Diagnostic Coronary and Pulmonary Angiography and Left Ventriculography
Jennifer A. Rymer
Sunil V. Rao
Richard A. Krasuski
Rajesh V. Swaminathan
INTRODUCTION
The first selective diagnostic coronary angiogram was performed by Dr. Mason Sones in 1958 while attempting to inject contrast into the ascending aorta. He inadvertently injected the right coronary artery (RCA) selectively with 30 mL of contrast media.1 Since that time, rapid developments have been made in the evolution of diagnostic coronary angiography and percutaneous coronary intervention (PCI), driven partly by catheter and stent development. This chapter outlines the indications and relative contraindications for performing diagnostic angiography, the various techniques for vascular access, and the potential complications of using these approaches. Also presented are the concepts surrounding radiation safety, including various measures of radiation dosage, and preventative measures to reduce exposure to both patient and operator. Finally, we present the most appropriate techniques to assess coronary, left ventriculography, and pulmonary artery (PA) angiography.
INDICATIONS
Before performing diagnostic coronary angiography, it is critical to determine whether the patient has an appropriate indication for the procedure.2
Suspected or Known Coronary Artery Disease
Patients with ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), unstable angina, and cardiogenic shock with suspected acute coronary syndrome meet indications for diagnostic coronary angiography. In the absence of prior history of PCI, coronary artery bypass grafting (CABG), or known lesion greater than or equal to 50%, the use of diagnostic coronary angiography is considered inappropriate in asymptomatic patients with low or intermediate global coronary artery disease (CAD) risk and in symptomatic patients with low pretest probability. In symptomatic patients with high pretest probability, proceeding to coronary angiography before noninvasive testing is generally considered an appropriate strategy. In patients with a prior history of revascularization or known obstructive coronary disease on a prior angiogram, it is appropriate to perform coronary angiography if the patient has either intermediate-risk or high-risk noninvasive findings and worsening symptoms.
Arrhythmias
In patients with cardiac arrest for whom there is return of spontaneous circulation and for patients who have ventricular fibrillation or sustained ventricular tachycardia, diagnostic coronary angiography is indicated to assess for ischemic etiologies. The results of the recent COACT (COronary Angiography after Cardiac Arrest) trial demonstrated that there was no significant difference in 90-day survival for patients who had an out-of-hospital cardiac arrest with no evidence of a STEMI with regard to an immediate versus delayed strategy for coronary angiography.3 In patients with new-onset atrial fibrillation/flutter or heart block with low- or intermediate-CAD risk, diagnostic coronary angiography is not indicated.
Valvular Heart Disease
For adult patients undergoing a preoperative assessment before valvular surgery, diagnostic coronary angiography with right heart catheterization is generally indicated. For patients with pulmonary hypertension or left ventricular (LV) dysfunction out of proportion to the severity of valvular heart disease, right heart catheterization, or diagnostic coronary angiography with right heart catheterization may be considered.
Other Indications
Right heart catheterization with or without coronary angiography/left ventriculography is often indicated in patients with newly diagnosed or suspected cardiomyopathy with or without heart failure. In situations where there has been a change in clinical status and hemodynamics are necessary, right heart catheterization is helpful. In cases of suspected constrictive or restrictive physiology, right and left heart catheterization may be necessary to assess hemodynamics.
CONTRAINDICATIONS TO CORONARY ANGIOGRAPHY
Although there are no true absolute contraindications to coronary angiography, there are multiple relative contraindications (Table 41.1).4 Among those listed here, several warrant further discussion. In patients with documented prior anaphylactic reaction to contrast media, proceeding with coronary angiography is likely safe if the patient is first premedicated with a steroid and antihistamine. A common steroid preparation
includes 50 mg of oral prednisone at 13 hours, 7 hours, and 1 hour before expected contrast media injection, in addition to 50 mg intravenous (IV) diphenhydramine 1 hour before contrast media injection. Another potential regimen includes 32 mg oral methylprednisolone 12 and 2 hours before contrast media injection, in addition to an IV antihistamine.5,6
includes 50 mg of oral prednisone at 13 hours, 7 hours, and 1 hour before expected contrast media injection, in addition to 50 mg intravenous (IV) diphenhydramine 1 hour before contrast media injection. Another potential regimen includes 32 mg oral methylprednisolone 12 and 2 hours before contrast media injection, in addition to an IV antihistamine.5,6
TABLE 41.1 Relative Contraindications to Diagnostic Coronary Angiography | ||
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In patients with acute renal failure, unless there is a compelling need for urgent or emergent coronary angiography, the procedure should be deferred until dysfunction resolves. Preprocedure hydration protocols are discussed in the section “Special Considerations.” For patients on oral anticoagulation, diagnostic angiography may be delayed depending on the degree of anticoagulation, or a radial artery approach may be pursued if urgently/emergently indicated. In emergent cases such as STEMI, relative contraindications may not be evident before the procedure. It is therefore always wise to utilize techniques that limit risks such as bleeding and acute kidney injury. Other relative contraindications do not preclude diagnostic coronary angiography, but may impact timing.
