• endovascular procedures are a cornerstone in the minimally invasive treatment of vascular disorders, encompassing a broad spectrum of interventions from diagnostic angiography to therapeutic endovascular aneurysm repair, stent placement, or thrombectomy
  • while these techniques offer significant benefits, they are not without risk
  • diagnostic digital subtraction angiography (DSA) is generally associated with a low risk of complications (risk of neurological deficit ~ 0.09-0.14%)
    • the risk increases in elderly patients with atherosclerotic disease of aorta and carotid arteries
  • most of the complications of endovascular procedures listed below are related to interventional procedures, both acute and elective
Central complications
  • artery/stent thrombosis, distal micro/macroembolization
  • hyperperfusion syndrome/hemorrhagic transformation (particularly in recanalization procedures)
  • vasospasms
  • artery dissection or perforation
  • specific complications during angioplasty and stenting (stent malposition, deformation, or rupture)
  • hypoperfusion (e.g. obstruction of the distal filter protection by thrombi)
Peripheral (access-site) complications
  • thrombosis of the femoral artery
  • dissecting pseudoaneurysm or arterio-venous shunt in the groin
  • groin hematoma
  • retroperitoneal hematoma
Systemic complications

Central complications

Artery thrombosis, distal thromboembolism

  • microembolization x macroembolization  Distal embolization from the aneurysm sac Distal embolization to the peripheral branch of the ACA during ACM recanalization. Follow-up CT shows extensive ischemia in the ACM territory and ischemia corresponding to the ACA branch occlusion Successful MCA recanalization complicated by embolization into the ACA    
    • separation of mural thrombus and plaque
    • thrombus washout from the aneurysm sac, etc.
  • minor embolizations may remain clinically silent
  • the highest risk is observed during the procedure and within the following 72 hours
  • dual antiplatelet therapy is essential for stenting procedures
  • in cases of thromboembolic complications during aneurysm coiling after subarachnoid hemorrhage (SAH), the successful use of IIb/IIIa inhibitors has been published   [Aviv, 2005]
  • mechanical thrombectomy and local thrombolytic therapy can be used to treat complications during DSA or recanalization procedures

(Integrilin) usually 1mL/2mg or 1mL/0.75 mg

  • IV bolus:  0.2 mg/kg within 5 minutes, followed by infusion  (Sedat, 2014)
  • IV infusion:  5mL(10mg) + 45mL of NS (1mL=0.2 mg)  …… 3mL/h (0.6 mg/h) 0.125ug/kg/min (max 10ug/min!)
  • IA bolus:  5mL /10mg) + 45 mL of NS (1mL=0.2 mg) …… bolus 10 mL (2mg) every 5 minutes till max dose 10 mg


(Reopro) 1mL/2mg

  • a monoclonal anti-glycoprotein IIb/IIIa receptor antibody
  • IV bolus: 0.25 mg/kg within 5 minutes, followed by infusion
  • IV infusion: 5mL (10mg) + 45mL NS (1mL of solution = 0.2 mg) ……   3mL/h (0.6 mg/h)   0.125ug/kg/min (max rate 10ug/min!)
  • IA bolus: 5mL (10mg) + 45 mL NS (1mL of solution = 0.2 mg) …… bolus 10 mL (2mg) every 5 minutes, max dose 10mg

Embolic complication (to the ACA) during mechanical thrombectomy of an occluded MCA
Carotid angioplasty complicated by an embolism into the ICA, which was treated by an aspiration embolectomy

Hemorrhagic infarction

ICH after mechanical thrombectomy

Hyperperfusion syndrome

  • complications occur after acute recanalization procedures or revascularization of severe stenoses
    • edema, intracerebral/intraventricular hemorrhage, SAH
  • strict periprocedural and postprocedural blood pressure control is essential Hyperperfusion syndrome with edema

Hyperperfusion syndrome


  • most vasospasms are transient and resolve after catheter removal
    • more common in young individuals
  • symptomatic x asymptomatic
  • if a hemodynamically significant vasospasm persists, percutaneous transluminal angioplasty (PTA) may be performed and/or vasodilators (IA or IV) may be administered

