1.Presented by Dr. Muhammad Mobarock Hossain, MD (cardiology) phase B( final part) BSMMU, Dhaka. Coronary angiogram

2. Definition: Coronary angiography is a procedure that uses a special dye (contrast material) and x-rays to see how contrast material filled blood flows through the coronary arteries of the heart. 3. Importance of Coronary Angiogram: Coronary angiogram, is the "gold standard" for the evaluation of coronary artery disease (CAD). A coronary angiogram can be used to identify the exact location and severity of CAD. 4. Indications: Acute MI Unstable angina Chronic stable angina (uncontrolled by medication) Abnormal stress test Ventricular arrythmias Left ventricular dysfunction Valvular heart disease Preoperative coronary assessment for cardio vascular surgery Periodic follow up after cardiac transplantation 5. Contraindications: Coagulopathy Active bleeding Malignant hypertension Acute or chronic renal failure Severe anemia ( Hb < 10gm/dl of blood) Electrolyte imbalance Fever Active systemic infection Uncontrolled rhythm disturbances (arrhythmias) Uncompensated heart failure Transient Ischemic attack Patient unable to cooperate or does not desire procedure 6. Requisite for coronary angiogram: Cardiac cath lab. Puncture needle Introducer Short guide wire Cordis sheath with dilator Left Judkins catheter Right Judkins catheter contrast media 7. Left Judkins catheter: 8. Right Judkins Catheter: 9. Tiger catheter for Trans radial: 10. Contrast media: Types of radiocontrast agents : Iodinated radio contrast agents are either ionic or nonionic and are of variable osmolality. First generation: Ionic Highly hyperosmolal (1400 to 1800 mosmol/kg compared with the osmolality of plasma.) 11. Cont Second generation: Iohexol, nonionic monomers lower osmolality than the first generation but have an increased osmolality (500 to 850 mosmol/kg) compared with plasma. The newest nonionic contrast agents: iso-osmolal, with an osmolality of approximately 290 mosmol/kg (iodixanol agent). 12. Steps of Coronary Angiogram: Step 1 ( pre cath): Written consent. Fasting for at least 4 hours Pre cath investigations. Selection of arterial access point. Shaving of the groin/ wrist according to the choice. Opening the I/V line. Connect with the cardiac monitor. Oral or I/V sedatives. 13. Cont. Step 2: Radiation protection for the health care personnel. An area of the arm or groin, is cleaned and numbed with a local numbing medicine (anesthetic 15 ml). Draping of the patient. Using local anesthetics around the puncture site. Puncture and introducing the short guide wear through the puncture needle. Introducing the cordis sheath and removal of dilator along with short guide wire. Flush the channel with heparinized solution. 14. Cont. Step 3: The cardiologist passes a thin hollow tube, called a catheter, through an artery and carefully moves it up into the heart. X-ray images help the doctor positioning the catheter. Once the catheter is in place, dye (contrast material , better to use 15 mm. Short LMCA when the length is 5 mm. Occasionally, a third branch vessel, the Ramus Intermedius arises from the LMCA. In a small number of patients, the two major branch vessels arise from separate origins. 18. Left Anterior Descending Artery (LAD) LAD provides blood supply to the anterior wall of the left ventricle. It provides multiple septal branches to the interventricular septum and diagonal branches to the anterior lateral wall. The LAD in some patients wraps around the apex to supply a small amount of the posterior apex. 19. Left Circumflex Artery (LCx) LCx courses around the lateral or left atrio-ventricular groove and gives rise to multiple marginal or lateral branches. The branches are termed obtuse marginal (OM) branches. OM branches are sequentially numbered (OM1, OM2 etc). As the LCx courses the AV groove it also gives rise to several atrial branches, and occasionally the sino-atrial branch (40% of the population). 