ANATOMIC CONSIDERATIONS
Femoral Artery Access
Femoral artery access is increasingly being replaced with radial artery access as operators change their practice because of patient preference and a decreased risk of bleeding. However, femoral access is still used, particularly for mechanical support devices and large-bore catheters, and in some patients, may be the only route of access. Therefore, appropriate technique is critical to avoid vascular complications and bleeding.
The external iliac artery becomes the common femoral artery (CFA) after passing under the inguinal ligament. Femoral arterial puncture should occur above the bifurcation of the CFA into the deep femoral artery (also known as the profunda femoris artery) and the superficial femoral artery (SFA), but below the inferior epigastric artery takeoff from the external iliac artery (Figure 41.1). High punctures may result in a greater risk of retroperitoneal bleed, especially if the inferior epigastric artery is punctured. Low punctures may result in pseudoaneurysms, dissection, or arteriovenous fistulae.
In most patients, the ideal puncture site lies between the superior and inferior borders of the femoral head. As such, most operators will palpate the pulse and determine where the maximal point of impulse occurs within the borders of the head of the femur using fluoroscopic guidance. Because anatomy varies between patients, ultrasound guidance can be useful to identify the CFA bifurcation, look for calcification, and assess the dimensions of the CFA (particularly helpful if large-bore access is required).
Traditionally, femoral access was obtained using the Seldinger technique, which involved a posterior wall stick and withdrawal of the access needle until pulsatile arterial flow was visualized. Because a posterior wall stick increased the risk of bleeding and access site complications, the technique has evolved such that an anterior wall stick is now the accepted manner of obtaining femoral access. After determining the ideal access site, the operator should administer local anesthetic (typically 1% lidocaine) to reduce discomfort. The anesthetic should be injected to the depth of the femoral artery. Traditionally, an 18-gauge needle is utilized to obtain access and a 0.035″ J-tip wire is then delivered through the needle into the vascular lumen. After removal of the needle, the sheath with its dilator can be delivered over the 0.035″ wire, with subsequent removal of the dilator.
Many operators now utilize a micropuncture kit (Figure 41.2) for femoral access.7 With this method, a 21-gauge needle is used to obtain arterial access, and a 0.018″ wire is advanced through the needle lumen with its position confirmed fluoroscopically. The needle is then removed, and a 4-Fr sheath with introducer is inserted over the wire. The guide wire and introducer are removed, and a 0.035″ J-tip wire is passed through the 4-Fr sheath. The 4-Fr sheath may then be removed and up-sized (typically 5 Fr or 6 Fr for diagnostic angiography) over the wire. A single-center, randomized trial of femoral micropuncture access versus standard 18-gauge access found no significant difference in vascular complications, including retroperitoneal bleeds, arteriovenous fistulae, pseudoaneurysms, and arterial perforations requiring intervention.7 This study, however, was underpowered. Nevertheless, prespecified subgroups including female patients and those with final sheath sizes less than or equal to 6 Fr showed significant or near-significant reductions in complications with micropuncture access.
There is increasing evidence to suggest that obtaining femoral access via ultrasound guidance reduces the number of access attempts and potential complications. The Femoral Arterial Access with Ultrasound Trial (FAUST) is the largest randomized trial of patients undergoing CFA cannulation via ultrasound guidance compared to fluoroscopic guidance.8 A significant improvement in first-pass success rate (83% vs. 46%, P < .0001), reduction in the number of access
attempts (1.3 vs. 3.0, P < .0001), and median time to access (136 seconds vs. 148 seconds, P = .003) was found using ultrasound. Vascular complications were also significantly reduced using ultrasound.
attempts (1.3 vs. 3.0, P < .0001), and median time to access (136 seconds vs. 148 seconds, P = .003) was found using ultrasound. Vascular complications were also significantly reduced using ultrasound.
