›GP IIb IIIa inhibitor bailout for large residual thrombus burden
›Thrombus aspiration consideration
›Recurrent occlusion despite adequate antiplatelet loading
›Evaluate for stent underexpansion or malapposition with intravascular imaging
Dual antiplatelet therapy management
›Minimum duration by stent type and indication
›Bare metal stent minimum 1 month
›Drug-eluting stent minimum 6 months for stable ischemic heart disease
›Drug-eluting stent minimum 12 months for acute coronary syndrome indication
›Shorter duration considered in high bleeding risk patients with newer-generation drug-eluting stents per evolving trial evidence
›Maintenance dosing
›Aspirin PO 75 mg to 100 mg daily
›Clopidogrel PO 75 mg daily
›Ticagrelor PO 90 mg twice daily
›Prasugrel PO 10 mg daily
›Consider 5 mg daily if body weight under 60 kg
›Avoid in age 75 years or older unless high ischemic benefit
›Perioperative management when surgery is needed
›Elective surgery deferred until minimum dual antiplatelet therapy duration is complete when possible
›Continue aspirin through surgery when bleeding risk allows
›P2Y12 inhibitor hold windows before surgery when interruption is unavoidable
›Clopidogrel held 5 to 7 days before surgery
›Ticagrelor held 3 to 5 days before surgery
›Prasugrel held 7 to 10 days before surgery
›Bridging in high thrombotic risk patients needing urgent surgery within the minimum duration window
›Cangrelor IV infusion 0.75 mcg per kg per minute without bolus
›Discontinued 1 to 6 hours before surgery
›Cardiology consultation for bridging decision
›The patient who has stopped dual antiplatelet therapy
›Treat any new chest pain in this context as stent thrombosis until proven otherwise
›Immediate reloading dose of aspirin and P2Y12 inhibitor
›Cath lab activation in parallel with reloading
›Determine the reason for discontinuation
›Bleeding event
›Told to stop for a procedure without a bridging plan
›Cost or access barrier
›Unaware of the importance of continued therapy
›Document the discontinuation reason to prevent recurrence
Bleeding on dual antiplatelet therapy
›Balancing bleeding against stent thrombosis risk
›Minor bleeding
›Continue dual antiplatelet therapy with local measures
›Major bleeding
›Multidisciplinary decision with cardiology before any interruption
›Stopping both agents simultaneously carries highest thrombosis risk
›Life-threatening bleeding
›Hold antiplatelet therapy and pursue source control
›Platelet transfusion consideration for active bleeding with recent antiplatelet dosing and a critical bleeding site
›Anticoagulant reversal cross-reference
›For a patient on concomitant oral anticoagulation, see Anticoagulant overdose management for detailed reversal agent selection and dosing
›Protamine for reversal of intraprocedural or ongoing heparin
›1 mg per 100 units of heparin given in the previous 2 to 3 hours
›Maximum 50 mg per dose in many protocols
›Slow IV administration to reduce hypotension risk
›Restart planning after hemostasis
›High thrombotic risk favors earlier restart
›Source not secured favors delayed restart
Access-site hemorrhagic complications
›Retroperitoneal hemorrhage
›Recognition
›Flank or back pain with unexplained hypotension
›Falling hemoglobin without external bleeding
›Management
›Hold antiplatelet and anticoagulant therapy per bleeding severity
›Permissive hypotension with a target SBP around 90 mmHg until source control unless active cardiac ischemia dictates a higher target
›Crystalloid resuscitation with caution to avoid diluting clotting factors
›Type and crossmatch with transfusion for hemodynamic instability
›Interventional radiology consultation for embolization
›Manual compression is not effective for a retroperitoneal source
›Vascular surgery consultation if embolization fails or is unavailable
›Femoral pseudoaneurysm
›Diagnosis by duplex ultrasound
›Ultrasound-guided compression
›Effective for small pseudoaneurysms
›Ultrasound-guided thrombin injection
›Typical injection 100 to 1000 units in small aliquots under direct visualization
›Avoid intra-arterial injection
›Surgical repair
›Rapidly expanding or large pseudoaneurysm
›Infected pseudoaneurysm
›Compromised overlying skin
›Arteriovenous fistula
›Many close spontaneously and are managed with observation
›Ultrasound-guided compression for symptomatic low-flow fistula
›Covered stent or surgical repair for high-flow or symptomatic fistula
Radial artery occlusion and forearm compartment syndrome
›Radial artery occlusion
›Usually asymptomatic due to dual hand blood supply from the ulnar artery
›Anticoagulation continuation during the hemostasis period reduces occlusion risk
›Management
›Ipsilateral ulnar compression technique to promote recanalization
›Conservative management in most asymptomatic cases
›Forearm compartment syndrome
›Recognition
›Pain out of proportion to exam
›Tense swollen forearm
›Paresthesia or weakness of the hand
›This is a vascular surgery emergency
›Emergent fasciotomy
›Do not delay for compartment pressure measurement if the clinical picture is clear
›Source is often a perforation or hematoma dissecting from the access site into the forearm
Coronary perforation and tamponade
›Immediate management
›Prolonged balloon inflation at the perforation site to tamponade the leak
