A total of 2340 diagnostic catheter angiographies were performed from January 2010 to May 2020 and 1247 (53.29%) angiographies were performed in female patients. The mean age of patients was 55 years (IQR 46–66; range 2 months–94 years), 305 (13.03%) angiographies were performed under emergency conditions, 189 (8.08%) angiographies were spinal, 4F and 5F catheter sheaths were used most frequently (1321/2340; 56.45% and 881/2340; 37.65%, respectively). An angio-seal system was used for puncture site closure in 87 (3.72%) patients.
Technical Complications
A total of 55 technical complications were noted: these included 24 difficult or failed punctures (1.03%), 12 unfinished examinations (0.51%), 9 vasospasms (0.38%), 9 vascular injuries (0.38%) and 1 iatrogenic arteriovenous (AV) fistula (0.04%) (Table
1).
Table 1
Complications in 2340 diagnostic angiographies. Data are presented as n (%)
Local |
Hematoma | 31 (1.32) |
Systemic |
Headache | 11 (0.47) |
Nausea and vomiting | 5 (0.21) |
Transient hypotension | 1 (0.04) |
Rash | 1 (0.04) |
Pruritus | 1 (0.04) |
Fever | 1 (0.04) |
Toxic contrast medium reaction | 2 (0.09) |
Cardiac instability | 5 (0.21) |
Transient confusion | 3 (0.13) |
Neurologic |
Reversible | 6 (0.26) |
Transient | 7 (0.3) |
Permanent | 3 (0.13) |
Technical |
Difficult puncture | 24 (1.03) |
Ceasing the examination | 12 (0.51) |
Vasospasm | 9 (0.38) |
Vascular injury | 9 (0.38) |
Arteriovenous (AV) fistula | 1 (0.04) |
Of the technical complications 5 occurred after spinal angiography (5/189, 2.65%) and the remaining 50 were noted after cerebral angiography (50/2151, 2.32%). The frequency of technical complications did not differ between spinal and cerebral angiographies (p = 0.791).
Puncture was difficult because of scarring (n = 2) or atherosclerosis (n = 1) and needed to be performed multiple times at the same site in six cases. A switch to the opposite femoral artery side was performed in 13 patients, the brachial artery was used in 2 cases and the radial artery in 1 case. In the remaining 1 case, puncture attempts failed completely.
Angiographies remained unfinished in 12 cases (0.51%), 11 angiographies (0.47%) were aborted because catheterization through the iliac or subclavian level was not possible. Another examination was terminated because the total amount of injected contrast agent was considered too high in a patient with renal insufficiency.
Vasospasm occurred 9 times (0.38%), most frequently in the internal carotid artery (n = 6), followed by the vertebral artery (n = 1) and segmental spinal arteries (n = 1). Nimodipin was administered for vasospasm therapy in 3 of the 9 cases, in all 3 cases with success. In the remaining 6 cases vasospasm normalized without therapy.
Vessel injury in form of dissection occurred 9 times (0.38%), most frequently in the iliac artery (n = 5), followed by the internal carotid artery (n = 2) and the spinal arteries (n = 1). No treatment was needed for these injuries as they were stable and hemodynamically irrelevant.
A small AV fistula (0.04%) occurred after complicated puncture and initial malposition of the sheath in the superficial femoral vein without any consequences.
Age, sex, and emergency conditions had no significant impact on the occurrence of technical complications (p = 0.663, p = 0.477 and p = 0.972, respectively).
Clinical Complications
A total of 75 complications (3.21%) were noted: 31 were local, 28 were systemic, and 16 were neurological (Table
1).
Of the clinical complications five occurred after spinal angiography (5/189, 2.65%). The remaining 70 clinical complications were observed after cerebral angiography (70/2151, 3.25%). The frequency of clinical complications did not differ significantly between spinal and cerebral angiographies (p = 0.690).
