Coronary Angiogram : Tips and Tricks

for doing procedures

“Independently and Safely ”
Dr. Kam Tim, Chan
Queen Elizabeth Hospital
HKCC / HKPHCA
Hong Kong
July, 2018
 Conflicts of Interest

• I have NOTHING to disclose concerning this

presentation
The First Selective Coronary Angiogram

Cleveland Clinic
 Indications for Coronary Angiogram
1/ Diagnosis of CAD in clinical suspected pats

2/Peri-interventional information to PCI

3/Study Coronary anomalies

4/Exclude CAD before non-coronary cardiac surgery

e.g. Valve surgery > 40 yrs of age

5/Determine pateny of CABG

6/NSTEMI- ACS with high risk features e.g.ongoing ischemia;

High Grace Score; unstable hemodynamics

7/ STEMI – to Primary PCI

Contraindication : Coronary Angiogram
 The BASICS

• Standard VIEWS for

Coronary Angiogram
Rt System
Imaging
( OMs )
•Interpretation of
Coronary Angiogram
Coronary Angiogram- Proper Interpretation
Coronary Artery Dominance
CO- DOMINANCE
Myocardial Perfusion Score – The
BRUSH GRADE
AHA/ACC- Lesion Classification
Rentrop– Collaterals GRADING
 TIMI Grade of Collateral Filling
• TIMI Grade 1 Collaterals ( Absent )
absence of any collaterals to occluded vessel supplying the area of infarct

• TIMI Grade 2 Collaterals ( Minimal )

collaterals resulting in faint opacification to a diameter not exceeding
1 mm in occluded vessel or its branches, visualized distal to the
obstruction in occluded vessel supplying the area of infarct

• TIMI Grade 3 Collaterals ( Well Developed )

collaterals resulting in full opacification to a diameter > 1 mm in occluded
vessel or its branches, visualized distal to the obstruction in
occluded vessel suppling the area of infarction
 TIPS and Tricks for Performing
Good Coronary Angiogram

• Proper Catheters Selection for

Cannulation

• Understand the Anatomy and

Variation
Frequently used catheters for diagnostic
trans-radial coronary angiogram
More than
250
Catheters !

Understand
and Familiar
with YOUR
Workhorse
Diagnostic
catheters
NORMAL Coronary Artery
Coronary Artery OSTIUM – Anatomical Variation
Selection of Catheters

VITAL
PRINCIPLE
AORTIC WIDTH determine the CURVE
JUDKINS Catheters
LCA- HIGH Left TAKEOFF
RCA- Diagnostic Catheters Selection
Selection and Support of Guide Catheters
( More x PCI )
Support of Various Guiding Catheters
GUIDE Catheter with Extra Backup Support
Solution to Difficult RCA Cannulation
SHEPHERD’S
CROOK
HOCKEY STICK
Catheter
Techniques for Cannulating CABG Grafts
Catheters for Saphenous Vein grafts
Catheters for Saphenous Vein grafts
Techniques for Cannulating IMA Grafts
Techniques for Cannulating IMA Grafts
Techniques for Cannulating IMA Grafts
Techniques for Cannulating IMA Grafts
Understand the Vascular Access Anatomy
 Femoral
Anatomy

Fluroscopy Guided
or
USG Guided
Others :
Ulnar / Brachial
Snuffbox
Slender Club etc
Anatomical Variants – Radial Artery
Radial Artery –Anatomical Variation
(Trans-Femoral )
 Arteria Lusoria
• Most common Aortic ARCH Anomaly
• In 0.5 to 2.5%
• Aberrant Rt subclavian artery- course upwards
and to the right in posterior mediastinum
• Usually Asymptomatic
• Or dysphagia lusoria; dyspnea, chronic cough
• Treatment is indicated for symptomatic relief of
dysphagia lusoria and prevent complications
due to aneurysmal dilatation
Arteria Lusoria
Abbereant Rt
Subclavian artery

Aortic Arch

ARTERIA
LUSORIA
Myocardial Bridging
 Myocardial Bridging

Haager et al. Heart 2000;84 ;403-8

 Coronary Arterial Fistula

LAD to PA Fistula
Coronary Anomalies
LAD

LCX
Coronary Artery Aneurysms
•Prevention and
Management of
Complications due to
Coronary Angiogram
Coronary Angiogram Complications
• Death
• AMI
• Arrhythmia
• CVA
• Bleeding
• Hematoma ( Retroperitoneal )
• Vascular Injury
• Contrast induced AKI
• Allergy/ Anaphylaxis
• Pulmonary odema
• AIR/ CLOT embolism
• Vagal reaction ………………..
Coronary Angiogram- Mortality
MAJOR COMPLICATIONS
 MAJOR COMPLICATIONS

