Coronarography

(coronary angiography)
 Coronary angiography is a specialised X-ray
test to find out detailed information about
your heart (coronary) arteries.

In diagnosing coronary artery disease, it is

. invaluable to be able to "see" the coronary
arteries and the shape and function of the
heart chambers
 Coronary angiography remains the gold
standard for detecting clinically significant
atherosclerotic coronary artery disease.

The technique was first performed by Dr.

Mason Sones at the Cleveland Clinic in 1958
 Goals

To visualize coronary arteries, branches,

collaterals and anomalies
Precise localization relative to major and minor
side branches, thrombi and areas of calcification
To visualize vessel bifurcations, origin of side
branches and specific lesion characteristics
(length, eccentricity, calcium etc)
 Indications

To rule out the presence of coronary stenosis,

define therapeutic options, and determine
prognosis.
Used as a research tool for follow-up after
invasive procedures or pharmacologic therapy.
High-risk criteria include low ejection fraction
and poor exercise capacity on an exercise test.
 In patients with nonST-segment elevation
acute coronary syndromes with high-risk
features (e.g., ongoing ischemia, heart failure)
In patients with acute ST-segment elevation
myocardial infarction (STEMI)
Primary percutaneous intervention (PCI) is
usually performed in the same procedure,
immediately after the diagnostic procedure
 How does pacient prepares for a coronary
angiography?
Before the day of the test is required a blood
test and an ECG to make sure the pacient is
OK to have the procedure.
If he takes a 'blood-thinning' drug
(anticoagulant), such as warfarin, then he is
likely to need to stop this for 2-3 days before
the test. (This prevents excessive bleeding
from the site of the small, flexible tube
(catheter) insertion.)
If there is insulin or medicines for diabetes,
the timing of when to take these on the day
of the test may need to be clarified.
 Pacient preparation-cont

In case of pregnancy, you need to tell the

doctor who will do the test.
The pacient may be asked to stop eating and
drinking for a few hours before the test.
He may be asked to shave both groins
before the test.
He will have to sign a consent form at some
point before the test to confirm that he
understands the procedure, understands the
possible complications (see below), and
agrees to the procedure being done.
 Before the catheterization begins, the
pacient receives a mild sedative, but he will
remain conscious during the procedure.
Leads (wires) of an electrocardiograph
machine will be placed upon chest so that
the physician can monitor the action of the
heart throughout the test. A needle attached
to a tube and bottle of 5 percent dextrose in
water will be placed in a peripheral vein.
 Performing the procedure

An artery in your arm, leg, or groin will be

selected for insertion of the tube (catheter
that is to be gently guided into your heart or
other area. The insertion site is cleansed
with an antiseptic and draped in a sterile
fashion. A local anesthetic is injected into
the skin and deeper tissues; there should be
no further pain after this.
 The procedure for making an angiogram
involves insertion of a catheter (a hollow,
flexible tube) into an artery at your groin or
elbow. This catheter is guided through your
main artery, the aorta, into your heart.

Then it is guided into a coronary artery. A

dye that is opaque to x-rays is injected
through the catheter to make the inside of
the heart and artery visible on an x-ray
picture.
Diagnostic catheters
 When the catheter is in place, a contrast
medium (dye) will be delivered through the
catheter to the coronary arteries to provide a
clearer x-ray picture. If the physician also
wants to widen the blood vessels he may be
asked to hold a nitroglycerine tablet under
your tongue. At certain times the pacient
will be asked to take deep breaths, which
improves the quality of the x-ray pictures
that are made during the examination.
Coronary projections
 Pacient monitoring

Results of the catheterization are monitored

on a television screen during the test. These
video images are also recorded on a CD for
further study and for your own records.Then
the catheter is removed and the examination
is complete. For the first 20 to 30 minutes
after removal of the catheter, direct pressure
is placed on the insertion site.
First coronary angiogram Ohio oct 30, 1958
 After the procedure
The pacient will stay in bed for at least 4
hours. His vital signs will be checked
periodically. lf needed, he will also be given
pain medication, and the insertion site will
be checked for soreness,swelling, or blood
loss. In most circumstances, the pacient will
be allowed home after four to six hours.
 Are there any risks or side-effects?
Although this is a common procedure, some
risks are associated with it. For example, if
the catheter loosens an existing blood clot or
cholesterol deposit within an artery, the
result can be a stroke or heart attack. In rare
instances, the heart or kidneys can be
damaged. Anyone with a blood clotting
disorder or poor kidney function is at
increased risk
 Still, the risk of a serious complication (such
as stroke, heart attack, or even death) is
approximately 1 in 1,000. The risks are
lowest in young, healthy persons and
highest in older persons with serious
medical problems. Because of risks
associated with this test, a surgical team
usually is available during the
catheterization procedure and can be called
upon in the event surgery is required
Pathologic coronary arteries
Coronary aneurysms
Coronary collaterals for LAD
Muscular
Anomalous origin of LCx from RC sinus
Polyarteritis nodosa
 What, Why and Where?
What is coronary angioplasty?
Why do we do it (which patients)?

