Coronary angiography

Coronary Angiography

1. Coronary Angiography 27-08-2015 Dr. Y. Madhu Madhava Reddy

2. 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 Coronary Angiography

3. 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) Goals

4. Coronary artery Coronary artery is a vasa vasorum that supplies the heart. Coronary comes from  the latin  ” Coronarius ”  Meaning “Crown”. 4

5. Coronary artery The coronary artery arises just superior to the aortic valve and supply the heart The aortic valve has three cusps – #left coronary (LC), #right coronary (RC) #posterior non-coronary (NC) cusps. 5

6. Right coronary artery Originates from right coronary sinus of Valsalva Courses through the right AV groove between the right atrium and right ventricle to the inferior part of the septum 6

7. Branches of RCA 7 Conus branch SINU NODAL BRANCH AV Nodal Branch

8. Conus branch – 1 st branch supplies the RVOT Sinus node artery – 2 nd branch - SA node.(in 40% they originate from LCA) Acute marginal arteries- Arise at acute angle and runs along the margin of the right ventricle above the diaphragm.  Branch to AV node Posterior descending artery : Supply lower part of the ventricular septum & adjacent ventricular walls. Arises from RCA in 85% of cases. 8

9. Area of distribution RT CORONARY ARTERY 1)Right atrium 2)Ventricles a ) greater part of rt. Ventricle except the area adjoining the anterior IV groove. b) a small part of the lt. ventricle adjoining posterior IV groove. c )Posterior part of the IV septum d )Whole of the conducting system of the heart, except part of the left branch of AV bundle 9

10. Left coronary artery Arises from left coronary cusps Travels between RVOT anteriorly and left atrium posteriorly . Almost immediately bifurcate into left anterior descending and left circumflex artery. Length – 10-15mm 10

11. 11

12. LT CORONARY ARTERY DISTRIBUTION 1) Left atrium. 2) Ventricles i ) Greater part of the left ventricle, except the area adjoining the posterior IV groove. ii) A small part of the right ventricle adjoining the anterior IV groove. iii) Anterior part of the IV septum. iv) A part of the left br. Of the AV bundle. 12

13. DOMINANCE Determined by the arrangement that which artery reaches the crux & supply posterior descending artery The right coronary artery is dominant in 85% cases. 8% cases - - circumflex br of the left coronary artery 7% both rt & lt coronary artery supply posterior IVseptum & inferior surface of the left ventricle-here it is balanced dominance. 13

14. Normal coronaries (LCA)

15. Normal coronaries (RCA)

16. CORONARY ANGIOGRAPHY

17. INDICATION Diagnosis of CAD in clinically suspected pts. Providing peri -interventional information for percutaneous coronary intervention Coronary anomalies To exclude stenoses before non-coronary cardiac surgery (valve surgery after 40 yrs of age) Determine patency of coronary artery bypass grafts 17

18. INDICATIONS In patients with non–ST-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

19. CONTRAINDICATIONS Coagulopathy Decompensate congestive heart failure Uncontrolled Hypertension CVA GI Hemorrhage Pregnancy Inability for patient cooperation Active infection Renal Failure Contrast medium allergy 19

20. Before the Procedure After patient is properly identified, the procedure must be explained before consent can be signed Baseline vital signs will be done and as long as these are within the doctor’s interest, can proceed with the procedure Blood tests must be done including BUN, creatnine , PTT, INR, insulin/sugar levels

21. Patient Prep After patient is put on table, the area being puncture must be free from hair Hair removal done by disposable electric razor and removed by sticky side of cloth tape Patient must be surgically cleaned with hospital approved sterile surgical prep solution

22. Sterile Field and Patient The technologist working with the cardiologist must be scrubbed in following basic sterile surgical technique The patient is then draped from neck down with sterile drapes All equipment (radiation shields, image intensifier, equipment used to manipulate machine) must be prepped with sterile covers

23. Sterile equipment needed Procedure tray should include: -sterile gowns and gloves for scrub tech and doctor -sterile towels and drapes for procedure -equipment covers -gauze -scalpel, needles, scissors, hemostats -syringes for heparin/saline flush, lidocaine , and blood draw -labels with marking pen for any item filled with a solution -basin for heparin/saline mixture, basin for waste fluids, small cup for lidocaine -skin prep solution -high power manifold -connection tubing Fig. 2

24. Catheters, wires and sheaths Fig. 3 -Three catheters are used: JR4 (advances to right coronary arters , JL4 (advances to left coronary arteries), and 145 degree pigtail catheter (to advance into ventricles -One 135cm wire -Sheath corresponds with catheter size (5F cath gets 5F sheath etc.) -Size of catheter depends on doctor’s preference but generallly 6F is used

