Complications of PCI by Dr Sh.Golmohammadzadeh Interventional cardiologist

Classification General classification ( AHA ): 1- Contrast nephropathy 2- Vascular 3-CVA 4- Emergency CABG 5-MI 6- Death

Practical & Detailed Classification Medical complications : - Atheroembolism - Neurologic - Infection - Contrast related reactions & complications - Hematologic complications Peripheral Vascular complications Coronary complications

Causes of Renal Insufficiency in PTCA patient PRE-RENAL CAUSES : 1) Volume depletion :NPO status, Contrast - induced diuresis,Blood loss. 2)Diminished cardiac output :Contrast-induced myocardial depression,Myocardial ischemia RENAL CAUSES: Contrast-induced Renal ischemia,Atheroembolism PERI-RENAL CAUSES: Aortic dissection, malaposition of LABP,drugs POST –RENAL CAUSES

Renal Insufficiency -2 Prevention : 1- IV fluids 2- Non-Ionic Contrasts 3- Avoid nephrotoxic drugs ( NSAIDs ) 4- Avoid loop diuretics 5- Dopamine 6- Theophylline 7- N-Acetylcysteine 8- Fenoldopam

Renal Insufficiency -3 Risk factors for CM induced nephropathy : - baseline Cr > 1.5 mg% or Ccr<60 cc/min - diabetic nephropathy - heart failure ( FC III-IV ) - large volume of CM **( 5ml per kg / Cr ) - prior CM induced nephropathy - intravascular volume depletion * hypertension,* advanced age,* proteinuria

Contrast Reactions -1 Hemodynamic effects Electrophysiological effects Minor reactions ( urticaria, nausea,…. ) Moderate reactions (angioedema,laryngeal edema, bronchospasm ) Severe reactions (anaphylaxis, hypotension) Thrombosis Nephrotoxicity

Contrast Reactions -2 Pre – medication for prevention of reactions - Prednisone - Diphenhydramine - H 2 receptor antagonists - Low-Osmolar Contrasts

Hematologic Complications Thrombocytopenia - HIT – 1 - HIT – 2 - GP II b /III a inhibitors Neutropenia -Ticlopidin TTP - Ticlopidin and Plavix

Peripheral Vascular Complication Local bleeding & hematoma Retro peritoneal hemorrhage Pseudo-Aneurysm A-V fistula Thrombotic occlusion Arterial perforation Dissection

Coronary Complications Coronary artery spasm Dissection and Acute Closure No-Reflow and Slow-Flow Phenomena Coronary artery perforation Emergent CABG for failed PCI Restenosis ?

Coronary Artery Spasm -1 Balloon Angioplasty : 1- intra-lesional spasm 2- distal epicardial spasm 3- micro-vascular spasm 4- post procedural spasm Non-Balloon Devices Pathophysiology Managements

Coronary Artery Spasm Management Nitrates Removal of interventional hardware Calcium Antagonists Repeat balloon dilatation Systemic circulatory support Stents Rule out Dissection and Thrombus

Dissection & Acute Closure -1 Classification : - Acute closure - Imminent closure - Threatened closure Incidence & Timing of Acute closure Causes of Acute closure Risk factors for Acute closure Prevention of Acute closure Management of Acute closure

Types of Coronary artery Dissection

Dissection & Acute Closure -2 Causes of Acute closure : 1- dissection* 2- elastic recoil 3- spasm 4- thrombus % of probability of Acute closure.Classification of dissection ( * ): type A ( 0%), type B ( 3%), type C ( 10%), type D ( 30%), type E ( 9%), type F ( 69%). ( * ) : % of probability of Acute closure.

Coronary Artery Dissection

Coronary artery Dissection

Coronary Artery Thrombosis

Dissection & Acute Closure -3 Risk factors for Acute closure : - female,- DM,- MI,- UA,- age, …. - bend > 45,- long lesions,- tandem lesions - thrombus,- eccentric lesions,- calcified.., - residual stenosis > 35%,- prolonged post PTCA heparin,….. Prevention : 1- anti-platelet agents 2- anticoagulants 3- PTCA technique

Dissection & Acute Closure -4 Management : 1- Initial management. 2- Poor results after repeat PTCA. a- vessels > 2.5 mm b- vessels < 2.5 mm 3- Refractory Acute closure. 4- In-hospital management after successful reversal of Acute closure.

No-Reflow Phenomena -1 Definition Etiology Incidence Clinical manifestations Management

No-Reflow Phenomena -2 Management 1- reverse superimposed spasm 2- exclude coronary dissection 3- apply intra-coronary Ca 2+ blockers 4- GP II b /III a inhibitors 5- treat distal embolization 6- clear micro vascular plugging 7- increased coronary perfusion pressure 8- CABG 9- triage to ICU 10- others

Coronary Artery Perforation -1 Incidence and Classification Mechanisms and Risk factors Outcome Prevention: - guide wire positioning - device sizing - other devices considerations Management

Coronary Artery perforation

Coronary Artery Perforation -2 Management : A- non-operative 1- prolonged balloon inflation 2- Stents 3- pericardiocentesis 4- embolization 5- reversal of anticoagulation 6- monitoring & close follow-up B- operative

Emergency CABG -1 Indications : a- Acute occlusion of a major coronary artery. b- Sub optimal angioplasty with refractory myocardial ischemia. c- Coronary artery perforation with tamponade d- Left main injury or occlusion. e- Retained intra-coronary foreign bodies.

Emergency CABG -2 Contraindications : a- Acute cerebral injury. b- Metastatic or untreated malignancy c- AIDS d- End-stage lung disease e- Inoperable diffuse CAD f- Multiple previous cardiac operations g- Irreversible LV failure h- Cardiogenic shock* and Age > 80 yrs

Restenosis ?!!

Coronary Artery Dissection