Prior to Gruentzig’s seminal development of balloon angioplasty, coronary arteriograms were largely used to discriminate patients with and without coronary artery disease and to select those who should be referred for coronary bypass surgery. In the modern era, the cardiac interventionalist must be supremely competent in performing, interpreting, and understanding the studies that define the coronary anatomy and cardiac function. The unique demands of decision making for interventional cardiology require a new understanding of the principles and procedures that enable percutaneous coronary revascularization to be performed. To this end, acquiring high-quality diagnostic cardiac angiographic studies is critical. This chapter will review special considerations of coronary and left ventricular angiography.

In the 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines,¹ the indications for coronary arteriography are summarized as below:

1. 
   

   Patients with stable angina or asymptomatic individuals with high-risk criteria on noninvasive testing.

   
   
2. 
   

   Patients resuscitated from sudden cardiac death or having threatening ventricular arrhythmias.

   
   
3. 
   

   Patients with unstable coronary syndromes of all varieties, including acute myocardial infarction as a preamble to primary angioplasty and those who developed complications of acute infarction.

   
   
4. 
   

   Patients with ischemia at low levels of exercise in the recovery phase of myocardial infarction.

   
   
5. 
   

   Patients with suspected or known coronary artery disease undergoing preoperative evaluation.

   
   
6. 
   

   Patients undergoing heart valve replacement or in those patients in whom there is a need to establish the etiology of congestive heart failure. Table 21-1 lists indications and contraindications for cardiac catheterization and coronary angiography.

The physician should not proceed to coronary angiography without the proper workup. The subtle clinical presentations of myocardial ischemia require diligent interpretation of the patient’s complaints. The judgment of a well-trained and knowledgeable physician skilled at taking an accurate history is critical to appropriate diagnosis and treatment. A superficial history identifying chest pain of any type is not a license to perform coronary arteriography. To establish the indications for coronary arteriography, results of the medical history, the electrocardiogram, and various other indices of myocardial ischemia are needed. Understanding the relationship of increased metabolic demands on fixed lesions and understanding the pathophysiology of acute coronary syndromes is fundamental to the practice of treating patients with ischemic heart disease. Depending on the clinical findings, stress testing during exercise or at-rest (pharmacologic) stress testing with nuclear perfusion studies or echocardiographic imaging may be needed. Interventional cardiologists should not let their skills in interpreting these studies lapse and should not simply read the reports. The location and extent of ischemic defects, as well as the level of exercise performed, are important in determining the relative benefit of revascularization.

Noninvasive diagnostic imaging of the coronary arteries with electron beam computed tomography or multi-slice computed tomography can identify the presence of coronary artery disease. The detection of a large amount of calcium in the coronary arteries in young individuals heralds the presence of atherosclerosis, but does not confirm obstructive disease. Multislice computed tomography is accurate in identifying calcification in coronary arteries, the course of vessels, and a degree of coronary obstruction. In the future, such technology may supplant diagnostic coronary arteriography; however, at this time, coronary arteriography remains the standard for selecting patients for coronary interventions and for the planning and performance of the interventional procedure.

Coronary angiography and ventriculography is accomplished by a series of linked procedures beginning with vascular access and moving to angiographic catheter passage and engagement of coronary arteries and image acquisition through appropriate imaging angulations to display the critical features of the diseased artery. With the basic information of the angiograms, the interventional procedure can proceed as detailed elsewhere. Following the intervention, vascular hemostasis is performed for the particular method through a number of vascular closure devices.

Vascular Access

Vascular access for coronary angiography is performed from either the femoral or the radial artery. In the United States, the most popular approach has been femoral access, while the radial approach is favored outside the United States. (The brachial artery should be reserved as access of last resort when the other arteries cannot be cannulated.) The radial approach has gained acceptance in the United States of late because of the increased safety associated with reduced access site bleeding.² Any debate about which vascular access is better can be summarized in one sentence: Femoral access is quicker and easier, but with more complications, while radial access is more difficult and takes more skill and time, but has fewer complications. It should be noted that neither femoral nor radial access technique can be used exclusively, due to complicated anatomy and patient-specific factors. Hence, operators are required to learn and employ both access methods. We currently recommend radial access as the default approach. The new generation of cath lab operators should be able to do procedures from both approaches with the same facility and safety.

