Understanding Diagnostic Cardiac Catheterization Complications.

Dr. Zayed | Published : 03, May 2025.

Diagnostic cardiac catheterization, though regarded as a relatively safe and essential procedure in modern cardiovascular medicine, is not devoid of complications. These complications can be broadly categorized into cardiovascular and non-cardiovascular events, with further subdivisions based on the anatomical systems involved. Understanding these complications and their underlying mechanisms is essential for both clinical preparedness and patient safety.

Cardiovascular complications remain the most directly attributable outcomes of cardiac catheterization and are best understood by separating them into Cardiac and vascular events.

Cardiac Complications:

Cardiac complications include Myocardial infarction, Arrhythmias and Traumatic injury to the vasculature. 

Myocardial infarction although rare in diagnostic procedures, can result from  Coronary artery dissection, perforation, Stent Thrombosis formation due to endothelial disruption during catheter manipulation. These events may lead to acute obstruction of coronary blood flow, culminating in ischemia and infarction. The incidence is low approximately 0.05% to 0.1% but it requires immediate recognition and management.

Arrhythmias, particularly ventricular ectopy and atrial fibrillation, are not uncommon during catheter navigation through the cardiac chambers. They are generally transient and result from mechanical irritation of the endocardial surfaces, particularly the atrial and ventricular myocardium, by the catheter tip. In rare cases, such disturbances may progress to hemodynamically significant tachyarrhythmias or bradyarrhythmias, necessitating pharmacologic or electrical intervention.

Traumatic injury to vessels (Coronary artery & Aorta), Coronary artery complications mainly  due to guide wire/catheter induce, stent induced and contrast induced. coronary dissection, perforation, coronary spasm and thrombosis can happen in all etiologies. These occur due to high pressure, leading to disruption of the arterial intima for dissection or even transmural injury for perforation. A dissection can propagate along the vessel wall, jeopardizing coronary perfusion, whereas a perforation may lead to pericardial effusion and potentially cardiac tamponade, a life-threatening emergency. the completion of intervention by placing of stent commonly presents with complications such as Stent Fracture, Stent Thrombosis (acute - days to weeks) and Restenosis (chronic - months to years). contrast media causes temporary spasm of coronary artery which can mimic chest pain for a brief period before being metabolized. aortic complications are discussed in vascular complications.

Vascular Complications:

Vascular complications encompass a broader spectrum. 

Aortic dissection, though exceedingly rare, is a catastrophic event resulting from an iatrogenic intimal tear during catheter passage or forceful contrast injection. It typically presents with sudden chest or back pain and may rapidly evolve if not addressed promptly. Type A is relatively more severe dissection which results as the coronary ostia lies close in the root of aorta. an

Pseudoaneurysm, formation at the femoral artery access site is a more frequent but less severe complication. It arises when arterial puncture fails to seal adequately, allowing continuous blood flow into surrounding tissue with persistent communication to the arterial lumen. Diagnosis is typically confirmed with duplex ultrasonography, and management may range from ultrasound-guided thrombin injection to surgical repair.

arteriovenous fistula, may form when both an artery and adjacent vein are punctured, resulting in an abnormal communication that diverts arterial blood directly into the venous system. This may present as a continuous bruit or signs of high-output cardiac failure in chronic cases. Hematomas are among the most common complications, resulting from perivascular bleeding. They are generally benign and self-limited; however, if the arterial puncture site is too high, bleeding can extend into the retroperitoneal space, leading to significant hemodynamic compromise. Retroperitoneal hemorrhage is particularly insidious, often presenting only as hypotension and back pain without visible groin swelling.

Retroperitoneal hemorrhage is a rare but life-threatening vascular complication of percutaneous coronary intervention (PCI), typically resulting from high femoral artery access above the inguinal ligament. This misplacement can lead to arterial injury and uncontrolled bleeding into the retroperitoneal space, which may remain clinically silent until hemodynamic collapse. Patients often present with hypotension, flank or abdominal pain, and a sudden drop in hemoglobin without visible bleeding. Prompt diagnosis using non-contrast CT imaging and immediate hemodynamic stabilization are critical. Preventive strategies, including ultrasound-guided vascular access and adherence to anatomical landmarks, are essential to minimize risk.

