Table 3 Open in new tab Complications...

Prevention

Management

Coronary

Rupture

Proper contemporary RA or OA technique¹
Avoid excessive high-pressure dilation with large balloons
Intravascular imaging-guided selection and sizing of devices

Covered stent implantation
Immediate pericardial drainage in case of tamponade
Surgical standby

Perforation

Proper contemporary RA or OA technique¹
Avoid excessive high-pressure dilation with large balloons (especially in eccentric calcified lesions)
Intravascular imaging-guided selection and sizing of devices

Prolonged balloon inflation
Covered stent implantation
Coils in case of distal vessel perforation

Late pericardial tamponade

Limit the use of temporary pacemakers: e.g. by administering IV atropine boluses during the procedure, or use pacing on the wire technique. Prefer balloon-tipped temporary pacemakers

Consider clinical follow-up and/or transthoracic echocardiography 2 h after the procedure
Pericardial drainage in case of tamponade

Periprocedural myocardial infarction

Proper contemporary RA or OA technique¹
Prefer low-speed OA
Procedural antithrombotic therapy according to the coronary syndrome

According to guidelines⁴¹

No/slow flow

Prophylactic IC dilators +/− RA saline infusion plus heparin and nitrates
Short RA runs
Start with a small burr size
Avoid high speeds
ACT > 250 s

Adenosine IC
Nitroprusside IC
Nicardipine IC
Verapamil

AV block

More frequent in case of RA or OA of RCA and dominant LCX
Small burrs
Lower speed
Preventive placement of temporary pacemakers
IVL-induced ventricular captures might be associated with a drop in systemic blood pressure and seldom with non-sustained tachyarrhythmias

Physical manoeuvres (i.e. coughing) if the patient is stable
Atropine
Temporary pacemaker

Vascular and haemodynamic

Major bleeding

Favour radial access
Consider DUS-guided femoral puncture
Consider patient blood management before the elective procedure (e.g. pre-PCI IV ferric cardoxymaltose, etc.) in patients with iron deficiency chronic anaemia

Consider patient blood management after the procedure (e.g. follow-up with haemoglobin check at discharge and 7–10 days after discharge, etc.)
In case of haematoma at the puncture site, perform DUS

Renal

Contrast-induced nephropathy

Assess for the risk of contrast-induced nephropathy
Adequate hydration
Use of low-osmolar or iso-osmolar contrast media
In patients with moderate/severe CKD, perform pre- and post-hydration with isotonic saline or, alternatively, tailored hydration regimens
Minimize the contrast media volume
Consider IVUS to reduce angiographic incidences with the associated contrast volume
Prefer IVUS to OCT as intravascular imaging to avoid additional contrast media

Check GFR before discharge and 24–48 h post-procedure in all patients; then repeat GFR control 7–10 days after discharge in selected patients
Liberal hydration
Consider haemodialysis or renal ultrafiltration in case of severe contrast-induced nephropathy

Prevention

Management

Coronary

Rupture

Proper contemporary RA or OA technique¹
Avoid excessive high-pressure dilation with large balloons
Intravascular imaging-guided selection and sizing of devices

Covered stent implantation
Immediate pericardial drainage in case of tamponade
Surgical standby

Perforation

Proper contemporary RA or OA technique¹
Avoid excessive high-pressure dilation with large balloons (especially in eccentric calcified lesions)
Intravascular imaging-guided selection and sizing of devices

Prolonged balloon inflation
Covered stent implantation
Coils in case of distal vessel perforation

Late pericardial tamponade

Limit the use of temporary pacemakers: e.g. by administering IV atropine boluses during the procedure, or use pacing on the wire technique. Prefer balloon-tipped temporary pacemakers

Consider clinical follow-up and/or transthoracic echocardiography 2 h after the procedure
Pericardial drainage in case of tamponade

Periprocedural myocardial infarction

Proper contemporary RA or OA technique¹
Prefer low-speed OA
Procedural antithrombotic therapy according to the coronary syndrome

