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 <30 ml to prevent CIN) is injected into the catheter.
X-ray images are taken to see how the dye moves through
the artery. The dye helps highlight any blockages in blood
flow.
 The procedure may last 30 to 60 minutes.

15. Coronary Anatomy
 The left and right coronary cusp give rise to their respective
coronary arteries.
 The major epicardial vessels are the left main coronary
artery that divides into the Left anterior Descending artery
and Left Circumflex Artery, anrespective coronary arteriesd
the Right Coronary artery.

16. Dominance
 Coronary dominance is based on the vessel that gives rise to the
posterior descending artery which supplies the Atrio-ventricular
node.
 Recognized by the presence of septal perforating branches,
arises from the RCA in 80% and from the LCX in 10% of the
population.
 Co-Dominance is found in 10% of the population where the
posterior interventricular artery is formed by both the RCA and
LCx.

17. Left Main Coronary Artery (LMCA)
 The Left main coronary artery originates from the left coronary
cusp and bifurcates to give rise to the Left anterior descending
and Left Circumflex arteries.
 Long LMCA when the length is > 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 patient’s 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): 471–473. 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