Route cause analysis for Embolization Mistakes
🔴 1. Inadequate Pre-procedure Planning
• Lack of cross-sectional imaging (e.g., missing CTA or MRI) to map vascular anatomy.
• Failure to identify arterial variants (e.g., replaced hepatic artery, uterine–ovarian collaterals, etc.).
• Poor assessment of contraindications (e.g., renal failure, infection, coagulopathy).
• Incomplete discussion with referring team about goals (e.g., curative vs palliative).
🔹 Impact: Non-target embolization, incomplete treatment, increased morbidity.
🔴 2. Poor Vascular Access Technique
• Using inappropriate sheath size or site (e.g., femoral vs radial vs brachial).
• Traumatic multiple access attempts.
• Not securing hemostasis post-procedure (leads to pseudoaneurysm, hematoma).
• Not using ultrasound guidance in difficult access cases.
🔹 Impact: Access site complications like bleeding, hematoma, AV fistula, thrombosis.
🔴 3. Non-target Embolization
• Inadequate superselective catheterization.
• Inappropriate embolization material size or type (e.g., small particles migrating distally).
• Backflow due to overinjection or lack of flow control.
• Failure to identify dangerous collaterals (e.g., spinal artery, vasa recta, ophthalmic branch).
🔹 Impact: Ischemia of bowel, spinal cord, skin, or other vital organs.
🔴 4. Wrong Embolic Agent Selection
• Using coils in high-flow AVM without flow reduction → risk of migration.
• Using small particles in hypervascular organs → risk of infarction.
• Lack of understanding the hemodynamics of the lesion.
🔹 Impact: Incomplete embolization or distal tissue necrosis.
🔴 5. Incomplete Embolization
• Not embolizing all feeders or collaterals.
• Premature termination due to radiation/time pressure.
• Not repeating post-embolization angiographic check for residual blush.
🔹 Impact: Persistent bleeding, recurrence of symptoms or lesion.
🔴 6. Over-embolization or Embolizing Healthy Tissue
• Overestimating required volume of embolic material.
• Misidentifying vessels due to poor roadmap planning.
• Not stopping once endpoint is achieved.
🔹 Impact: Unnecessary infarction, abscess formation, pain, or organ failure.
🔴 7. Inappropriate Anticoagulation Management
• Embolizing while patient is fully anticoagulated → risk of bleeding.
• Not restarting anticoagulation in stent-assisted cases → thrombosis.
🔹 Impact: Post-procedural bleeding or thromboembolic events.
🔴 8. Poor Documentation and Communication
• Failure to document embolized arteries, embolic used, access site, and complications.
• No clear instructions for post-procedure care (pain, antibiotics, follow-up imaging).
• Lack of communication with ICU or surgical team.
🔹 Impact: Delayed recognition of complications, medico-legal risks.
🔴 9. No Post-embolization Syndrome Management
• No prophylactic anti-emetics, analgesics, or antipyretics.
• Underestimating patient’s pain or inflammatory response.