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