According to guidelines⁴¹

No/slow flow

Prophylactic IC dilators +/− RA saline infusion plus heparin and nitrates
Short RA runs
Start with a small burr size
Avoid high speeds
ACT > 250 s

Adenosine IC
Nitroprusside IC
Nicardipine IC
Verapamil

AV block

More frequent in case of RA or OA of RCA and dominant LCX
Small burrs
Lower speed
Preventive placement of temporary pacemakers
IVL-induced ventricular captures might be associated with a drop in systemic blood pressure and seldom with non-sustained tachyarrhythmias

Physical manoeuvres (i.e. coughing) if the patient is stable
Atropine
Temporary pacemaker

Vascular and haemodynamic

Major bleeding

Favour radial access
Consider DUS-guided femoral puncture
Consider patient blood management before the elective procedure (e.g. pre-PCI IV ferric cardoxymaltose, etc.) in patients with iron deficiency chronic anaemia

Consider patient blood management after the procedure (e.g. follow-up with haemoglobin check at discharge and 7–10 days after discharge, etc.)
In case of haematoma at the puncture site, perform DUS

Renal

Contrast-induced nephropathy

Assess for the risk of contrast-induced nephropathy
Adequate hydration
Use of low-osmolar or iso-osmolar contrast media
In patients with moderate/severe CKD, perform pre- and post-hydration with isotonic saline or, alternatively, tailored hydration regimens
Minimize the contrast media volume
Consider IVUS to reduce angiographic incidences with the associated contrast volume
Prefer IVUS to OCT as intravascular imaging to avoid additional contrast media

Check GFR before discharge and 24–48 h post-procedure in all patients; then repeat GFR control 7–10 days after discharge in selected patients
Liberal hydration
Consider haemodialysis or renal ultrafiltration in case of severe contrast-induced nephropathy

Table 3

Open in new tab

Complications potentially occurring during PCI of calcified lesions with related management

	Prevention	Management
Coronary
Rupture	Proper contemporary RA or OA technique¹ Avoid excessive high-pressure dilation with large balloons Intravascular imaging-guided selection and sizing of devices	Covered stent implantation Immediate pericardial drainage in case of tamponade Surgical standby
Perforation	Proper contemporary RA or OA technique¹ Avoid excessive high-pressure dilation with large balloons (especially in eccentric calcified lesions) Intravascular imaging-guided selection and sizing of devices	Prolonged balloon inflation Covered stent implantation Coils in case of distal vessel perforation
Late pericardial tamponade	Limit the use of temporary pacemakers: e.g. by administering IV atropine boluses during the procedure, or use pacing on the wire technique. Prefer balloon-tipped temporary pacemakers	Consider clinical follow-up and/or transthoracic echocardiography 2 h after the procedure Pericardial drainage in case of tamponade
Periprocedural myocardial infarction	Proper contemporary RA or OA technique¹ Prefer low-speed OA Procedural antithrombotic therapy according to the coronary syndrome	According to guidelines⁴¹
No/slow flow	Prophylactic IC dilators +/− RA saline infusion plus heparin and nitrates Short RA runs Start with a small burr size Avoid high speeds ACT > 250 s	Adenosine IC Nitroprusside IC Nicardipine IC Verapamil
AV block	More frequent in case of RA or OA of RCA and dominant LCX Small burrs Lower speed Preventive placement of temporary pacemakers IVL-induced ventricular captures might be associated with a drop in systemic blood pressure and seldom with non-sustained tachyarrhythmias	Physical manoeuvres (i.e. coughing) if the patient is stable Atropine Temporary pacemaker
Vascular and haemodynamic
Major bleeding	Favour radial access Consider DUS-guided femoral puncture Consider patient blood management before the elective procedure (e.g. pre-PCI IV ferric cardoxymaltose, etc.) in patients with iron deficiency chronic anaemia	Consider patient blood management after the procedure (e.g. follow-up with haemoglobin check at discharge and 7–10 days after discharge, etc.) In case of haematoma at the puncture site, perform DUS
Renal
Contrast-induced nephropathy	Assess for the risk of contrast-induced nephropathy Adequate hydration Use of low-osmolar or iso-osmolar contrast media In patients with moderate/severe CKD, perform pre- and post-hydration with isotonic saline or, alternatively, tailored hydration regimens Minimize the contrast media volume Consider IVUS to reduce angiographic incidences with the associated contrast volume Prefer IVUS to OCT as intravascular imaging to avoid additional contrast media	Check GFR before discharge and 24–48 h post-procedure in all patients; then repeat GFR control 7–10 days after discharge in selected patients Liberal hydration Consider haemodialysis or renal ultrafiltration in case of severe contrast-induced nephropathy

