Percutaneous Coronary Intervention: Management of Complications

  • Robert T. Gerber
  • Athanasios Kosovitsas
  • Carlo Di MarioEmail author


  • PCI complications can be broadly grouped into:
    • Coronary ischemia:
      • Dissection

      • No-reflow, air or thrombotic embolism

    • Device-related factors:
      • Coronary perforation

      • Stent, wire, or catheter misadventures

    • Patient-related factors:
      • Contrast-induced nephropathy (CIN)

      • Contrast allergy/anaphylaxis

  • We describe a systematic process with which to recognize and manage the aforementioned complications associated with PCI and adopt a pragmatic “tips and tricks” approach on how to deal with these in the acute setting.

  • We also provide, where possible, evidence and case report experience from the literature to help the interventionalist when faced with the daunting task of tackling a life-threatening complication.


Perforation Dissection Atherosclerosis Coronary artery disease Intravascular ultrasound Nephropathy Drug-eluting stent Percutaneous coronary intervention (PCI) No-reflow 


  1. 1.
    Kereiakes D, Kuntz R, Mauri L, MD M, Krucoff M. Surrogates, substudies, and real clinical end points in trials of drug-eluting stents. J Am Coll Cardiol. 2005;45(8):1206.CrossRefPubMedGoogle Scholar
  2. 2.
    Force m A/T, Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014;35(37):2541–619.CrossRefGoogle Scholar
  3. 3.
    Ludman PF, British Cardiovascular Intervention Society. British cardiovascular intervention society registry for audit and quality assessment of percutaneous coronary interventions in the United Kingdom. Heart. 2011;97(16):1293–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Resnic FS, Wainstein M, Lee MK, Behrendt D, Wainstein RV, Ohno-Machado L, et al. No-reflow is an independent predictor of death and myocardial infarction after percutaneous coronary intervention. Am Heart J. 2003;145(1):42–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Huber MS, Mooney JF, Madison J, Mooney MR. Use of a morphologic classification to predict clinical outcome after dissection from coronary angioplasty. Am J Cardiol. 1991;68(5):467–71.CrossRefPubMedGoogle Scholar
  6. 6.
    Vrints CJ. Spontaneous coronary artery dissection. Heart. 2010;96(10):801–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Hong YJ, Jeong MH, Choi YH, Ko JS, Lee MG, Kang WY, et al. Impact of plaque components on no-reflow phenomenon after stent deployment in patients with acute coronary syndrome: a virtual histology-intravascular ultrasound analysis. Eur Heart J. 2011;32(16):2059–66.CrossRefPubMedGoogle Scholar
  8. 8.
    Rezkalla SH, Kloner RA. No-reflow phenomenon. Circulation. 2002;105(5):656–62.CrossRefPubMedGoogle Scholar
  9. 9.
    Lee CH, Wong HB, Tan HC, Zhang JJ, Teo SG, Ong HY, et al. Impact of reversibility of no reflow phenomenon on 30-day mortality following percutaneous revascularization for acute myocardial infarction-insights from a 1,328 patient registry. J Interv Cardiol. 2005;18(4):261–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Rezkalla SH, Dharmashankar KC, Abdalrahman IB, Kloner RA. No-reflow phenomenon following percutaneous coronary intervention for acute myocardial infarction: incidence, outcome, and effect of pharmacologic therapy. J Interv Cardiol. 2010;23(5):429–36.CrossRefPubMedGoogle Scholar
  11. 11.
    Airoldi F, Briguori C, Cianflone D, Cosgrave J, Stankovic G, Godino C, et al. Frequency of slow coronary flow following successful stent implantation and effect of Nitroprusside. Am J Cardiol. 2007;99(7):916–20.CrossRefPubMedGoogle Scholar
  12. 12.
    Kaul S, Ito H. Microvasculature in acute myocardial ischemia: part I: evolving concepts in pathophysiology, diagnosis, and treatment. Circulation. 2004;109(2):146–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Kaul S, Ito H. Microvasculature in acute myocardial ischemia: part II: evolving concepts in pathophysiology, diagnosis, and treatment. Circulation. 2004;109(3):310–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Kaplan BM, Benzuly KH, Kinn JW, Bowers TR, Tilli FV, Grines CL, et al. Treatment of no-reflow in degenerated saphenous vein graft interventions: comparison of intracoronary verapamil and nitroglycerin. Catheter Cardiovasc Diagn. 1996;39(2):113–8.CrossRefGoogle Scholar
  15. 15.
    Parikh KH, Chag MC, Shah KJ, Shah UG, Baxi HA, Chandarana AH, et al. Intracoronary boluses of adenosine and sodium nitroprusside in combination reverses slow/no-reflow during angioplasty: a clinical scenario of ischemic preconditioning. Can J Physiol Pharmacol. 2007;85(3–4):476–82.CrossRefPubMedGoogle Scholar
  16. 16.
    Klein LW, Kern MJ, Berger P, Sanborn T, Block P, Babb J, et al. Society of cardiac angiography and interventions: suggested management of the no-reflow phenomenon in the cardiac catheterization laboratory. Catheter Cardiovasc Interv. 2003;60(2):194–201.CrossRefPubMedGoogle Scholar
  17. 17.
    Romaguera R, Waksman R. Covered stents for coronary perforations: is there enough evidence? Catheter Cardiovasc Interv. 2011;78(2):246–53.CrossRefPubMedGoogle Scholar