›Reversal of intraprocedural heparin
›Protamine 1 mg per 100 units of heparin given in the previous 2 to 3 hours
›Maximum 50 mg per dose in many protocols
›Pericardiocentesis for tamponade physiology
›Bedside echocardiography guidance
›Autotransfusion of pericardial blood when feasible
›Definitive management by Ellis classification severity
›Type I and II perforation
›Prolonged balloon inflation often sufficient
›Close observation for delayed tamponade
›Type III perforation
›Covered stent deployment across the perforation
›Emergent cardiac surgery consultation if bleeding is refractory
›Troubleshooting persistent instability
›Hemodynamics not improving after pericardiocentesis
›Suspect ongoing hemorrhage requiring surgical repair
›Repeat echocardiography for reaccumulation
›Hemodynamic support during perforation management
›Norepinephrine infusion
›Initiate 0.05 mcg per kg per minute
›Titrate every 2 to 5 minutes to a MAP target of 65 mmHg
›Arterial line preferred for titration
›Fluid administration
›Modest bolus may support preload before pericardiocentesis
›Not a substitute for pericardiocentesis or bleeding control
Contrast-associated complications
›Contrast-associated acute kidney injury
›Prevention
›Isotonic IV fluid 1 to 1.5 mL per kg per hour for 6 to 12 hours before and after contrast exposure
›Minimize contrast volume
›Hold NSAIDs
›Hold metformin at the time of contrast exposure due to lactic acidosis risk if renal function declines
›Recognition
›Creatinine rise of 26.5 micromol/L or more within 48 to 72 hours
›Creatinine rise of 50 percent or more from baseline within 48 to 72 hours
›Management
›Supportive care and avoidance of further nephrotoxins
›Nephrology consultation for oliguria or severe renal impairment
›Contrast anaphylaxis
›Premedication for known contrast allergy before elective repeat exposure
›Prednisone PO 50 mg at 13 hours, 7 hours, and 1 hour before the procedure
›Diphenhydramine PO or IV 25 mg to 50 mg 1 hour before the procedure
›Acute anaphylaxis management
›Epinephrine IM 0.3 mg to 0.5 mg of 1 mg per mL concentration
›Repeat every 5 to 15 minutes as needed
›Epinephrine IV infusion for refractory hypotension
›Diphenhydramine IV 25 mg to 50 mg
›Methylprednisolone IV 125 mg
›Famotidine IV 20 mg as an adjunct H2 blocker
Late and systemic post-procedural complications
›Cholesterol embolization
›Recognition
›Livedo reticularis and blue toe syndrome
›Subacute acute kidney injury days to weeks after catheterization
›Eosinophilia
›Management
›Supportive care
›Avoid further arterial catheterization and anticoagulation when clinically feasible
›Nephrology and vascular surgery consultation
›Access-site infection
›Cellulitis
›Cephalexin PO 500 mg every 6 hours
›Abscess
›Surgical drainage
›Vancomycin IV 15 mg to 20 mg per kg every 8 to 12 hours for suspected MRSA or systemic infection
›Distinguish from sterile post-procedural inflammation
›Fluctuance and purulent drainage favor true infection
Iatrogenic harms in the post-PCI patient
›Intubation
›Positive pressure ventilation can precipitously drop preload and worsen hypotension in tamponade
›Pericardiocentesis before intubation when feasible
›Ketamine IV 1 mg to 2 mg per kg or etomidate IV 0.3 mg per kg preferred hemodynamically neutral induction agents
›Sedation
›Benzodiazepines can worsen hypotension in hemorrhagic or obstructive shock
›Reduced doses and cautious titration in active bleeding
›Fluid loading
›Aggressive crystalloid in retroperitoneal hemorrhage can dilute clotting factors and raise pressure enough to dislodge a forming clot
›Permissive hypotension preferred until source control
›Modest fluid may transiently support preload in tamponade but is not a substitute for pericardiocentesis
›Oxygen
›Routine supplemental oxygen not beneficial when SpO2 is 90 percent or higher
›Oxygen escalation reserved for respiratory distress or hypoxemia
›Target differs in chronic lung disease, cyanotic congenital heart disease, and chronic hypoxemia
›Vasopressors
›Norepinephrine appropriate first-line support for cardiogenic shock or tamponade bridge
›Vasopressors can mask ongoing hypovolemia in retroperitoneal hemorrhage and delay recognition of the need for source control
›Mechanical circulatory support including intra-aortic balloon pump
›Consider for refractory cardiogenic shock from stent thrombosis
›Relatively contraindicated with severe peripheral arterial disease limiting safe access
›Femoral device placement is higher risk when the femoral access site is already compromised by hematoma or pseudoaneurysm
›Anticoagulation
›Needed to prevent thrombus propagation in stent thrombosis
›Must be held or reversed in active retroperitoneal hemorrhage or coronary perforation with tamponade
›Fibrinolysis
›Relatively contraindicated as primary therapy for stent thrombosis due to reduced efficacy against organized thrombus
›Contraindicated if retroperitoneal hemorrhage or other active major bleeding is suspected
›Analgesia
›Morphine slows gastric motility and can delay absorption and onset of oral P2Y12 inhibitors given for reloading
›Fentanyl IV 25 mcg to 50 mcg preferred, repeat every 5 to 10 minutes as needed
›Opioids can mask the pain characterization needed to localize a retroperitoneal hemorrhage