CORONARY ANGIOGRAPHY

DR. MIR JAMAL UDDIN

Associate Professor of Cardiology
National Institute of Cardiovascular Diseases

Indications:
a) To establish presence or absence of coronary artery stenosis. b) Define Therapeutic options. c) Determine the prognosis of patients with sign symptoms of CAD. d) To evaluate serial changes following PCI or pharmacological therapy as a research tool.

Following indications are in clinical use:

1. Asymptomatic or stable angina CCE class iii-iv on medical therapy. 2. Unstable angina 3. After ST with MI/NSTEMI 4. Post revascularisation ischemia 5. To evaluate nonspecific chest pain.

Details description: Class I

1. Asymptomatic/Stable angina CCS class iii-iv on medical therapy non invasive testing irrespective high risk criteria of angina. a) Resting or exercise induced left ventricular dysfunction (LVEF <35%). b) ETT demonstrates - Hypotension - 1/2 mm or more ST seg-depression associated with decreased exercise capacity c) Stress imaging demonstrates moderate or large perfusion defect - Multiple defects - Large fixed perfusion defect with LV dilatation - Increased lung uptake.

d) Dobutamin induced wall motion abnormality

e) Successfully resuscitated from sudden cardiac death with sustained monomorphic VT or nonsustained polymorphic VT.

Class IIa
CCS class III or iv which improves to class I or II with medical therapy Worsening non invasive testing Patients with angina & severe illness that precludes risk stratification. CCS class I or II angina with intolerance to medical therapy Individnals whose occupation affects the safety of others.

2. Unstable angina Class I:

High or intermediate risk for adverse outcome in patients refractory to medical therapy. High or intermediate risk that stabilizes after medical therapy. Initially low risk but that is high risk on non-invasive testing. Suspected prinizmetal variant angina High risk features includes. i) Prolonged ongoing (>20 minutes) chest pain ii) Pulmonary edema iii) Worsening MR iv) Dynamic ST seg. Depression 1mm v) Hypotension

Intermediate risk features

1) Angina at rest (>20 minutes) relieved with rest or sublingual GTN. 2) Angina associated with dynamic ECG change. 3) Recent onsent angina with high likelihood of CAD. 4) Pathological Q wave or ST seg. Depression <1mm.

3. After STEMI/NSTEMI Class I

Spontaneous myocardial ischemia or ischemic provoked with minimal exertion. Before surgical therapy for acute MR, VSD, True or Pseudoaneurysm. Persistent hemodynamic instability

Class IIa
Suspected MI due to coronary embolism, arteritis, trauma, certain metabolic diseases. Survivors of acute MI with LVEF <40% CHF, Prior PCI, CABG, Malignant ventricular arrhythmia.

4. Postrevascularisation ischemia Class I

Suspected abrupt closure or subacute stent thrombosis after PCI. Recurrent angina and high risk criteria on noninvasive evaluation within 9 months of PCI.

Class IIa
Recurrent symptomatic ischemia within 12 months of CABG. Non-invasive evidence of high risk criteria occuring any time after CABG. Recurrent angina inadequately controlled by medications.

5. Nonspecific chest pain Class I

High risk features on non-invasive testing

Contraindications:

No absolute contraindication Relative contraindications includes.

Unexplained fever. Untreated infections Severe anaemia with Hb<8gldi. Severe electrolyte imbalance Severe active bleeding Uncontrolled systemic HTN Digitalis toxicity Previous contrast reaction but no pretreatment with corticosteroids. Ongoing stroke Acute renal failure Decompensated CHF Severe inrinsic or iatrogenic congulopathy (INR >2.0) Active endocarditis

Complication:
1. 2. 3. 4. 5. 6. 7. 8. Vascular access site complication Myocardial infarction Cerebravascular accident Arrhythmia Contrast reaction Hemodynamic complications Perforation of heart chamber Radiodrematitis related to prolonged x-ray exposure 9. Mortality

Complications:

Vascular access site complications are classified as follows

Access site bleeding - Major bleeding - Minor bleeding less severe bleeding Retroperitoneal bleeding Psendoaneurysms Arteriovenous fistulas Arterial thrombosis Arterial dissection

Major vascular access site bleeding is defined as causing 15% hematocrit fall (or Hb 5gldl) from baseline. Minor bleeding is defined as causing as 10% drop in hematocrit Less severe vascular access site bleeding is defined as insignificant.

Retroperitoneal bleeding
inguinal ligament

Primary cause-Arterial puncture above the

Sign sumptoms Suprainguinal tenderness & fullness in 100% cases. Severe back & lower quadrant pain 64%. Femoral neuropoathy 36%

Suspicion of RPH due to Lower quadrant /flank pain Lower extremity pain Unexplained hypotension Falling hematocrit without obvious source of bleeding Diagnosis confirm by pelvic CT Management Hemodynamic stability secured - If necessary surgical repair of the culprit site.

Pseudoaneunrysm
Pseudoaneunrysm is a pulsatils hemotoma that communicates with an artery through a disruption in the arterial wall/

Cause : 1) Faulty technique involving multiple arterial puncture 2) Lower puncture site 3) Large sheath size 4) Intense anticoagulation 5) Obesity

Diagnosis-

Pulsatile mass & an audible to & fro murmur

Treatment- i) Manual compression ii) Ultrasonic compression iii) Surgical repair iv) Thrombin injection

A-V fistulas
A femoral A-V fistula is a connection between the femoral artery or its branches & the femoral vein or its branches Cause-1. Faulty arterial puncture below the femoral bifurcation which simultaneously enters the superficial femoral artery or the profunda femoral & its corresponding veins. Diagnosis-1. By clinical examination of bruit confirmed by duplex:

Treatment1) Manual compression 2) Coil embolization 3) Covered stent 4) Surgical repair is the sold stranded

Radiological views for detecting coronary artery lesions:

Left main coronary artery (LMCA) 1) AP view is the best view 2) LAO caudal 3) LAO cranial Left anterior descending coronary artery (LAD) Ostium best seen by LAO caudal view.

Proximal path RAO caudal LAO Cranial RAO cranial Mid path - LAO cranial RAO cranial AP cranial Lateral Distal path LAO cranial RAO cranial Diagnosis Ostium by RAO cranial LAO cranial

Left circumflex artery :

Ostium by LAO Caudal Proximal path RAO Caudal AP Caudal Distal path LAO caudal LAO cranial Lex PD LAO cranial view Obtuse marginals
By RAO caudal LAO caudal AP caudal

Ratnus intermediasOstium LAO caudal Rest by AP caudal RAO caudal

Right coronary artery:

Ostium LAO with or without cranial/caudal angulations Proximal path LAO cranial MID path LAO cranial - RAO or Left latsel Distal path AP cranial - LAO cranial