Pitfalls to be avoided include inadequate preprocedural planning and incomplete understanding of the occlusion and surrounding anatomy. Careful study of noninvasive imaging prior to the procedure is extremely important in this regard. As stated above, balloon angioplasty is contraindicated until there is certainty that the wire has crossed the occlusion and has entered the vascular space on the other side of the occlusion.

Complications include subintimal wire passage, which is generally benign, or complete perforation of the vessel wall. As long as no bulky catheters or balloons are advanced across the perforation, bleeding should be negligible. Failure to recognize that the wire is extravascular could result in an uncontrolled tear during angioplasty. Stenting could result in stent malposition or frank embolization. In cases with abundant fresh clot, clot emboli could result in end-organ damage such as pulmonary embolism or stroke. Thrombectomy with AngioJet is well reported to potentially cause hypotension, bradycardia, and even asystole, particularly if close to the heart. Thrombectomy systems that result in significant erythrocyte lysis, such as AngioJet, will also cause hemoglobinuria, which could lead to renal failure. Contrast nephropathy and radiation injury are always potential concerns during long and complex cases such as these.