Radial Artery Catheterization

Compared to the femoral artery, the superficial location of the radial artery permits easy access, is not located near significant veins or nerves, and enables secure control of bleeding. In patients with a normal Allen’s test confirming a patent dual blood supply to the hand, concerns about radial artery occlusion are negligible. Importantly, patient satisfaction is enhanced by the ability to sit up and walk immediately after the procedure.

Patient Selection and Use of the Allen’s Test

The Allen’s test is used to demonstrate patency of both the ulnar and radial circulation through an intact palmar arch. Most operators require a normal or near-normal test before proceeding. The Allen’s test is performed as follows: After the patient makes a fist, both the radial and ulnar arteries are occluded simultaneously. When the hand is opened, it appears blanched. Release of the ulnar artery should result in return of pink hand color within 8 to 10 seconds. Satisfactory ulnar flow can also be documented by using the pulse oximeter. The pulse wave is displayed with both arteries open. The radial artery is then compressed and the pulse wave of ulnar flow observed. The results of the oximetric Allen’s test are divided into 3 grades of wave forms during radial artery occlusion: type A, no change in pulse wave; type B, a damped but distinct pulse wave; type C, loss of phasic pulse waveform. Radial artery cannulation can proceed with either type A or B and is not recommended for type C or D (Fig. 21-1).

In addition to type C Allen’s test, we also avoid patients who have forearm dialysis A-V fistulae or in whom the radial artery may be used for coronary artery bypass graft (CABG) surgery. In patients with CABG including a left internal mammary artery (LIMA) graft, the left radial approach is usually successful.

Use of the left radial artery approach provides easier manipulation of the Judkins shapes with minimal effort. The left arm should be brought over the abdomen so that the operator can work from his or her usual position on the right of the patient. In patients of small stature (under 5’5” in height) or those with CABG with LIMA, the left radial approach is preferred.

Technique of Radial Artery Access and Catheter Selection

The patient should be well sedated and comfortably positioned with a movable arm board allowing the arm to be positioned at the patient’s hip after radial sheath placement. The radial pulse is palpated, and lidocaine is given. Using a 0.018-in micropuncture needle, the artery is entered at 30° to 45° angulation.

Both arterial and venous access for either the femoral or radial approaches may be facilitated with ultrasonic direct visualization transducers (Fig. 21-2).^3,4 Ultrasound access may be particularly valuable in patients who have altered anatomy, obesity, or scarring caused by prior surgical procedures (eg, peripheral vascular surgery, multiple prior catheterizations, or prior intraaortic balloon pumps [IABP] or support cannulas), where standard access technique may be unsuccessful.

After introducing the guide wire and sheath, a vasodilator cocktail of verapamil or other calcium channel blockers can be given, followed by heparin or bivalirudin intravenously. The arm can now be moved to patient’s side for catheter introduction.

The most common catheters selected for the radial approach are the numerous specialized ‘universal’ shapes like the Jacky, TIG or multipurpose catheter (Fig. 21-3). A decrease in catheter exchanges has been shown to decrease the incidence of upper extremity vasospasm. The standard preformed diagnostic Judkins or Amplatz catheter shapes may also be used, but require more manipulation. For selective engagement of the left coronary ostium, a Judkins left 3.5 catheter instead of the 4.0 size is typically used.

Femoral Artery Access and Catheter Selection

The femoral artery is palpated at the inguinal (groin) ligament which is often, but not always, denoted by the skin crease. Because of the uncertainty of external landmarks, a metal clamp can be laid over the proposed entry site visualizing the tip of the clamp over the medial edge of the middle of the head of the femur. The common femoral artery, between the lower edge of the inferior epigastric artery and above the bifurcation of the superficial and profunda branches, is the optimal location for introduction of the interventional sheaths and support devices (Fig. 21-4).