20. Right Coronary Artery (RCA) RCA arises from the right coronary cusp and follows the right AV groove. The most proximal branches of the RCA are the conus- branch which supplies the Right ventricular outflow tract and a branch that supplies the sino-atrial (SA) node (60% of patients). RCA gives off the postero lateral and posterior descending branches at the crux cordis 21. Normal coronaries (LCA) 22. Normal coronaries (RCA) 23. Angiographic views Anatomic landmarks formed by the spine, catheter and diaphragm provide information to view the image. In the LAO view the catheter and spine are seen on the left side of the image, while in the RAO they are found on the right. 24. Cont PA imaging places these landmarks in the center. Cranial can usually be distinguished from caudal angulations by the presence of the diaphragm. For cranial imaging, the patient should be asked to inspire to remove the diaphragmatic shadow from the image. 25. Left Coronary System Generally, for circumflex and proximal epicardial visualization the caudal views are most useful. For LAD and LAD/diagonal bifurcation visualization, the cranial views are most useful. 26. Angiographic views Left Main : AP, LAO cranial, LAO caudal Proximal LAD : LAO cranial, RAO caudal Mid LAD : LAO cranial, RAO cranial, Lateral Distal LAD : AP, RAO cranial, Lateral Diagonal : LAO cranial, RAO cranial 27. Angiographic views Proximal circumflex : RAO cranial, LAO caudal Intermediate : RAO caudal,LAO caudal Obtuse marginal : RAO caudal, LAO caudal, RAO cranial Proximal RCA : LAO, Lateral Mid RCA : LAO, Lateral, RAO Distal RCA : LAO cranial, Lateral PDA : LAO cranial Posterolateral : LAO cranial, RAO cranial 28. Grading stenosis The severity or degree of stenosis is measured by comparing the area of narrowing to an adjacent normal segment, and as a percentage reduction and calculated in the projection which demonstrates the most severe narrowing. 29. Classification of distal angiographic contrast runoff (TIMI Grade) Normal distal runoff (TIMI 3) Good distal runoff (TIMI 2) Poor distal runoff (TIMI 1) Absence of distal runoff (TIMI 0) Ref: Morton J. Kern/ p-131/2nd edition. 30. Grading of collateral circulation Grade Collateral appearance 0 No collateral circulation 1 Very weak reopcification 2 Reopacified segment, less dense than the feeding vessel and filling slowly. 3 3 Reopacified segment as dense as the feeding vessel and filling rapidly 31. Complication: Life threatening complications are rare (~1 in 1000) but more common in patients with serious disease, eg. Left main stem disease, aortic or peripheral vascular disease. Major complications: 1. MI 2. Stroke 3. Renal failure 4. Aortic or coronary dissection 5. Cardiac rupture 6. Air embolism 7. Arrythmia 8. Peripheral vascular damage 32. Cont Minor complication: 1. Haematoma (at the puncture site) 2. Angina 3. Vaso vegal reaction 4. Allergies to contrast agents and drugs 33. Management of complication: Hematoma: Most hematomas don't need intervention. Only analgesia. If it is tense, expansile,bruit or very tender then the altenative diagnosis will be femoral artery pseudoaneurysm. Pseudo aneurysm: Represents partial rupture of the femoral artery with formation of false aneurysm. Diagnosed by ultra sound. small prolong compression for 20-30 min under ultra sound guidance. large needs surgical repair. 34. Cont. Hemorrhage: Despite prolong pressure more than 30 min then use mechanical clamp or haemostatic device . Check for coagulation profile. To reverse the effect of heparin use protamine and for warfarin use factor IX concentrate. Limb Ischemia: Rare but usually occurs in patients with significant peripheral vascular disease. Check for the peripheral pedal pulses before and after angiogram for comparison. 35. Cont Contrast & Protamine reaction: Mild reaction: UrticariaI, mild fever and rigors- I/V or oral chlorpheniramine 10mg. Loin pain due to protamine : I/V hydrocortisone (100-200 mg) I/V chlorpheniramine (10mg) Opiate analgesia Anaphylaxis: I/V hydrocortisone 200mg, I/V chlorpheniramine 10 mg I/M adrenaline 0.5-1 mg Plasma expander 36. Cont Vaso-vegal reaction: The patient will develop hypotension and bradycardia . Disengage catheter Elevate patients leg I/V atropine 1 mg I/V plasma expander 200-500 ml rapidly. 