Complications of Complex PCI, with very recent sources and links.
Complications of Complex PCI, with very recent sources and links.
Sources:
• Circulation: Cardiovascular Interventions. Published August 19, 2025.
• Complications of PCI (Review). Postgraduate Medical Journal, 2025.
Takeaways :
1. Why “complex” PCI carries higher risk
Complex anatomy (heavy calcification, long/CTO lesions, bifurcations), high-risk clinical profiles (older age, CKD, ACS), and advanced tooling like atherectomy (catheter-based plaque-calcium removal using blades, rotating burrs, or laser energy)/IVL (balloon-based shockwave technology to fracture vascular calcium) all increase complication rates compared with routine PCI. Contemporary reviews and training statements highlight this gradient of risk.
2. Major acute complications to anticipate
• Coronary perforation/rupture (including Ellis II–III-tamponade)
• Dissection/acute vessel closure
• No-reflow/slow-flow (microvascular injury, distal embolization)
• Equipment loss/entrapment (wires, stents, atherectomy burr)
• Bleeding/vascular-access events
• Arrhythmias/hemodynamic collapse, stroke/embolization, contrast-associated AKI, and early stent thrombosis.
3. Perforation—incidence & impact
Large registries report perforation in ~0.3–1.0% of PCIs overall, with markedly higher risk in calcified/bifurcation/CTO work; perforation is tightly linked to emergency pericardiocentesis, covered stents, and increased mortality.
4. Perforation—rapid response essentials
Immediate steps: balloon tamponade, prompt covered stent deployment for proximal/large-vessel injury, Heparin reversal with protamine may be considered in life-threatening bleeding, on a case-by-case basis , particularly after failed mechanical measures, pericardiocentesis for tamponade, and surgical backup when needed.
5. No-reflow—how common and what works
No-reflow is common in STEMI primary PCI (reported up to ~25% in some cohorts); it worsens outcomes. Standard therapy uses intracoronary vasodilators (adenosine/calcium-channel blockers) and thrombus control; for refractory cases, intracoronary epinephrine has emerging supportive data.
6. Access choice—bleeding matters
Radial access reduces major bleeding and access-site complications versus femoral in RCT meta-analyses, and remains guideline-preferred; distal radial or ulnar can be alternatives when feasible.
7. Device entrapment/loss—rare but consequential
More frequent in CTO and calcified segments; Have a retrieval plan: attempt snare or microcatheter retrieval first; if unsuccessful, consider ‘crush and seal’ with a stent as a last resort.
8. Imaging-guided PCI—risk mitigation that changes outcomes
ESC 2024 guidance emphasizes IVUS/OCT-guided PCI (Class I) ensures proper device sizing, assesses calcium burden, and prevents stent under-expansion—reducing future complications.
9. Treating calcified lesions—tool selection affects risk
Rotational atherectomy, laser, and IVL each have different mechanism/risk profiles; comparative contemporary data and expert reviews help match tool to lesion (e.g., RA for balloon-uncrossable, IVL for concentric/deep calcium), and combination (“RotaShock”) may be synergistic in selected cases—while respecting perforation risk.
10. Team & system readiness—your best “bailout”
Pre-briefs, tamponade kits, covered stents on the table, defined retrieval tools, and rapid escalation pathways consistently separate good from bad outcomes when rare events occur.
Quick take-home lines for your panel
• “Imaging prevents what heroics try to fix.”
• “Perforation rescue = balloon tamponade → covered stent → pericardiocentesis; escalate early.”
• “Radial-first isn’t fashion—it’s fewer bleeds.”
• “Match the calcium tool to the lesion (and your experience), not the other way around.”
