Stroke in patients undergoing coronary angiography and percutaneous coronary intervention: incidence, predictors, outcome and therapeutic options

Abstract

In the present day, coronary angiography and percutaneous coronary intervention are considered to be safe procedures with low complication rates in general. Nevertheless due to their widespread use and their application in a continually aging population known to carry a higher risk for complications, periprocedural stroke affects thousands of patients undergoing coronary angiography and percutaneous coronary intervention worldwide every year. Stroke is reported to occur in 0.05-0.1% of diagnostic cardiac catheterizations and in 0.18-0.44% of patients treated with percutaneous coronary intervention in clinical routine today. Despite all improvements in pharmacological and technical issues, the rate of stroke after cardiac catheterization has remained almost constant over the last 20 years of invasive cardiology of invasive and interventional cardiology, which is most probably due to the immutability of the majority of risk factors before cardiac procedures. An advanced age, arterial hypertension, diabetes mellitus, coronary angiography performed under emergency conditions, history of stroke, renal failure, the use of an intra-aortic balloon pump, congestive heart failure and interventions at bypass grafts have been identified as risk factors for periprocedural stroke in large registries. Due to exceedingly high rates of mortality and disability stroke after coronary angiography still has an enormous impact on the patient's prognosis and on quality of life. If patients survive this devastating complication, most of them suffer from persistent neurological deficits such as motor or speech disorders. For its low incidence and consecutively missing data from randomized clinical trials, an evidence-based treatment could not yet be established, and treatment options are generally based on case series and small studies only. Nevertheless, intra-arterial thrombolysis and mechanical embolectomy seem to be promising and relatively safe approaches in the treatment of periprocedural ischemic stroke. Further research by randomized trials and large registries are needed to validate its efficacy and safety.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

“…436 In the United States, stroke is reported to occur in 0.05% to 0.1% of diagnostic cardiac catheterizations and in 0.18% to 0.44% of percutaneous coronary interventions in contemporary clinical practice. 439 The incidence of stroke during a diagnostic cerebral angiogram is <1%. 440 Treatment of acute ischemic stroke in patients who are undergoing (or have recently undergone) cardiac or cerebral angiographic procedures appears, on the basis of limited case report series, to lead to favorable outcomes with immediate neuroendovascular intervention, including local administration of alteplase if feasible and in instances when an intracranial arterial occlusion is demonstrable on angiography.…”

Neurologic complications after transradial or transfemoral approach for diagnostic and interventional cardiac catheterization: A propensity score analysis of 16,710 cases from a single centre prospective registry

“…In addition, within this timeframe, the proportion of neurologic events was actually higher (although non‐significantly) in transfemoral patients, thus reinforcing that the apparent association with the growing use of TRA is most likely a spurious finding. In our population, the relationship between baseline characteristics known to increase the risk of procedure‐related stroke (like old age, hypertension, clinically overt cardiovascular disease, prior stroke, previous CABG, interventional procedure, ACS and increased procedure complexity) and the actual event rate was not straightforward. The prevalence of these high‐risk features varied significantly over the entire study period in both study groups and there was no statistically significant association with stroke/TIA rates.…”

“…Periprocedural stroke, resulting from manipulation with dislodgment of debris made up of thrombus, calcific material, or cholesterol particles from atherosclerotic plaques, the formation and embolization of fresh thrombus at catheter and guidewire tips themselves or intra‐cranial bleeding , is a rare but potentially devastating event. Historically, rates of periprocedural stroke have been kept acceptably low— around one per thousand patients overall, perhaps higher in interventional procedures (up to 0.6%)—and have not decreased further in recent years .…”

Screening coronary angiography in patients with long‐standing diabetes mellitus undergoing kidney transplant evaluation

“…In clinical practice, there is some reluctance among cardiologists to perform angiography in KT candidates, particularly in asymptomatic individuals with negative stress test results. Coronary angiography is relatively safe with major complications such as death, stroke, and MI occurring in <1% . The complication rates are higher in patients with vascular disease and renal failure, and these need to be factored in when making decisions regarding screening angiography .…”

“…27,28 The complication rates are higher in patients with vascular disease and renal failure, and these need to be factored in when making decisions regarding screening angiography. 28 Another concern we have encountered with cardiologists regarding intervention for coronary artery disease is a reluctance to delay transplantation to allow for adequate dual anti-platelet therapy or recovery from CABG. However, given the increased waiting times for deceased donor kidney transplantation and the increasing number of centers willing to perform kidney transplantation without interruption of anti-platelet therapy, the decision to intervene on critical coronary lesions is not likely to significantly alter the timing of transplantation.…”