Table 3

Standard operating procedures (SOP) for the management of percutaneous coronary intervention complications

ComplicationKey elements of SOP
1Vascular complicationsAnticoagulation review (consider reversal), large bore venous access, blood transfusion and haemodynamic support.
Emergency CT scan if retroperitoneal bleed suspected.
Immediate assistance from vascular surgeon or immediate invasive angiography to balloon tamponade or stent bleeding vessel.
2Contrast reaction/anaphylaxisHigh-flow oxygen and anaesthetic support.
Intravenous crystalloid fluid challenge, epinephrine, hydrocortisone, chlorphenamine.
3Traumatic coronary dissectionAvoid further contrast injections.
Place or retain coronary wire in the true lumen (consider intravascular ultrasound guidance).
If significant dissection, appropriate stent placement.
4Air embolismHigh-flow oxygen.
Consider microvascular vasodilatation with adenosine, sodium nitroprusside or verapamil.
Consider wiring and aspiration of embolised vessel.
5Iatrogenic coronary thrombosisCheck adequate heparinisation and consider glycoprotein IIb/IIIa inhibitor or intracoronary thrombolysis.
Consider manual thrombus aspiration.
Consider gentle balloon inflation or agitation to disperse distal thrombi.
6Coronary perforationImmediate balloon tamponade.
Haemodynamic support, large bore venous access, fluid resuscitation, consider blood or autotransfusion.
Emergency echocardiography followed by emergency pericardiocentesis if tamponade evident.
Placement of covered stent (consider second access site, larger guide catheter) for large vessel perforation.
Distal embolisation with fat, coil, thrombin or autologous clotted blood for guidewire exit perforation.
7No-reflowCheck activated clotting time and administer intracoronary nitrates.
Consider distal contrast injection with microcatheter, aspiration catheter or over-the-wire balloon to confirm diagnosis, followed by distal delivery of intracoronary adenosine, verapamil or sodium nitroprusside.
8Side branch occlusionEnsure coronary wire in side branch to reduce risk of occlusion and guide rewiring (if unable to rewire, small balloon dilatation of side branch ostium over jailed wire may restore flow and facilitate rewiring).
Adequate proximal optimisation.
Consider use of hydrophilic coronary wire to rewire side branch.
9Loss of stents and other equipmentConsider deployment with serial insertion and dilatation of small to larger balloons.
Consider crushing stent against vessel wall with a balloon and second stent to cover the lesion.
Consider retrieval with advancement and dilatation of balloon distal to stent, wire braiding or use of a snare.