 FIGURE 41.1 Femoral artery anatomy for cardiac catheterization access. Bony landmarks are useful for identifying the level of the common femoral artery. The inguinal ligament runs between the pubic tubercle and the anterior superior iliac spine, marking the top of the common femoral artery. High puncture or laceration of the inferior epigastric artery can lead to serious retroperitoneal bleeding. Puncture at or below the femoral bifurcation is also to be avoided. (Reprinted with permission from Rasmussen TE, Clouse WD, Tonnessen BH. Handbook of Patient Care in Vascular Diseases. 6th ed. Philadelphia, PA: Wolters Kluwer; 2018. Figure 9.1.) |
 FIGURE 41.2 Illustration depicting micropuncture needle and dilator alongside an 18-gauge needle (In descending order: Micropuncture 0.018 inch guidewire, Micropuncture needle 21 gauge, Micropuncture dilatator, Standard 18-gauge arterial needle.) |
After obtaining successful femoral access, it is important to document a femoral angiogram. For patients with significant tortuosity, a femoral and abdominal angiogram may help decide whether a longer sheath should be utilized. A femoral angiogram can also help determine whether a vascular closure device is appropriate, because it allows for an assessment of sheath insertion site, arterial size, any access site complications, and calcification. The angiogram should be performed with the 0.035″ access wire in place to prevent the distal end of the access sheath from contacting the arterial wall and causing a retrograde dissection during angiography. A femoral angiogram can also be performed via the micropuncture sheath for the purposes of documenting an appropriate entry site before insertion of a larger sheath or inserting mechanical circulatory support.
Radial Artery Access
Although the rates of adoption of radial artery access in the United States have rapidly increased over the past decade, it still lags behind many European countries.9,10 Although only 1.32% of PCI was performed radially from 2004 to 2007, use grew to 16% by 2011. Most recently, radial artery access has been estimated to account for up to 50% of coronary angiography11 and it is expected to surpass femoral access over the next decade.
The brachial artery gives rise to the radial and ulnar arteries near the antecubital fossa (Figure 41.3). Most commonly, radial artery access is obtained with an angiocatheter or Cook needle (Cook Medical LLC, Bloomington, IN) a few
centimeters proximal to the wrist. Unlike femoral access where an anterior wall stick is the optimal approach, successful radial artery access is best obtained when the traditional Seldinger technique is used, advancing the needle “through and through” and withdrawing until the arterial flash is visualized. After passing a wire through the angiocatheter lumen, a standard 5- to 7-Fr sheath is inserted over the wire. Various radial “cocktails” including calcium channel blockers or nitrates are administered through the sheath to reduce the risk of arterial spasm. Unfractionated heparin is also administered to reduce the risk of radial occlusion.
centimeters proximal to the wrist. Unlike femoral access where an anterior wall stick is the optimal approach, successful radial artery access is best obtained when the traditional Seldinger technique is used, advancing the needle “through and through” and withdrawing until the arterial flash is visualized. After passing a wire through the angiocatheter lumen, a standard 5- to 7-Fr sheath is inserted over the wire. Various radial “cocktails” including calcium channel blockers or nitrates are administered through the sheath to reduce the risk of arterial spasm. Unfractionated heparin is also administered to reduce the risk of radial occlusion.
 FIGURE 41.3 Anatomy of the anterior aspect of the forearm. Superficial layer of the forearm muscles. Note the position of the radial artery between the brachioradialis and flexor carpi radialis distally. (Reprinted with permission from Court-Brown CM, Heckman JD, McQueen MM, et al. Rockwood and Green’s Fractures in Adults. 8th ed. Philadelphia, PA: Wolters Kluwer; 2015. Figure 33.16A.) |
There are several factors to consider when utilizing radial artery access for coronary angiography. If a patient has three or more of the following criteria, left radial is preferred over right radial artery access,12,13 because it is more likely to be successful owing to lesser subclavian artery tortuosity14: age 70 years or older, female sex, height less than or equal to 64 inches, or hypertension. In patients with a prior history of CABG, left radial access is preferred because of ease of injection of the left internal mammary (IM) artery and vein grafts. In patients with a right IM graft, right radial artery access may be necessary. Although radial spasm can easily be managed with verapamil and increased sedation, it is best to inquire preprocedurally about previous prohibitive radial artery spasm and provide appropriate medications prophylactically.
As with femoral access, there is increasing evidence that ultrasound guidance is beneficial for radial artery access. In the Radial Artery access with Ultrasound Trial (RAUST), investigators randomized patients to undergo radial artery access via palpation compared to ultrasound guidance.15 Use of ultrasound resulted in fewer access attempts and the first-pass success rate was significantly improved. Radial ultrasound may also help inform whether a larger sheath size (ie, 7 Fr) is possible in certain patients depending on vessel diameter. The PRIMAFACIE-TRI (Pre-procedure ultrasound IMaging of the Arm to FACIlitatE TRansradial coronary and diagnostic Interventional procedures) study examined the use of routine preprocedural ultrasound of the arm arteries to examine arm anatomy and increase procedural success,16 and showed that procedural success using transradial or transulnar access was more likely to be successful with improved outcomes when preprocedural ultrasound was used. In some patients, examination of the arm arteries before coronary angiography will reveal a larger ulnar artery compared with the radial artery, so that transulnar access may be preferred to transradial access.