	Prevention	Management
Coronary
Rupture	Proper contemporary RA or OA technique¹ Avoid excessive high-pressure dilation with large balloons Intravascular imaging-guided selection and sizing of devices	Covered stent implantation Immediate pericardial drainage in case of tamponade Surgical standby
Perforation	Proper contemporary RA or OA technique¹ Avoid excessive high-pressure dilation with large balloons (especially in eccentric calcified lesions) Intravascular imaging-guided selection and sizing of devices	Prolonged balloon inflation Covered stent implantation Coils in case of distal vessel perforation
Late pericardial tamponade	Limit the use of temporary pacemakers: e.g. by administering IV atropine boluses during the procedure, or use pacing on the wire technique. Prefer balloon-tipped temporary pacemakers	Consider clinical follow-up and/or transthoracic echocardiography 2 h after the procedure Pericardial drainage in case of tamponade
Periprocedural myocardial infarction	Proper contemporary RA or OA technique¹ Prefer low-speed OA Procedural antithrombotic therapy according to the coronary syndrome	According to guidelines⁴¹
No/slow flow	Prophylactic IC dilators +/− RA saline infusion plus heparin and nitrates Short RA runs Start with a small burr size Avoid high speeds ACT > 250 s	Adenosine IC Nitroprusside IC Nicardipine IC Verapamil
AV block	More frequent in case of RA or OA of RCA and dominant LCX Small burrs Lower speed Preventive placement of temporary pacemakers IVL-induced ventricular captures might be associated with a drop in systemic blood pressure and seldom with non-sustained tachyarrhythmias	Physical manoeuvres (i.e. coughing) if the patient is stable Atropine Temporary pacemaker
Vascular and haemodynamic
Major bleeding	Favour radial access Consider DUS-guided femoral puncture Consider patient blood management before the elective procedure (e.g. pre-PCI IV ferric cardoxymaltose, etc.) in patients with iron deficiency chronic anaemia	Consider patient blood management after the procedure (e.g. follow-up with haemoglobin check at discharge and 7–10 days after discharge, etc.) In case of haematoma at the puncture site, perform DUS
Renal
Contrast-induced nephropathy	Assess for the risk of contrast-induced nephropathy Adequate hydration Use of low-osmolar or iso-osmolar contrast media In patients with moderate/severe CKD, perform pre- and post-hydration with isotonic saline or, alternatively, tailored hydration regimens Minimize the contrast media volume Consider IVUS to reduce angiographic incidences with the associated contrast volume Prefer IVUS to OCT as intravascular imaging to avoid additional contrast media	Check GFR before discharge and 24–48 h post-procedure in all patients; then repeat GFR control 7–10 days after discharge in selected patients Liberal hydration Consider haemodialysis or renal ultrafiltration in case of severe contrast-induced nephropathy

RA, rotational atherectomy; IV, intravenous; IC, intracoronary; DUS, Doppler ultrasound; CKD, chronic kidney disease; GFR, glomerular filtration rate; OCT, optical coherence tomography; PCI, percutaneous coronary intervention; OA, orbital atherectomy; RCA, right coronary artery; LCX, left circumflex artery; ACT, activated clotting time; AV, atrioventricular; IVL, intravascular lithotripsy; IVUS, intravascular ultrasound.

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