Another severe but infrequent vascular complication is stroke. This is most often due to embolization of atherosclerotic debris or thrombi from the aortic arch or catheter equipment. The risk is increased in patients with known aortic arch atherosclerosis or with excessive catheter manipulation. While the incidence is low estimated around 0.1% to 0.3% the consequences can be devastating.

Non-Cardiovascular Complications

Moving beyond the cardiovascular system, non-cardiovascular complications also warrant attention. Chief among these is contrast-induced nephropathy (CIN), a form of acute kidney injury occurring after exposure to iodinated contrast media. The pathogenesis involves a combination of renal vasoconstriction, medullary hypoxia, and direct tubular epithelial toxicity. Patients with preexisting chronic kidney disease, diabetes mellitus, or volume depletion are particularly susceptible. Preventive strategies include periprocedural hydration, minimizing contrast volume, and using iso-osmolar contrast agents.

Hypersensitivity reactions to contrast media represent another non-cardiac complication. These reactions may range from mild urticaria and flushing to severe anaphylactoid reactions, including bronchospasm, hypotension, and shock. Most of these are non-IgE mediated and occur through direct activation of mast cells and basophils. Premedication with corticosteroids and antihistamines is often employed in high-risk individuals undergoing repeat procedures.

Finally, although rare, infection remains a potential risk. It can occur at the vascular access site or, more seriously, manifest as catheter-related bacteremia. Strict adherence to aseptic technique is paramount to mitigate this risk, particularly in immunocompromised individuals or those undergoing prolonged catheterization. staphylococcus and coagulase negative streptococcus are most common culprit. The risk of bacteremia is low with PCI (<0.1–0.6%), but femoral access and prolonged sheath dwell time increase risk.

In conclusion, while diagnostic cardiac catheterization is a cornerstone of cardiovascular diagnostics with a favorable safety profile, clinicians must remain vigilant for a spectrum of complications. A systematic understanding of both cardiovascular and non-cardiovascular risks—along with their underlying pathophysiology—not only informs clinical practice but also improves outcomes through timely recognition and intervention.

References:

1.

Writing Group Members. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Després JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jiménez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB., American Heart Association Statistics Committee. Stroke Statistics Subcommittee. Heart Disease and Stroke Statistics-2016 Update: A Report From the American Heart Association. Circulation. 2016 Jan 26;133(4):e38-360. [PubMed]

2.

Sobolev M, Slovut DP, Lee Chang A, Shiloh AL, Eisen LA. Ultrasound-Guided Catheterization of the Femoral Artery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Invasive Cardiol. 2015 Jul;27(7):318-23. [PubMed]

3.

Rognoni A, Lupi A, Sansa M, Secco GG, Santagostino M, Bongo AS. Radial approach for percutaneous coronary intervention. Rev Recent Clin Trials. 2012 May;7(2):127-32. [PubMed]

4.

Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009 Jan;157(1):132-40. [PubMed]

5.

Tavakol M, Ashraf S, Brener SJ. Risks and complications of coronary angiography: a comprehensive review. Glob J Health Sci. 2012 Jan 01;4(1):65-93. [PMC free article] [PubMed]

6.

Eisen A, Kornowski R, Vaduganathan M, Lev E, Vaknin-Assa H, Bental T, Orvin K, Brosh D, Rechavia E, Battler A, Assali A. Retroperitoneal bleeding after cardiac catheterization: a 7-year descriptive single-center experience. Cardiology. 2013;125(4):217-22. [PubMed]

7.

Werner N, Zahn R, Zeymer U. Stroke in patients undergoing coronary angiography and percutaneous coronary intervention: incidence, predictors, outcome and therapeutic options. Expert Rev Cardiovasc Ther. 2012 Oct;10(10):1297-305. [PubMed]

8.

Tsai TT, Patel UD, Chang TI, Kennedy KF, Masoudi FA, Matheny ME, Kosiborod M, Amin AP, Messenger JC, Rumsfeld JS, Spertus JA. Contemporary incidence, predictors, and outcomes of acute kidney injury in patients undergoing percutaneous coronary interventions: insights from the NCDR Cath-PCI registry. JACC Cardiovasc Interv. 2014 Jan;7(1):1-9. [PMC free article] [PubMed]