contained by adjacent tissue. Arterial tissue does not contribute to the wall of the pseudoaneurysm. The incidence of pseudoaneurysm has varied between 0.3% and 0.5% of cardiac catheterizations in large series. In a recent study of patients treated with platelet glycoprotein IIb/IIIa inhibitors, pseudoaneurysms were noted in 0.5% of patients treated with manual pressure, 0.8% of patients treated with Angio-Seal, and 0.4% of patients treated with Perclose.
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