26 complications
Coronary
Coronary perforation
Contrast leaves the vessel during PCI: seal the hole with a balloon at once, then a covered stent for a large vessel or coils or fat for a distal branch, and watch for tamponade.
Bailout: Covered stent through a second guide (ping pong)
Open the cardCoronary dissection, guide induced and aorto coronary
A flap or stain at the ostium or in the vessel: keep the wire, stop injecting, confirm the true lumen and stent, covering the ostium when the dissection reaches the aorta.
Bailout: Sealing an aorto coronary dissection with an ostial stent
Open the cardNo reflow and slow flow
Flow slows or stops after the vessel is opened, with no dissection or occlusion to fix: deliver small vessel vasodilators into the distal bed and support the pressure.
Bailout: Distal vasodilator delivery through a microcatheter
Open the cardCoronary air embolism
Air enters the coronary from the manifold or a device: stop injecting, give 100 percent oxygen, aspirate the guide and break the bubbles with a wire.
Bailout: Aspirating coronary air
Open the cardAcute vessel closure and stent thrombosis
Flow falls during or right after PCI: keep the wire, find the cause (dissection, thrombus, embolization, spasm) and treat that cause.
Bailout: Stent thrombosis in the lab, step by step
Open the cardStent loss and retrieval
A stent comes off its balloon: keep the wire through it, then retrieve it with a small balloon or a snare, or deploy or crush it where it lies.
Bailout: Small balloon technique
Open the cardWire fracture and entrapment
A wire will not come back, or comes back short: do not pull hard; free it with a microcatheter or a balloon, and stent over or snare a fragment.
Bailout: Freeing an entrapped wire
Open the cardSide branch occlusion
A side branch closes after main vessel stenting: rewire through a distal strut and open it with a balloon; use the jailed wire if you cannot.
Bailout: Rescue of an occluded side branch
Open the cardCardiac tamponade and pericardiocentesis
Hypotension with high venous pressure after a perforation or a transseptal puncture: drain the pericardium now, then find and seal the source.
Bailout: Subxiphoid pericardiocentesis
Open the cardAccess
Access site bleeding and hematoma
A growing lump at the groin or the forearm: compress the artery where it was punctured, not the skin, and grade a radial hematoma to know when to escalate.
Bailout: Holding femoral pressure that works
Open the cardRetroperitoneal hemorrhage
Hypotension after femoral access with back or flank pain and no visible hematoma: treat it as a bleed, find it with contralateral angiography and seal it with a balloon.
Bailout: Contralateral balloon tamponade and covered stent
Open the cardPseudoaneurysm and arteriovenous fistula
A pulsatile groin mass or a continuous bruit days after femoral access: ultrasound it; thrombin injection for a narrow neck pseudoaneurysm, watchful waiting for most fistulas.
Bailout: Ultrasound guided thrombin injection
Open the cardRadial artery spasm and occlusion
A catheter that will not move and a patient in pain: vasodilators, sedation and warmth, never force; and protect radial patency with heparin and patent hemostasis.
Bailout: Freeing a catheter trapped by radial spasm
Open the cardAcute limb ischemia
A cold, pale, painful leg after femoral access or a support device: find the cause with contralateral angiography and restore flow.
Bailout: Antegrade distal perfusion sheath for a large bore cannula
Open the cardVascular complications of large bore access
Bleeding, dissection or occlusion at a large bore access for TAVR or support: keep a wire across, tamponade with a balloon from the other side, and seal with a covered stent.
Bailout: Crossover balloon occlusion and covered stent
Open the cardStructural
Annular rupture and coronary obstruction in TAVR
Collapse right after valve deployment: echo and an aortic root injection separate a ruptured root (effusion) from a blocked coronary (wall motion, no flow), and each has its own bailout.
Bailout: Chimney stent for coronary obstruction after TAVR
Open the cardDevice embolization in structural cases
An occluder, appendage device or valve leaves its site: track it, keep the patient stable, and snare it back into a large sheath, or go to surgery.
Bailout: Snare retrieval through a long sheath
Open the cardPericardial effusion after LAAO or TEER
A new effusion during or after a transseptal case: it comes from the puncture, the sheath or the appendage; drain if it compromises, reverse heparin, and watch for late effusions.
Bailout: Drain during a structural case
Open the cardSystemic
Contrast reaction and anaphylaxis
Hives, wheeze, swelling or a falling pressure after contrast: stop the contrast and give epinephrine early for anything beyond skin; antihistamines and steroids do not treat shock.
Bailout: Severe reaction, the first five minutes
Open the cardContrast induced acute kidney injury
A creatinine rise in the days after contrast: prevent it with hydration and the least contrast possible; once it happens, support the kidney.
Bailout: A contrast plan for a patient with advanced kidney disease
Open the cardBradycardia and asystole
The rate falls during an injection, a right coronary PCI, atherectomy or a vagal reaction: stop the trigger, have the patient cough, atropine, then pace.
Bailout: Pacing through the coronary guidewire
Open the cardVentricular tachycardia and fibrillation
A wide fast rhythm or VF in the lab: shock immediately when there is no pulse, up to three quick shocks for a witnessed arrest, then treat the ischemia that caused it.
Bailout: Witnessed VF on the table
Open the cardHypotension and cardiogenic shock in the lab
The pressure falls: first make sure it is real, then sort hypovolemia, pump failure and vasodilation, treat the cause and support the circulation, early with a device when the heart fails.