  18. 18.
    Ellis SG, Ajluni S, Arnold AZ, Popma JJ, Bittl JA, Eigler NL, et al. Increased coronary perforation in the new device era. Incidence, classification, management, and outcome. Circulation. 1994;90(6):2725–30.CrossRefPubMedGoogle Scholar
  19. 19.
    Al-Lamee R, Ielasi A, Latib A, Godino C, Ferraro M, Mussardo M, et al. Incidence, predictors, management, immediate and long-term outcomes following grade III coronary perforation. JACC Cardiovasc Interv. 2011;4(1):87–95.CrossRefPubMedGoogle Scholar
  20. 20.
    Bartholomew BA, Harjai KJ, Dukkipati S, Boura JA, Yerkey MW, Glazier S, et al. Impact of nephropathy after percutaneous coronary intervention and a method for risk stratification. Am J Cardiol. 2004;93(12):1515–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Persson PB, Hansell P, Liss P. Pathophysiology of contrast medium-induced nephropathy. Kidney Int. 2005;68(1):14–22.CrossRefPubMedGoogle Scholar
  22. 22.
    Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, et al. A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004;44(7):1393–9.PubMedGoogle Scholar
  23. 23.
    Kelly SC, Li S, Stys TP, Thompson PA, Stys AT. Reduction in contrast nephropathy from coronary angiography and percutaneous coronary intervention with ultra-low contrast delivery using an automated contrast injector system. J Invasive Cardiol. 2016;28(11):446–50.PubMedGoogle Scholar
  24. 24.
    McCullough PA, Bertrand ME, Brinker JA, Stacul F. A meta-analysis of the renal safety of isosmolar iodixanol compared with low-osmolar contrast media. J Am Coll Cardiol. 2006;48(4):692–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Reed M, Meier P, Tamhane UU, Welch KB, Moscucci M, Gurm HS. The relative renal safety of iodixanol compared with low-osmolar contrast media: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 2009;2(7):645–54.CrossRefPubMedGoogle Scholar
  26. 26.
    Briguori C, Visconti G, Focaccio A, Airoldi F, Valgimigli M, Sangiorgi GM, et al. Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuard System in high-risk patients for contrast-induced acute kidney injury. Circulation. 2011;124(11):1260–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Marenzi G, Ferrari C, Marana I, Assanelli E, De Metrio M, Teruzzi G, et al. Prevention of contrast nephropathy by furosemide with matched hydration: the MYTHOS (induced diuresis with matched hydration compared to standard hydration for contrast induced nephropathy prevention) trial. JACC Cardiovasc Interv. 2012;5(1):90–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Merten GJ, Burgess WP, Gray LV, Holleman JH, Roush TS, Kowalchuk GJ, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. 2004;291(19):2328–34.CrossRefPubMedGoogle Scholar
  29. 29.
    ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation. 2011;124(11):1250–9.CrossRefGoogle Scholar
  30. 30.
    Leoncini M, Toso A, Maioli M, Tropeano F, Villani S, Bellandi F. Early high-dose rosuvastatin for contrast-induced nephropathy prevention in acute coronary syndrome: results from the PRATO-ACS study (protective effect of Rosuvastatin and antiplatelet therapy on contrast-induced acute kidney injury and myocardial damage in patients with acute coronary syndrome). J Am Coll Cardiol. 2014;63(1):71–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Marenzi G, Lauri G, Campodonico J, Marana I, Assanelli E, De Metrio M, et al. Comparison of two hemofiltration protocols for prevention of contrast-induced nephropathy in high-risk patients. Am J Med. 2006;119(2):155–62.CrossRefPubMedGoogle Scholar
  32. 32.
    Namasivayam S, Kalra MK, Torres WE, Small WC. Adverse reactions to intravenous iodinated contrast media: a primer for radiologists. Emerg Radiol. 2006;12(5):210–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Leder R. How well does a history of seafood allergy predict the likelihood of an adverse reaction to i.v. contrast material? AJR Am J Roentgenol. 1997;169(3):906–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Thomsen HS. European Society of Urogenital Radiology (ESUR) guidelines on the safe use of iodinated contrast media. Eur J Radiol. 2006;60(3):307–13.CrossRefPubMedGoogle Scholar
  35. 35.
    Standards for intravascular contrast administration to adult patients. 3rd ed. Royal College of Radiology; 2015.Google Scholar
  36. 36.
    Greenberger PA, Patterson R. The prevention of immediate generalized reactions to radiocontrast media in high-risk patients. J Allergy Clin Immunol. 1991;87(4):867–72.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Robert T. Gerber
    • 1
    • 2
  • Athanasios Kosovitsas
    • 2
  • Carlo Di Mario
    • 2
    • 3
    Email author
  1. 1.Department of CardiologyConquest Hospital Hastings and Eastbourne DGH, East Sussex Healthcare NHS TrustEast SussexUK
  2. 2.NIHR Cardiovascular Biomedical Research Unit, Royal Brompton HospitalLondonUK
  3. 3.Careggi University HospitalFlorenceItaly

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