The importance of correct femoral puncture to avoid bleeding complications after interventional procedures in patients who are often intensely anticoagulated cannot be underestimated. The correct puncture site above the femoral bifurcation is a requirement for utilization of various arterial closure devices. A puncture site that is above the common femoral artery engenders the high risk of retroperitoneal bleeding and, in some elective procedures, may necessitate postponement of the interventional portion of the procedure to another time when better access can be achieved. The steps to introduce a femoral artery sheath are similar to those for the radial artery sheath, and are described in detail elsewhere.⁵

For the femoral procedure, the Judkins left (JL) catheter 4.0 size is the most commonly used for diagnostic studies (Fig. 21-5). In small aortic roots, a JL 3.5 catheter may be preferred, and, in very large aortic roots, it may be necessary to move to a JL 5.0 catheter. Right coronary artery cannulation is usually accomplished with the right Judkins catheter, but in cases of high origin or anomalous takeoff from the aorta, the Amplatz right catheter may be helpful. The Amplatz curve catheters are sometimes required for entry into an ectopically placed left coronary ostium and some very large aortic roots. The Amplatz left coronary catheter is helpful in intubating high and anteriorly placed right coronary ostia. Other catheters, such as the hockey stick curve, the multipurpose catheter and the Amplatz right catheter, as well as the internal mammary catheter, can sometimes be helpful in intubating right coronary arteries. Of particular help in the anteriorly placed ostium of the right coronary artery is the out-of-plane right coronary catheter (Williams catheter).

Operators should familiarize themselves with several of the unique catheters available for cases of difficult coronary arteriography. For example, there is a specially designed internal mammary artery catheter, left and right coronary bypass graft catheters, and the unique Amplatz curved catheters. The Amplatz left (AL) 2 catheter is used predominantly for the left coronary artery and the AL 1 catheter most commonly for difficult right coronary intubation.

It is uncommon to perform coronary interventions with catheter sizes smaller than 6-French (Fr). For diagnostic studies, the most commonly used catheter sizes are 6-Fr, with some operators utilizing 5-Fr and, rarely, 4-Fr catheters. The advantage of 6-Fr diagnostic catheters over the 5-Fr and 4-Fr catheters is that their shape retention and torque control is optimal. While use of smaller size catheters may reduce femoral complications, most interventions require size 6-Fr to accommodate multiple stents or non-stent devices. While it is true that femoral vascular closure devices have reduced bleeding following the interventional procedures, their particular failure mode presents a source of continued concern in some patients.

Before PCI, the angiographer should use experience and multiple angiographic projections to do the following:

1. 
   

   Establish the relationship of the coronary ostium to the aorta for guide catheter selection.

   
   
2. 
   

   Verify target vessel, pathway, and angle of entry.

   
   
3. 
   

   Separate associated side branches and degree of ostial atherosclerosis.

   
   
4. 
   

   Visualize distribution of collateral supply.

   
   
5. 
   

   Determine the true (maximally vasodilated) diameter of the coronary artery at the target site. Angiography for coronary interventions requires establishing the lesion morphology, lesion length, degree of calcification, presence of thrombus and the associated involvement of side branches, and the extent of coronary artery disease which may lead to branch closure.

The routine coronary angiographic views used for diagnostic studies are normally incorporated into the interventionalist’s training and form the basic image set used for most interventions (Table 21-2). Individualized angiography projections may be needed to visualize the origin and course of both the major and branch vessels in at least two different projections to eliminate branch overlap. Because of the wide variation in coronary anatomy, one should expect to use several modified views. The optimal projections for viewing various segments of the coronary tree are illustrated in Figures 21-6, 21-7, 21-8, 21-9.