Bailout: Placing an Impella CP in the lab
Open the cardStroke during the procedure
A new deficit on the table: note the time, check the glucose and the sedation, and get the stroke team and imaging now; a lab with neurointervention can go straight to angiography.
Bailout: Stroke code from the cath lab
Open the cardAtheroembolism (cholesterol embolization)
Days to weeks after a catheter passes a diseased aorta: blue toes with good pulses, livedo and a rising creatinine; no specific treatment, so prevention matters.
Bailout: Catheter technique that lowers the embolic load
Open the cardRadiation skin injury
High air kerma on one skin area causes erythema, then ulceration weeks later: track the dose live, move the beam, and follow every patient over 5 Gy.
Bailout: Bringing the dose down during a long case
Open the cardComplications cart
One list of what a lab keeps on or next to the complications cart, drawn from the cards above. Each item opens in the equipment directory where we list it. Print the poster for the cart and check it off at your usual stock check.
Pericardium
- Pericardiocentesis traySheathed needles, J wire, 5 or 6 Fr sheath, multihole pigtail, drainage bottle · Directory: Lock pericardiocentesis set and tray, Pericardiocentesis kit
- Drainage catheterDirectory: Drainer centesis catheter
- Echo machine with a subcostal probeIn the room for complex PCI and structural cases
Perforation
- Covered coronary stents in the sizesPK Papyrus 2.5 to 5.0 mm; Graftmaster 2.8 to 4.8 mm · Directory: PK Papyrus, Graftmaster RX
- Coils, 0.014 and 0.018 inch compatibleNot in the directory yet
- Coil compatible microcatheterDirectory: Finecross M3
- Semicompliant balloons to seal, vessel sizedDirectory: Trek and Mini Trek
- Perfusion balloonDirectory: Ringer perfusion balloon catheter
- 8 Fr guide cathetersDirectory: Launcher guide catheter
Retrieval
- Coronary snares, 2 to 7 mm loopsNot in the directory yet
- Large multi loop snares, 18 to 30 mmNot in the directory yet
- Retrieval forceps or bioptomeNot in the directory yet
- Small balloons, 1.0 to 1.5 mmDirectory: Sapphire II Pro 1.0
- Guide extension and trapping deviceDirectory: GuideLiner V3, TrapLiner
- Long sheaths for device retrieval, 12 to 16 FrDirectory: DrySeal Flex introducer sheath
Flow and thrombus
- Aspiration thrombectomy cathetersDirectory: CAT RX, Export Advance aspiration catheter
- Embolic protectionDirectory: FilterWire EZ, SpiderFX
- IVUS or OCT catheterDirectory: Eagle Eye Platinum, Dragonfly OpStar imaging catheter
- Dual lumen microcatheterDirectory: Twin-Pass dual access catheter
Vascular
- Large bore sheathsDirectory: Sentrant introducer sheath, DrySeal Flex introducer sheath
- Peripheral balloons to tamponade a bleedDirectory: Armada 35, Mustang
- Aortic occlusion balloonDirectory: Coda balloon catheter
- Peripheral covered stentsDirectory: Viabahn VBX, Viabahn
- Crossover sheathDirectory: Pinnacle Destination guiding sheath
- Vascular plug for a bleeding branchDirectory: MVP micro vascular plug
- Stiff and hydrophilic 0.035 inch wiresDirectory: Amplatz Super Stiff, Glidewire
- Closure devices and compressionDirectory: Perclose ProStyle, MANTA vascular closure device, FemoStop Gold, TR Band
Rhythm
- Defibrillator with pads
- Temporary pacemaker generatorDirectory: Medtronic single chamber temporary pacemaker
- Pacing catheter kit and a venous sheathDirectory: Arrow pacing catheters and kits
- Pacing guidewireDirectory: Wattson temporary pacing guidewire
- Mechanical CPR device
Support, nearby
- IABP console and cathetersDirectory: Cardiosave IABP (Hybrid and Rescue), Sensation Plus IAB catheter
- Impella CP and its sheathDirectory: Impella CP with SmartAssist
- Venoarterial ECMO circuit and cannulasDirectory: Cardiohelp system
- Distal perfusion sheathDirectory: Super Arrow-Flex sheath
Drugs
- Atropine
- Epinephrine, 1 mg/mL and 0.1 mg/mL
- Vasopressin, norepinephrine, phenylephrine
- ProtamineDose in the Cath Med App
- Amiodarone and lidocaineDirectory: Lidocaine hydrochloride injection
- AdenosineDose in the Cath Med App
- Nicardipine, nitroprusside, verapamilDirectory: Verapamil hydrochloride injection
- NitroglycerinDirectory: Nitroglycerin in dextrose
- Cangrelor, eptifibatide or tirofibanDirectory: Kengreal (cangrelor), Aggrastat (tirofiban) · Dose in the Cath Med App
- Diphenhydramine, H2 blocker, hydrocortisone, albuterol, glucagon
- Naloxone and flumazenil
- DobutamineDose in the Cath Med App
- Thrombin for pseudoaneurysm
Each card has the same ten sections in the same order, so the team knows where to look. Numbers carry a numbered citation to the references at the bottom of the card. Where sources disagree, the card says so in one line. Most cards link to cases in the emergency simulator of the Cath Trainer app, where the complication shows only through its signs and is named in the debrief. Reference material for trained teams, not clinical guidance and not for use in place of a code team. Your local policy and current guidelines govern.