Complications of Radial Artery Access
Although bleeding complication rates are lower with radial than with femoral access, there are several potential complications of radial artery access. The primary cause of failure in
transradial coronary angiography is radial artery spasm. If the sheath diameter is greater than the diameter of the patient’s radial artery, radial artery stretch results in increasing vasomotor tone, leading to arterial spasm. Patients at higher risk of spasm include women, those with small wrist circumference, and younger age.17 If significant spasm develops, device entrapment may occur. In this case, increasing force should not be used to remove equipment because this may result in avulsion of the artery. Instead, deeper sedation, local anesthetics, and additional verapamil or nitroglycerin may aid in reducing spasm. The flow-mediated vasodilation technique may also facilitate device removal.18 In this technique, a blood pressure cuff is inflated in the upper arm to 40 mm Hg above systolic pressure for several minutes. Brisk release of the cuff results in a rapid increase in flow and vasodilation through nitric oxide release and endothelial relaxation, allowing for removal of the entrapped device.
transradial coronary angiography is radial artery spasm. If the sheath diameter is greater than the diameter of the patient’s radial artery, radial artery stretch results in increasing vasomotor tone, leading to arterial spasm. Patients at higher risk of spasm include women, those with small wrist circumference, and younger age.17 If significant spasm develops, device entrapment may occur. In this case, increasing force should not be used to remove equipment because this may result in avulsion of the artery. Instead, deeper sedation, local anesthetics, and additional verapamil or nitroglycerin may aid in reducing spasm. The flow-mediated vasodilation technique may also facilitate device removal.18 In this technique, a blood pressure cuff is inflated in the upper arm to 40 mm Hg above systolic pressure for several minutes. Brisk release of the cuff results in a rapid increase in flow and vasodilation through nitric oxide release and endothelial relaxation, allowing for removal of the entrapped device.
Radial artery occlusion is another known complication of radial access, and occurs in 1% to 10% of patients undergoing transradial coronary angiography.19 Sheath insertion can result in radial artery endothelial damage and subsequent thrombosis with arterial occlusion. Administration of 50 to 100 U/kg IV heparin once the 0.035” guidewire is successfully positioned in the ascending aorta is one strategy that significantly reduces radial artery occlusion, with evidence that high-dose heparin (100 U/kg) significantly reduces the risk compared with standard-dose heparin (50 U/kg).20,21 The risk of radial artery occlusion is also reduced with the use of patent hemostasis,22,23 as well as ipsilateral ulnar compression.24 An indication of radial artery occlusion25 may be the persistence of arm pain after the procedure, or absence of a radial pulse. However, patients may have occlusion without the loss of a radial pulse, because there may be collateral flow from the anterior interosseous artery, giving the false impression of a radial pulse. To diagnose radial artery occlusion, Doppler ultrasonography may be used, or the reverse Barbeau test, performed by occluding the ulnar artery and placing an oximeter on the ipsilateral thumb; the absence of a plethysmographic waveform indicates radial artery occlusion.
Radial artery pseudoaneurysms and arteriovenous fistulas are infrequent complications, and can usually be monitored if small and asymptomatic. Prolonged compression with a radial hemostasis device often resolves most radial artery pseudoaneurysms. If prolonged compression fails, then surgical treatment can be generally performed under local anesthesia with high success rates. A very rare complication of transradial cardiac catheterization is upper extremity compartment syndrome. In these cases, early consultation with vascular surgery is imperative.
Radial versus Femoral Artery Access
There is a large body of observational and trial data that has focused on comparing the outcomes of radial and femoral access. In patients presenting with an acute coronary syndrome, particularly in the subset presenting with STEMI, there is evidence for improved outcomes with radial access. In the RadIal Versus FemoraL RandomizED Investigation in ST-Segment Elevation Acute Coronary Syndrome (RIFLE-STEACS) study, the composite outcome of net adverse clinical events and cardiac death was reduced significantly in patients who had radial access.26 Similarly, the RIVAL (RadIal vs. FemoraL Access for Coronary Intervention) study demonstrated a significant reduction in the primary composite outcome of death, myocardial infarction, stroke and non-CABG-related major bleeding in patients with STEMI but not in patients with NSTEMI who had radial access.27 The MATRIX (Minimizing Adverse hemorrhagic events by TRansradial access site and systemic Implementation of angioX) trial, however, showed a reduction in all-cause mortality in patients with STEMI and NSTEMI who underwent radial access.28 In general, radial access should be considered for most patients requiring a diagnostic coronary angiogram, particularly in patients presenting with a STEMI after operator proficiency is attained.
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