The most common local complication was groin hematoma (31/2340; 1.32%). Out of 31 hematomas 2 required treatment (2/2340; 0.09%), in 1 case, because of a hemodynamically relevant hemorrhage that required volume and erythrocyte substitution and in the other case a pseudoaneurysm required surgery. An Angio-Seal system was used in the latter case. Overall, 4 groin hematomas were noted after the use of the Angio-Seal system (4/87, 4.6%), whereas 27 groin hematomas were noted in patients without Angio-Seal (27/2253, 1.2%). The frequency of groin hematomas did not differ significantly with respect to the use of the Angio-Seal system (p = 0.066). Taken together, local complications were more likely in patients in whom the angiography was performed under emergency conditions (p = 0.042). Age and sex had no significant impact on the occurrence of local complications (p = 0.749 and p = 0.637, respectively).
The most common systemic complication was headache (11/2340; 0.47%), closely followed by allergic symptoms (9/2340; 0.38%), of which nausea and vomiting were the most frequent. Of the patients five (5/2340, 0.21%) suffered from cardiovascular instability, three of the latter succumbed to a pre-existing cardiovascular disease during subsequent hospitalization but death was not considered to be attributed to angiography. Of the patients three (3/2340, 0.13%) suffered transient confusion and two patients (2/2340, 0.09%) suffered from toxic reactions to the contrast agent. Age, sex, and emergency conditions had no significant impact on the occurrence of systemic complications (p = 0.137, p = 0.549, and p = 0.369, respectively).
Neurological complications (Table
2) during the inpatient stay occurred in 0.68% (
n = 16) of patients. The majority of complications were transient (
n = 7, 0.30%) or reversible (
n = 6, 0.26%). Aphasia and hemiparesis were the most common neurological complications (
n = 5, 0.21%) followed by dysarthria and visual disturbances (
n = 4, 0.17%). Facial palsy (
n = 3, 0.13%), anisocoria (
n = 2, 0.09%), somnolence (
n = 2, 0.09%), and conjugate eye deviation (
n = 1, 0.04%) were less common. No patient suffered from cortical blindness.
Table 2
Neurologic complications in 2340 diagnostic angiographies. Data are presented as n (%)
Hemiparesis/hemiplegia | 0 | 2 (0.09) | 3 (0.13) |
Aphasia | 1 (0.04) | 3 (0.13) | 1 (0.04) |
Dysarthria | 2 (0.09) | 1 (0.04) | 1 (0.04) |
Visual disturbances | 2 (0.09) | 2 (0.09) | 0 |
Somnolence | 1 (0.04) | 0 | 1 (0.04) |
Weakness of buccal branch of the facial nerve | 1 (0.04) | 1 (0.04) | 1 (0.04) |
Conjugate eye deviation | 0 | 1 (0.04) | 0 |
Anisocoria | 1 (0.04) | 1 (0.04) | 0 |
Three patients had permanent neurologic symptoms (0.13%): one patient suffered from left-sided hemiparesis with central facial palsy and dysarthria. Another patient suffered from expressive aphasia. The last patient suffered from right-sided hemiparesis.
As shown in Table
3, most of the patients were no longer symptomatic at the time of discharge.
Table 3
Classification of neurologic symptoms at the time of discharge
0 | 6 | 5 | 0 |
1 | 0 | 0 | 1 |
2 | 0 | 0 | 0 |
3 | 0 | 2 | 1 |
4 | 0 | 0 | 1 |
5 | 0 | 0 | 0 |
6 | 0 | 0 | 0 |
One neurological complication occurred after spinal angiography. After the examination, the patient showed a weakness of the buccal branch of the left facial nerve with dysarthria the next morning. Magnetic resonance imaging (MRI) performed immediately after the angiography showed an acute embolic infarct in the territory of the right middle cerebral artery, as well as small embolic infarcts in the territory of the left middle cerebral artery. Systemic lysis with recombinant human-tissue plasminogen activator (rtPA) was performed. The clinical symptoms regressed completely during the course.
None of the participants with neurological complications died during their inpatient stay. Age, sex, and emergency conditions had no significant impact on the occurrence of neurological complications (p = 0.337, p = 0.263, and p = 0.474, respectively).
Clinically noted complications were recorded in 13 patients (0.56%) who had undergone an angiographic investigation under emergency conditions (13/305, 4.26%). A significant correlation between symptomatic complications and emergency conditions could be found (p = 0.009).
Deaths caused by angiography did not occur.