Textbook Review: Complications of Cardiovascular Procedures (Mauro Moscucci)

Complications have fortunately become less common in the catheterization laboratory as cardiovascular procedures have matured. At the same time, eventually every cath lab operator will encounter an adverse event. Since no single physician, lab, or institution will have the prior experience to manage every possible complication, we must rely on the collective experience of the field to be adequately prepared for the unexpected.

“Complications of Cardiovascular Procedures,” edited by Mauro Moscucci, MD, is the closest thing we have to a comprehensive compendium of complications in cardiology. Whereas most texts present complications as an afterthought, complications and their prevention are the focus here, with only brief overviews of the procedures to place the complications in context. The book’s 629 pages appears intimating at first glance, before you realize that the chapters are well-illustrated, the sections succinct, and the tables frequent. The mark of good editing is bringing together the content from multiple distinguished contributors into a unified style, and Moscucci makes each chapter read as though it were written by the same author.

Section 1 focuses on general principles including risk assessment, quality assurance, legal considerations, training requirements and moderate sedation. Although not always the most exciting portion of the book to read, it does bring together very important content that cannot be found elsewhere in such a concise format. One chapter on the legal implications of procedural complications provides vivid real-life case examples, making the content both relatable and memorable. The moderate sedation chapter summarizes the relevant airway and sedation assessment increasingly required by many hospitals for conscious sedation, including the first clear tables of the Aldrete and Mallampati scores that we have seen in a cardiology text.

Section 2 gets into an overview of the general complications of all invasive procedures, including access site complications, stroke, periprocedural myocardial infarctions, and infection. Overall, the content is interesting and easy to read in this section, with one of the strongest chapters providing a great overview of percutaneous coronary intervention and technical factors including guides, wires, balloons/stents, etc. Each chapter covers the range of adverse reactions that can occur, and to the extent supported by the data, how to prevent them. The chapters are very much up to date as of 2010 — for example, including the use of ultrasound for arterial access. But like any published textbook it cannot possibly include more recent data (i.e. the failure of N-acetylcysteine to prevent contrast nephropathy in the ACT [Acetylcysteine for the prevention of Contrast-induced nephropaThy] trial). The absence of any discussion on remote ischemic preconditioning to prevent periprocedural infarction is notable in what is otherwise a thorough review of prevention techniques, and may reflect a lack of general acceptance of the practice despite the data.

Section 3 covers complications specific to coronary interventions (dissection, side branch closure, abrupt closure, perforation, distal embolization), and is where the book really stands out as an important text for the coronary interventionalist and the training interventional fellow. It discusses pertinent clinical issues in depth, with sections focusing on prevention, management strategies and pitfalls to avoid.  Tables with the typical grading systems of complications are provided, along with frequent and illustrated case examples (often with intravascular ultrasound). The biggest strength of this and the following sections are algorithms that outline prevention and management of complications (especially no-reflow, perforation, and dissections). 

Sections 4-7 are similar in structure to section 3 and focus on specific complications of structural interventions, peripheral vascular procedures, pediatric interventions and EP procedures. While it is unlikely that all of these will be relevant to any one physician, the section will adequately prepare the cath lab manager and technologist to assist in the full spectrum of cath lab procedures. This is particularly true for less common procedures such as balloon pericardiotomy, alcohol septal ablation, TandemHeart support device implantation, and congenital heart disease procedures, all of which are included.

The book includes online access to the entire text, along with downloadable movies of 36 complications.  This may be helpful for mobile access, but runs on Adobe Flash Player which may not be optimized or playable on your particular mobile device. The online movies are necessarily low resolution but download quickly. 

It is very apparent that the author and contributors meticulously planned the structure of the book and executed it effectively. Reading the book one is not as exciting as watching a series of car crashes, as is seen in some conference sessions devoted to complications, but rather provides a clear-headed summary of what can happen in the cath lab, how to manage it if it happens, and how to prevent it from happening again. For the experienced cardiologist, the book serves as an illustrated teaching tool, a review of the grading systems and prevention techniques of complications, and a toolbox of expert techniques for rescue. For the starting interventional fellow, reading this book may not be sufficient to pass the Interventional Cardiology Boards, but is a good start to safely performing interventions independently. For cath lab staff, the book provides expertise on preparing the lab for complications, with processes that make it run safer and equipment that is needed for the unexpected.