Where should it be done?

 Definitions

Angiography = pictures of blood vessels

Angioplasty = changing shape of blood vessel
PCI = Percutaneous Coronary Intervention
PPCI = Primary PCI = PCI during acute infarction
Rescue PCI = PCI if lysis failed
 Questions (blue = yes)

Primary PCI saves lives

PCI in stable angina saves lives
PCI can be done as a day case
PCI is cheaper than CABG
After PCI, patients should not drive for 1 week
After PCI, patients should not work for 1 month
 Human angioplasty
1974 Andreas
Gruentzig performs first
peripheral human balloon
angioplasty
1976 Gruentzig
presents results of animal
studies of coronary
angioplasty at AHA
meeting
 Coronary angioplasty

1977 First human

coronary balloon
angioplasty performed
intraoperatively
1977 Andreas
Gruentzig performs first
cath lab PCI on awake
patient in Zurich; starting
with this case, all PCI data
is entered into a registry
 Standard PCI kit

Guiding catheters

Guidewires

Angioplasty balloon Deployed stent

New developments
What does the patient experience?

FEAR!
 Cath Lab Team

CCU / ward staff / ITU

Cardiology medical staff
 Why do we do it (which
patients)?
Myocardial Infarction
NSTEMI ~600/pa
STEMI ~100/pa

Chronic Stable Angina

??% of 10,000
Asymptomatic Ischaemia
 Peripheral Vascular
Disease
Acute & Chronic Limb
Ischemia

Lipi Shukla
 What is PVD?
Definition:
Also known as PAD or PAOD.

Occlusive disease of the arteries of

the lower extremity.

Most common cause:

o Atherothrombosis
o Others: arteritis, aneurysm +
embolism.

Has both ACUTE and CHRONIC Px

Pathophysiology:
Arterial narrowing Decreased
blood flow = Pain

Pain results from an imbalance

between supply and demand of
blood flow that fails to satisfy
ongoing metabolic requirements.
 Risk Factors:
Typical Patient:
Smoker (2.5-3x)
Diabetic (3-4x)
Hypertension
Hx of Hypercholesterolemia/AF/IHD/CVA

Age 70 years.

Age 50 - 69 years with a history of smoking or diabetes.

Age 40 - 49 with diabetes and at least one other risk factor for
atherosclerosis.

Leg symptoms suggestive of claudication with exertion or ischemic pain at

rest.

Abnormal lower extremity pulse examination.

Known atherosclerosis at other sites (eg, coronary, carotid, or renal artery

disease).
 30% Buttock & Hip Claudication
Impotence Leriches Syndrome

Thigh Claudication

60% Upper 2/3 Calf Claudication

Lower 1/3 Calf Claudication

Foot Claudication
DDx of Leg Pain
1. Vascular
a) DVT (as for risk factors)
b) PVD (claudication)

2. Neurospinal
a) Disc Disease
b) Spinal Stenosis (Pseudoclaudication)

3. Neuropathic
a) Diabetes
b) Chronic EtOH abuse

4. Musculoskeletal
a) OA (variation with weather + time of day)
b) Chronic compartment syndrome
Pictures:
Tardus et parvus = small amplitude + slow rising pulse
CT Angiography Digital Subtraction
Angiography

Value of angiography
Localizes the obstruction
Visualize the arterial tree & distal
run-off
Can diagnose an embolus:
Sharp cutoff, reversed meniscus or clot silhouette
 Treatment:
1. RISK FACTOR MODIFICATION:
a) Smoking Cessation
b) Rigorous BSL control
c) BP reduction
d) Lipid Lowering Therapy

2. EXERCISE:
a) Claudication exercise
rehabilitation program
b) 45-60mins 3x weekly for 12 weeks
c) 6 months later +6.5mins walking
time (before pain)

3. MEDICAL MANAGEMENT:
a) Antiplatelet therapy e.g.
Aspirin/Clopidogrel
b) Phosphodiesterase Inhibitor e.g.
Cilostazol
c) Foot Care
 PCI/Surgery:
Indications/Considerations:
Poor response to exercise rehabilitation + pharmacologic therapy.
Significantly disabled by claudication, poor QOL
The patient is able to benefit from an improvement in claudication
The individuals anticipated natural hx and prognosis
Morphology of the lesion (low risk + high probabilty of operation success)

PCI:
Angioplasty and Stenting
Should be offered first to patients with significant comorbidities who are not
expected to live more than 1-2 years

Bypass Surgery:
Reverse the saphenous vein for femoro-popliteal bypass
Synthetic prosthesis for aorto-iliac or ilio-femoral bypass
Others = iliac endarterectomy & thrombolysis
Current Cochrane review = not enough evidence for Bypass>PCI

Amputation: Last Resort