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  1. Felipe C Albuquerque
  1. Correspondence to Dr Felipe C Albuquerque, Division of Neurological Surgery, Barrow Neurological Institute, Phoenix, AZ 85013, USA; felipe.albuquerque{at}bnaneuro.net

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The hard part was over. A 76-year-old woman presented with a large cavernous aneurysm and a sixth nerve palsy. Despite her age-related arterial tortuosity, placement of a flow diverter and coils went uneventfully. Two steps remained: obtaining a dynaCT scan to evaluate proper apposition of the stent and femoral closure. Unfortunately, because the injector had been improperly loaded, the initial CT scan had to be aborted. This prolonged the procedure by roughly 10 min. By the time we placed the femoral closure device, the general anesthetic had largely worn off and the patient bucked, lifting both legs off the table and kinking the closure device wire. We were unable to deploy the device successfully and were relegated to holding pressure at the puncture site. The patient was fully heparinized, had received a loading dose of abciximab (ReoPro) and had been compliant with her pretreatment regimen of aspirin and clopidogrel (Plavix). Her blood, essentially, was water.

The patient remained on the angiography table for three more hours as we eventually stopped her puncture site bleeding by reversing her heparinization and transfusing platelets. She really needed those 10 minutes. The root cause of this complication was basically a trivial error: failure to put enough contrast in the injector. Trivial errors probably occur with great frequency during the performance of medical procedures but rarely produce catastrophic outcomes. In her case, reversal of her coagulopathy subjected her to …

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