(Dilceren / Nimotop) usually 1 mL/0.2 mg


  • IV:  1-2 mg/h (5-10mL/h) by continuous infusion + 10 ml/h NS concomitantly
    • AEs: hypotension, tachycardia
    • combine with vasopressors in case of hypotension
    • parenteral administration is not more effective than oral administration in preventing vasospasm
    • infusion pumps with polyethylene tubing and needles with polyethylene handles (or all-metal) must be used, infusion solution is light sensitive, must not be used in direct sunlight
  • IA:  50 mL (10mg) + 50mL NS (to get 10% solution; 10mL containing 1mg)  … IA infusion 1mL/min (0.1mg /min)
    • 0.5-2 mg into a single artery, total max dose 5 mg   [Kim,2009]

(Verapamil / Isoptin / Lekoptin)  usually 1mL/2.5 mg


  • IA:   bolus 1-3 mg (or 44 μg/kg) locally  [Feng,2002] 
  • AEs: hypotension, bradycardia



  • IA:  0.5-2 mg as a slow bolus

(Asicord / Primacor)


  • IA: 1mg/ml  –  0.25 mg/min – infused for 30 minutes
  • regression of vasospasm with combined IA and subsequent IV administration has been reported  [Arakawa, 2001]  [Fraticelli, 2008]
  • IV administration alone seems to be effective  [Crespy, 2019]

(Magnesium sulfate)  usually 1mL/40 mg or 1mL/80mg


  • IA: 10mL (1g) + 28 mL NS …. 0.25-1 g per artery  [Shah, 2009]
    • may be used in combination with nicardipine (2.5-20.0 mg/h for 30-60 min)
    • magnesium is believed to inhibit cerebral vasospasm by causing smooth muscle relaxation and vasodilation by mechanisms similar to the calcium channel antagonists
  • IV: a large phase III study showed no significant benefit in cerebral vasospasm prevention or improved favorable outcomes when administered via IV infusion (Wong, 2010)

(Papaverine hydrochloride)  1mL/30mg


  • IA:  300mg (10 mL) + 100mL of NS (solution concentration is < 3mg/mL)  …. IA infusion 3mL/min for 30 minutes or 1.3 mL/min for 60 minutes [Kassel, 1992][Clouston, 1995] 
  • usually not used due to AEs
Vasospasm in the M1 segment of the MCA and in terminal ICA
Vasospasms on DSA
ICA vasospasm occurring during the acute stroke endovascular procedure

Arterial dissection/perforation

  • dissection and pseudoaneurysm      Dissection with pseudoaneurysm formation
    • small dissections without thrombosis ⇒ observe
    • consider the use of abciximab for small dissections associated with significant thrombosis
    • symptomatic dissection may require acute stenting
    • consider intervention for hemodynamically significant dissection (TIMI 0-1) (extracranial arteries)
  • arterial rupture/perforation ⇒ SAH/ICH
    • immediate endovascular intervention or surgery is required
    • neutralize heparin → see here
    • administer platelets (reverses the effect of antiplatelet therapy)
    • bleeding after stenting poses a problem – stopping the bleeding increases the risk of stent thrombosis

Stenting-related complications

Peripheral (access-site) complications of endovascular procedures

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Systemic complications

Complications related to contrast media

Hemodynamic instability with hypoperfusion

  • hemodynamic depression has been reported after both carotid artery stenting (CAS) and carotid endarterectomy (CEA)
  • bradycardia with hypotension is usually a consequence of carotid sinus manipulation (parasympathetic activation)
    • occurs to varying degrees in up to 42% of procedures [Gupta, 2006]
    • bradycardia is significantly influenced by the extent of dilation performed
    • given the risk of delayed onset, monitoring of vital signs for a minimum of 12 hours post-procedure is recommended
  • severe bradycardia ⇒  administer  ATROPINE 0.5 mg IV bolus
    • ATROPIN can also be used prophylactically in the following cases:
      • severely calcified stenoses
      • lesions in the carotid bulb
      • history of myocardial infarction
  • moderate-severe hypotension ⇒ consider vasopressors + fluids

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Complications of endovascular procedures
link: https://www.stroke-manual.com/complications-of-endovascular-procedures/