NEUROIMAGING

Complications of endovascular procedures

Created 14/05/2021, last revision 02/04/2023

diagnostic DSA carries a low risk of complications (risk of neurological deficit ~ 0.09-0.14%)
- the risk increases in elderly patients with atherosclerotic disease of the aorta and carotid arteries
most of the complications listed below are related to interventional procedures (both acute and elective)

Central complications

artery/stent thrombosis, distal micro/macro embolization
hyperperfusion syndrome/hemorrhagic transformation (especially in recanalization procedures)
vasospasms
artery dissection/perforation
specific complications during angioplasty and stenting (stent malposition, deformation or rupture, etc.)
hypoperfusion (e.g. obstruction of distal filter protection by thrombi)

Peripheral (access-site) complications

Systemic complications

allergic reaction
hemodynamic instability with hypoperfusion (e.g., after carotid sinus manipulation)
contrast-induced nephropathy
contrast-induced encephalopathy (CIE)

Central complications

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Integrilin

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Reopro

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bleeding most commonly occurs during reperfusion procedures in patients with concurrent extensive early ischemia (low ASPECT score)
- petechial hemorrhage/parenchymal hematoma → classification of hemorrhagic complications
- hemorrhagic transformation of ischemia may be associated with intraventricular bleeding or SAH
clinically symptomatic x asymptomatic
if detected, neutralize heparin → see here
in patients on DAPT or patients treated with an IIb/IIIa inhibitor, administer platelets and SOLUMEDROL 25mg i.v. (if the patient is on clopidogrel) [Qureshi, 2008] → neutralizing effect of antiplatelet therapy

occurs after acute recanalization procedures or revascularization of severe stenoses
- edema, intracerebral/intraventricular hemorrhage, SAH
strict blood pressure control periprocedurally and in the following days is essential

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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 degree of dilation performed
- the risk of delayed onset may justify monitoring vital signs for at least 12h post-procedure
severe bradycardia ⇒ administer ATROPIN 0.5 mg IV
- ATROPIN can also be given prophylactically in the following cases:
  - severely calcified stenoses
  - lesions in the carotid bulb
  - history of myocardial infarction
moderate or severe hypotension ⇒ consider vasopressors + fluids