25. Medications Used Patient relaxed with Versed or Fentanyl , sometimes both Two 500mL bags of saline infused with 2,000 units (2cc) heparin each for flushing all tubing, catheters, sheaths Lidocaine for tissue numbing Visipaque contrast unless otherwise specified

26. Start Procedure When doctor and tech are scrubbed and all equipment and supplies are ready, the procedure may begin

27. Arterial Puncture Access is easiest from right side of patient due to aortic bend Puncture is generally done via the femoral artery Alternative sites include the radial and brachial arteries of the arm

28. Catheter introduction After puncture of femoral, radial or brachial artery (primarily on right side of patient), a catheter is advanced into the aorta and then the coronary arteries

29. Steps to Insert Catheter After numbing the groin area, the femoral artery is palpated and a needle is inserted in that direction When blood comes out of needle, the artery has been accessed A small, flexible guidewire is then inserted into the lumen of the needle The needle can then be removed but the wire must maintain position

30. Inserting Catheter After removing the needle, a flexible plastic tube can be placed over the wire and introduced into the artery. This is called a one-way sheath (allows insertion of catheters and wires without blood escaping) The catheter is then inserted over the guidewire but through the sheet and advanced into placement to the aorta. MC Catheter used is Judkins .

31. Catheter Placement Movement of catheter is monitored under fluoroscopy with the cardiologist manipulating its movements The fluoroscopic machine is manipulated by a qualified, scrubbed in, radiologic technologist When catheter is in place, wire can be removed and contrast administered

32. Catherization

33. Important safety aspects It is essential that the catheter tip does not wedge into a narrow coronary ostium and cause occlusion of flow. The catheter tip must be axially oriented in proximal vessel rather than being angulated against the side wall, which may cause intimal damage. Contrast injection with catheter tip impacted to side wall of coronary artery can cause osital dissection. Above mentioned are the fatal complications.

34. Contrast Media Contrast media- Low osmolarity , Non-ionic Dose-3-10 ml;320-370 mg of iodine/mg, using a hand-held syringe filled from a reservoir. Left coronary artery is filled with 6-8 ml, right coronary artery is filled with 3-5 ml usually 35

35. Angiographic projection The heart is oriented obliquely in the thoracic cavity, the coronary circulation is generally visualized in the RAO & LAO projection to furnish true PA & LAT views of the heart. using both cranial & caudal angulations. For LCA branches, views - -AP ,RAO, LAO with cranial tilt For RCA branches, views reqd. are -AP,RAO ,LAO ĉ or ĉout cranial

36. 38 Angiographic view of LCA

37. Angiographic view of RCA 39

38. Pitfalls of coronary angiography 1. Inadequate vessel opacification- May give impression of ostial stenoses, missing side branches or thrombus . 2. Eccentric stenosis - Coronary atherosclerosis often leads to eccentric or slit–like narrowing than central narrowing; so if the long axis of the vessel is projected, the vessel may appear to have a normal or near normal caliber. 3. Superimposition of branches 4. Foreshortening of the stenotic segment due to projectional defect 40

39. Rotational CA X-ray system rotates around the patient during the acquisition of a single run Significant reduction in both contrast agent usage and radiation dose of up to 30%, without compromising image quality Contrast medium is injected automatically (3 mL /s for the LCA and 2 mL /s for the RCA) range 12-18 cc After this preload, rotation of the C-arm was started automatically and X-rays taken 41

40. Possible complications Femoral : Dissection of femoral / iliac artery or aorta , Haematoma Aorta : Damage to aortic intima , Embolus to head and neck vessels, aortic root dissection. Coronary : Ostial dissection, coronary embolus, arrhythmia due to catheter wedging or contrast medium, spasm due to catheter or contrast medium. General : Hypotension, left heart failure – contrast overload, Contrast allergy

41. 43 Tight stenosis noted involving the mid segment of right coronary artery. Distal branches are normal. A partially obstructive narrowing noted in the proximal segment of the LAD

42. Left main stem stenosis

43. Muscle Bridge

44. Pigtail catheter in left ventricle to measure ventricular pressure Aortagram used to assess ascending and descending aorta

45. Fluoroscopy machine The x-ray machine is suspended from the ceiling. It can be manipulated in multiple angles and views to achieve a desired picture. The x-ray comes from the bottom of the machine and the image intensifier that transmits the image is above the patient. Lead shielding and a radiation badge is required for all personnel in the room during the procedure.

46. Finished Procedure The procedure is complete when the ra diologist or cardiologist has seen all the views and anatomy desired and all pressures recorded. The catheter can be removed and manual pressure must be applied to entry site for 15 minutes.

47. Post Procedure Instructions The patient must lie flat and supine for a minimum of two hours to ensure the artery does not reopen. Dressing must remain dry, no lifting over five pounds for three days. No shower for 24 hours.

48. Cardiac Catheterization

49. Thank you