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INTRODUCTION The word iatrogenic, derived from the Greek iatros, meaning physician or healer, is defined as “induced inadvertently by a physician or surgeon or by medical treatment or diagnostic procedures.” The practice of modern cardiology has evolved into a procedure-­ laden field with increasing indications for catheter-­ based interventions. This has led to an increase in complications, which are classified as iatrogenic as they arise from the procedure and pres­ ent new medical challenges. Iatrogenic complications of cardiac procedures have a major impact on morbidity, mortality, health care costs, and overall clinical outcomes. Procedure-­ related iatrogenic complications include patient identification and medi­ cation errors, drug interactions, anesthetic complications, and inadvertent consequences of the procedure itself. This chapter reviews some of the commonly encountered iatrogenic complications of interventional and electrophysiological procedures and pres­ ents evidence-­ based ways to minimize ­ these complications. IATROGENIC ASPECTS OF INVASIVE REVASCULARIZATION PROCEDURES Percutaneous coronary revascularization is perhaps the most commonly performed cardiac intervention worldwide. It has been ­ adopted universally, with major technological breakthroughs improving efficacy and safety of the procedure. However, widespread ac­ cep­ tance has also led to an increase in complications. This chapter focuses on some of the major complications associated with percutaneous revascularization and the strategies that can help reduce complication rates. Contrast-­Induced Nephropathy Contrast-­ induced nephropathy (CIN), or contrast-­ induced acute kidney injury, is one of the leading ­ causes of hospital-­ acquired renal injury. The International Society of Nephrology and the Eu­ ro­ pean Society of Urogenital Radiology define CIN as a rise in serum creatinine by more than 0.5 mg/dl (44 mmol/1), or a 25% increase CHAPTER 20 Iatrogenicity Associated With Interventional Treatment Modalities in Cardiology Naga Venkata Pothineni, Aatish Garg, Hakan Paydak, and Jawahar L. Mehta 234 / Iatrogenicity Associated With Interventional Treatment Modalities in Cardiology hour. Despite much debate, several ­ trials have failed to demonstrate the benefit of N-­ acetyl cysteine and sodium bicarbonate. Anaphylactoid Reactions The incidence of anaphylactoid reactions to contrast media is around 1%. However, the recurrence rate among patients with a known history of allergy approaches almost 40% but is completely preventable with close attention (3). A regimen of 50 mg of prednisone administered 13 hours, 7 hours, and 1 hour before the procedure along with 50 mg of diphenhydramine 1 hour before the procedure has been shown to reduce the risk of recurrent anaphylactoid reactions (4). Existing evidence does not support cross-­ reactivity between shell fish allergy and contrast allergy. Access Site Complications Hemorrhagic complications of cardiac catheterization remain among the most common adverse outcomes of the procedure. ­ Factors predisposing to access site complications are listed in Box 20-2.­ Until the early 2000s, the femoral artery was the from the baseline, within 48 to 72 hours of administration of contrast, in the absence of an alternate etiology (1). CIN peaks around 5 days postcardiac catheterization and tends to resolve between day 7 and 10. The incidence of CIN in most recently published registries and studies varies between 0.9% and 5.4%. Renal vasoconstriction in response to hypertonic contrast–­and direct contrast–­ induced tubular damage are proposed mechanism of CIN. Risk ­ factors are presented in Box 20-1. CIN has been associated with prolonged hospital stay, increased health care costs, poor prognosis, increased mortality, and risk of requiring hemodialysis. The first step in preventing CIN is to identify high-­ risk patients. A ­ simple risk scoring system is widely used (2). In patients at risk, the only strategies shown to reduce the incidence of CIN are hydration with isotonic saline and minimizing the amount of contrast media. The most commonly used approach is the administration of intravenous 0.9% sodium chloride at a rate of 1 ml/kg/hour for 24 hours, beginning 12 hours before administration of the contrast medium, to achieve a urine output of greater than 150 ml per BOX 20-1 ​ Risk ­ Factors Predisposing to Contrast-­ Induced Nephropathy Patient related: • Advanced age • Chronic kidney disease • Diabetes mellitus • Hypertension • Metabolic syndrome • Anemia • Hypoalbuminemia • Renal transplant • Hypovolemia Procedure related: • Urgent versus elective • Arterial versus venous • Diagnostic versus therapeutic Contrast related: • Volume of contrast • Contrast characteristics (osmolarity, ionicity, molecular structure, viscosity) Iatrogenic Aspects of Invasive Revascularization Procedures / 235 key components of management. Other complications of femoral arterial access include aortic/ femoral occlusion, hematoma formation, and formation of atrioventricular (AV) fistulas. The advent of radial arterial access over the past de­ cade has been a boon to the interventional community in decreasing vascular access complications. Major ­ trials comparing radial and femoral...


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