Angiogram complications

Background

• Complications from diagnostic or interventional catheterization (cardiac or peripheral) via femoral, radial, or brachial access
• Complication rate ~1-2% for diagnostic procedures, higher for interventional
• Patients typically present to ED within hours to days after discharge from cath lab

Clinical Features

Access Site Complications

• Hematoma: Most common; swelling, ecchymosis, tenderness at puncture site
• Pseudoaneurysm: Pulsatile mass with bruit; risk of rupture or compression
• Arteriovenous fistula: Continuous bruit (machinery murmur) over access site
• Retroperitoneal hemorrhage: Abdominal pain, back/flank pain, hypotension, dropping hematocrit without visible bleeding — HIGH mortality if missed
• Arterial thrombosis/occlusion: Cool, pale, pulseless limb distal to access site

Systemic Complications

• Contrast-induced nephropathy: Rise in creatinine 24-72 hrs post-procedure
• Cholesterol embolization (blue toe syndrome): Livedo reticularis, blue/purple toes, preserved pedal pulses
• Stroke: From catheter-related thromboembolism
• Stent thrombosis: Chest pain, ST changes after recent PCI (especially if antiplatelet therapy was interrupted)
• Allergic/anaphylactoid reaction: To contrast dye (usually during procedure)
• Cardiac tamponade: From coronary perforation (rare)

Differential Diagnosis

• Hematoma (visual exam)
• Arteriovenous fistula (bruit)
• Retroperitoneal hemorrhage
• Acute kidney injury (creatinine)
• Vascular injury
• Cholesterol embolization

Evaluation

• Focused exam of access site: inspect, palpate, auscultate for bruit
• Distal pulses and neurovascular exam of affected limb
• Labs: CBC, BMP (creatinine), coagulation studies
• CT abdomen/pelvis with contrast if retroperitoneal hemorrhage suspected
• Duplex US of access site for suspected pseudoaneurysm or AV fistula
• ECG if chest pain or concern for stent thrombosis

Management

• Hematoma: Direct pressure, reverse anticoagulation if expanding
• Pseudoaneurysm: US-guided thrombin injection or compression; surgery if failed
• Retroperitoneal hemorrhage: Aggressive fluid resuscitation, blood products, reverse anticoagulation, emergent IR or surgery consult
• Arterial occlusion: Emergent vascular surgery consult, heparin if no contraindication
• Stent thrombosis: Emergent cardiology consult for repeat catheterization
• Hold anticoagulation decisions in consultation with interventional cardiology

Disposition

• Admit expanding hematomas, retroperitoneal hemorrhage, acute limb ischemia, stent thrombosis
• Small stable hematomas may be observed and discharged with close follow-up

See Also

• Acute arterial occlusion
• Vascular injury
• Retroperitoneal hemorrhage
• Contrast-induced nephropathy