• Systems Process to Prepare You and Your Staff for the Management of Cath Lab Disasters

    September 20, 2016

    By Craig J. Beavers, PharmD and Jayant Bagai, MD, FSCAI

    Procedural complications are an inevitable part of the practice of invasive and interventional cardiology. Fortunately, due to staff diligence and careful attention to case selection and technical aspects, serious complications are rare. However, it is precisely the rarity of their occurrence that makes these “cath lab disasters” so dangerous. A long time interval since the occurrence of a serious complication carries the risk of making the operator and cath lab staff complacent. The lack of preparedness, or even worse, the lack of necessary equipment and knowledge base to deal with them, can rapidly result in serious morbidity or mortality. Everyone in the cath lab knows the trauma of a complication or death in the cath lab. We also know the satisfaction of averting a tragedy by quick recognition and action.

    In this Tip Of The Month, we focus on systems processes to mitigate cath lab disasters with the intention of improving the quality of care delivered in these circumstances to potentially save lives.

    This tip restricts its focus to complications occurring during diagnostic and interventional coronary procedures. By intention, it does not include structural heart, peripheral or electrophysiological procedures.

    Some selected cath lab disasters and staff response are listed in Table 1.

    Complication Incidence and predisposing conditions Prevention and preparation strategies Staff knowledge base Staff response
    Serious coronary perforation (Ellis Class II/III) 0.5% (1 in 200)1,2

    Female patients, advanced age, calcified lesions, CTO PCI, cutting balloon, atherectomy, myocardial bridge PCI, over-sized balloon/stent, polymer jacketed wire
    Identify availability of covered stents and coils in adequate sizes especially prior to CTO PCI Protamine dose and side effects

    Impact of platelet infusion for reversal of GPI effect

    Location and sheath compatibility of covered stents and coils
    Stop anticoagulation

    Call for extra hands

    Call for stat ECHO

    Notify anesthesia and respiratory for airway support

    Notify cardiac surgery (if available on site). For PCI sites without cardiac surgery, notify partner institution and assess transport options.

    Identify pericardio-
    centesis kit, covered stents, coils, IABP
    Severe left main dissection 0.06% diagnostic angiography (~1 in 1700) 0.1% PCI (1 in 1000)3

    Non-coaxial engagement of left main, especially with Judkins catheters, Amplatz catheters, guide deep throating during balloon withdrawal, left main disease
    Careful deliberate, co-axial engagement of left main

    Extra care when using Amplatz catheters, use of “soft tip” Amplatz catheters

    Careful monitoring of guide pressure

    Never inject with damped pressure
    Recognize significance of damped pressure and do not inject if noted

    Recognition of contrast staining, NHLBI grades of dissection and their significance
    Call for extra hands

    Notify cardiac surgery

    IABP / Impella / ECMO depending on patient’s hemodynamics

    In the presence of reduced flow and hemodynamic instability, percutaneous approaches to restoration of flow should be considered with the use of stents.

    Anticipate possible use of GPI
    Iatrogenic ascending aortic dissection during coronary angiography or PCI 0.02-0.04% (1 in 2500-5000)4,5

    Angiography or PCI during acute MI, RCA PCI, Amplatz guide,  injection of contrast in presence of damped pressure or ostial dissection
    Never inject with damped pressure

    Use of side hole guide for ostial RCA PCI to decrease hydraulic pressure of injection

    Stop injecting additional contrast if aortic cusp stain / dissection noted and stent vessel ostium quickly
    Recognize significance of damped pressure and do not inject if noted

    Recognition of classes of iatrogenic ascending dissection and their outcomes
    Perform aortic root angiography in LAO view to ascertain extent of dissection  - particularly if aortic root and carotid vessels are involved

    Call for stat ECHO to r/o pericardial effusion

    Pain and BP/HR control

    Notify cardiac surgery for Class 2 (extension up ascending aorta < 4 cm) or Class 3 (extension up aorta > 4 cm) dissection
    Severe air embolism Use of 4 or 5 F systems, large volume injection from injector  without air detection capability Always aspirate for air bubbles before injecting

    Avoid making a “running connection” with a pressurized saline bag

    Check for air in the barrel of the injector

    Drip saline on catheter hub while withdrawing wire, especially with 4 or 5 F systems.
    Identification of air in barrel of injector when preparing for large volume injection

    Identification of air in line of manifold or automatic injector

    Identification of empty saline bag

    Recognition of  “sucking sound” as air is entrained into the catheter
    Call for extra hands (if patient arrests)