37. Contrast nephropathy(CIN): Radiocontrast media can lead to a usually reversible form of acute kidney injury (formerly called ARF) that begins soon after the contrast is administered . In most cases, there are no permanent sequelae, but there is some evidence that its development is associated with adverse outcomes. Contrast-mediated nephropathy (CIN) was defined by an absolute increase of serum creatinine 0.5 mg/dL or a relative increase of 25% measured 2 to 5 days after the procedure. (AHA) 38. Prevention of CIN: American Heart Association Ascorbic acid, 3 g at least 2 hours before the procedure and 2 g in the night and the morning after the procedure. Ref: (Ascorbic Acid Prevents Contrast-Mediated Nephropathy in Patients With Renal Dysfunction Undergoing Coronary Angiography or Intervention Konstantinos Spargias, MD; Elias Alexopoulos, MD; Stamatis Kyrzopoulos, MD; Panayiotis Iacovis, MD; Darren C. Greenwood, MSc; Athanassios Manginas, MD; Vassilis Voudris, MD; Gregory Pavlides, MD; Christopher E. Buller, MD; Dimitrios Kremastinos, MD;Dennis V. Cokkinos, MD 39. Prevention of CIN: European Heart Journal Sodium chloride 0.9% 1 mL/kg/h for at least 12h prior and after the procedure Sodium bicarbonate (166 mEq/L) 3 ml/kg for 1h before and 1 ml/kg/h for 6h after the procedure. Sodium bicarbonate (166 mEq/L) 3 ml/kg over 20min before the procedure plus sodium bicarbonate orally (500 mg per 10 kg). Volume supplementation with 24 h sodium chloride 0.9% is superior to sodium bicarbonate for the prevention of CIN. A short-term regimen with sodium bicarbonate is non-inferior to a 7 h regimen. Ref: (Oxford Journals Medicine European Heart Journal Volume 33, Issue 16 Pp. 2071-2079) 40. Follow up: Check for the peripheral pulses, local temperature of the limbs and any abnormal feelings like numbness,coldness etc. Check for the body temperature. Check for the hematoma, rashes, loin pain. Ask the patient for any chest pain or discomfort. Check for the urinary out put. Advice the patient to immobilize the limb where the procedure was done for several hours. 41. References: 1) Indications for and objectives of cardiac catheterization in aortic valve disease. A D Johnson. West J Med. 1977 June; 126(6): 471473. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1237633 2) Effect of Transradial Access on Quality of Life and Cost of Cardiac Catheterization: A randomized Comparison. Christopher J. Cooper, MD, Reda A. El-Shiekh, MD, David J. Cohen, MD, MSc, Linda Blaesing, RN, Mark W. Burket, MD, Asish Basu, MD, etal. Am Heart J 138(3):430-436, 1999. 3) The effect of early education on patient anxiety while waiting for elective cardiac catheterization. Harkness K, Morrow L, Smith K, Kiczula M, Arthur HM. European journal of cardiovascular nursing: journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology 2003 July. Other Internet References1) Cardiac catheterization http://www.nlm.nih.gov/medlineplus/ency/article/003419.htm 2) Cardiac Catheterization http://www.webmd.com/heart-disease/cardiac-catheterization 3) Cardiac Catheterization http://www.cardiologychannel.com/cardiaccath/ 4) Diseases and conditions: What is diagnostic cardiac catheterization? http://mo.essortment.com/whatisdiagnost_ojn.htm 5) Cardiac Catheterization and Coronary Angiogram http://www.cpmc.org/services/cardiac/card-cath.html 6) Preparing a patient for cardiac catheterization http://findarticles.com/p/articles/mi_qa3689/ is_200209/ai_n9145642 42. Cont 7) Cardiac Catheterization http://www.childrens.com/cardiology/diagnoses/ cardiac_catheterization.cfm 8) Cardiac Catheterization http://www.merck.com/mmpe/sec07/ch070/ch070b.html 9) Cardiac Catheterization http://www.sjm.com/procedures/procedure.aspx? name=Cardiac+Catheterizationsion=Overview 10) Cardiac Catheterization And Angiography http://www.answers.com/topic/ cardiac-catheterization-and-angiography?cat=health 11) Interventional Procedures - Questions and Answers about Stents, Angioplasty and New Approaches to Treat Heart Disease May 25, 2007 http://www.clevelandclinic.org/heartcenter/pub/guide/ webchat/ellis052507.htm 12) Cardiac Catheterization FAQs http://www.hfmhealth.org/card-cath-faq.htm Read more: Cardiac Catheterization - References | Medindia http://www.medindia.net/patients/patientinfo/cardiac-catheterization-references.htm#ixzz2IJtXsuK8 13) Rudnick M, Feldman H. Contrast-induced nephropathy: what are the true clinical consequences? Clin J Am Soc Nephrol 2008; 3:263. 14). Cardiology-neil r grub and manual of cardioliovascular medicine by Brain P Griffin 43. THANK YOU SO MUCH