    Start CPR if patient arrests Institute aggressive ACLS as patient can invariably be resuscitated

    Administer 100% oxygen

    Trendelenburg position to avoid transit to cerebral vessels 

    Forceful injection of saline or blood to displace air to distal segment of coronary artery can be attempted6

    Identify aspiration catheters to remove intra coronary air

    Anticipate need for IABP, transvenous pacemaker
    lactoid shock
    Incidence ~ 0.23% (1 in 430) Death- 1 in 55,0007

    History of severe contrast allergy
    Ask every patient about known history of contrast allergy

    Pre-medicate for known or suspected contrast allergy
    Recognize signs and symptoms of serious reaction (hives, lip swelling, stridor, hypotension)

    Knowledge of dose and  correct dilution of SC and IV epinephrine
    Systemic anaphylactoid reactions to iodinated contrast media during cardiac catheterization procedures: guidelines for prevention, diagnosis and management
    Cardiac arrest Pre cath lab arrest

    Cardiogenic shock

    High risk PCI (last remaining vessel)

    Severe LV dysfunction
    Recognize hemodynamic deterioration and take prompt action to determine its cause and reverse it before arrest

    Pre PCI placement of mechanical circulatory support for high risk PCI and/or shock
    Recognition of pre arrest scenario (no reflow, narrowing pulse pressure, runs of VT, severe bradycardia)

    Set up and role of different MCS devices

    Vasopressor and inotrope  effect and dose
    Call for extra hands

    2 person chest compressions and bag mask ventilation

    Call anesthesia and respiratory therapy / code blue

    Prepare for defibrillation / pacing

    Prepare drugs for ACLS, IC Epinephrine

    Notify perfusion and set up ECMO (preferable and if available) or Impella; IABP if ECMO and Impella unavailable

    Other serious but less common complications include rupture of the pulmonary artery during right heart catheterization, stent loss, device embolization, entrapped rotablator burr, bioptome, catheter or wire and femoral or retroperitoneal hemorrhage while patient is on the table, serious brady or tachyarrhythmias, unexplained hypotension, respiratory depression/arrest, stroke and pulseless limb during or after intervention.

    The following are some of the methods to prepare cath lab staff so that they can manage these complications.

    1. Run mock drills on a quarterly basis to assess staff and lab preparedness to deal with the most serious complications, which have the potential to cause rapid death or serious disability. A list of elements to include in the drills is located in Table V of the SCAI Expert Consensus Statement: 2016 Best Practices in the Cardiac Catheterization Laboratory

    2. The drills should focus on defined roles for cath lab staff, assessing the knowledge base of staff, especially staff that are recent additions or part time. A special “Disaster Cabinet” should be organized with clearly identified location of rarely used equipment such as covered stents, snares, aortic occlusion balloons, pericardiocentesis tray, etc. The cabinet should contain folders with instructions on how to prepare the correct dilution of medications for IV and intra coronary (IC) use and updated contact numbers for anesthesia, respiratory therapy, perfusion, cardiac surgery, ECHO lab and ORs.

    3. Protocols designed to identify patients at increased risk for rare complications as well as for the management of serious complications as agreed on by the cath lab director, operators and staff should be pre-printed in large font, and kept in labeled binders in the marked “Disaster Cabinet”. These issues should be highlighted during the “time out” with specific roles assigned.  

    4. Post-procedure de-briefing in the event of a serious complication or “near-miss” to identify what went wrong. QI techniques including Root Cause analysis, if appropriate, should be used.

    5. All major complications should be reviewed in a morbidity and mortality (M&M) conference. In-lab death, cardiac arrest, stroke, emergency CABG and unanticipated PCI due to iatrogenic etiology must be reviewed.  Deaths must be reviewed within 30 days of occurrence. The M&M should occur at least quarterly and representation from cath lab staff is ideal. The conference is non punitive with the goal of quality improvement.

    6. Comparison of rates of serious complications in your cath lab with national benchmarks, and if a significantly higher rate is noted, to determine the cause(s) and solution(s) by initiating a QI project. A system such as used by the Veterans Affairs catheterization laboratories can be modeled and adapted for local use to improve quality 8.


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    2. Kiernan TJ, Yan BP, Ruggiero N, Eisenberg JD, Bernal J, Cubeddu RJ, Witzke C, Don C, Cruz-Gonzalez I, Rosenfield K, Pomersantev E, Palacios I. Coronary artery perforations in the contemporary interventional era. J Interv Cardiol. 2009 Aug;22(4):350-3.
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