ASK FOR HELP PLEASE IF MAJOR

COMPLICATION OCCUR !!
 Potential Access Site Complications
eg . Trans-radial approach
• Radial artery occlusion
• Radial artery spasm
• Persistent post procedural pain
• Upper Limb – Loss of strength
• Haematoma
• Pseudo aneurysm/ AV Fistula
• Radial/ Brachial artery perforation
• Radial artery eversion during sheath removal
• Hand ischemia
• Compartment Syndrome
 Pre-operative Assessment
• NEVER NEVER NEVER START a Procedure
Without KNOWING the Patient
(Study the Notes ( Hx ; Relevant investigations ;
EF; Indications/ Contraindications etc )
• Proper TIME In/ Out procedures
• GOOD Planning

Though procedures may seen “ ROUTINE ” ;

There is “ NO ROUTINE ” procedures
 Practical Tips and Tricks
• Usg / Fluro guidance for vascular access
• Use of Terumo Radifocus GW to overcome
tortuosity
( CAUTION - NOT move Terumo GW within the
puncture needle  Unsheathing of polymer
coating and Embolization )
- MUST WATCH the TIP of Terumo GW
( It can go ANYWHERE !!!)
• Use 0.014/ 0.018 PCI Guidewires for difficult
crossing +/- microcatheter
• Frequent regular flushing ( 3 minutes rules )
- to Prevent Thrombus
 Heparin in Diagnostic Coronary Angiogram
• Indicated in Radial / Brachial route
• For Femoral access :
RCT compare heparin 5000u vs 2000u vs NO
heparin ( Speedy procedures < 30 mins )
 NO differences in thrombotic Cxs

NB> Extreme Caution in Difficult / Lengthy Cases

eg. CABG; Challenging anatomies; crossing AS

J. of First Military Med. University 2005, Nov; 25(11); 1429-1431. WangYQ, WongY, CaiBN, DY Jun, Y Da, Xue Bao.
Clinical analysis of 1400 cases of coronary artery angiography without heparin
MOST Important Safety Concern
 Contrast Staining at LMN ?

LMN

•Realign the Guide :

Guide Catheter – Deep seat Good Flow, No contrast
staining
POOR alignment •Patient – NO Symptoms at all
IVUS to CLARIFY

LMN INTRAMURAL
HEMATOMA
What is the Diagnosis ?

LMN
• Must Be VERY OBSESSIVE / Meticulous about Pressure
Tracing

• CAUTION : NEVER NEVER Inject WITHOUT LOOKING

AT the PRESSURE Tracing !!
 PLEASE LOOK at Pressure TRACING
- Beware of DAMPIMG or Ventricularization !!!!!
- May be Live and Death Issue

BEWARE of Massive AIR

EMBOLISM !!
- in 0.2%
- Sentinel Event
- VERY Meticulous in
Preparation of Manifold
( AIR –tight )
- Caution in Injection
( upright syringe etc )
- Attention to Contrast Bottle
- NEVER Give up in
Resuscitation
Caution with Amplatz Catheters / Guide
Caution- Amplatz Catheter Withdrawal

Catheter TIP DIVE in or hit

against inferior wall if
simple pull back
 Retroperitoneal Hematoma
• Infrequent but serious complication of Transfemoral
procedures
• Incidence of approximately 0.5%
• Mortality 4-12%
• Higher 30-day mortality in RPH after PCI
• Severe Morbidity
• Risk Factors :
low body weight, female; emergency procedure,
pre and post procedure heparin, pre-procedure
IIb/IIIa inhibitors, and HIGH Puncture above the
mid femoral head/ Inguinal ligament ; DOUBLE wall
puncture
 RPH - Clinical Features
• Presentation varies and may be vague

• Diagnosis delayed since retroperitoneum - non-compressible

area where large amount of blood accumulate rapidly without
causing obvious stigmata of underlying expanding hematoma

• No cutaneous bruising early in the course

• Common clinical features were lower abdominal pain and

fullness, back or flank pain, diaphoresis abdominal tenderness,
bradycardia, hypotension and anemia

• High Index of Suspicion Needed

 RPH- Complications

• Hypovolemic shock, need blood transfusion and increase length of

stay

• Abdominal Compartment Syndrome :

-Rare but serious complication
-often present as acute renal failure with severe abdominal pain,
distention causing respiratory distress and cardiovascular collapse
- Emergent surgical or CT-guided drainage

• Femoral neuropathy - weakness of iliopsoas (hip flexion) and quadriceps

(knee extension) muscles and dysesthesia involving anterior/medial thigh
and medial calf

• Majority resolve with conservative therapy but severe cases may

require surgical decompression
Management of Retroperitoneal Hematoma
 Contrast Induced -Acute Kidney Injury
• Contrast induced Nephropathy
• Definition : 25% increase in Serum Cr from baseline OR
0.5mg/dL ( 44umol/L ) increase in Absolute Value within
48-72 hrs after IV contrast
• Mehran Risk Score :
8 variables : Hypotension
IABP
CHF
CKD
DM
AGE> 75 yrs
Anemia
Contrast Volume
 Prevention of CIN
• Strongest predictors of CI-AKI : DM; CrCl; Contrast Volume
• ADEQUATE IV Volume Expansion / Prehydration with isotonic NaCl
or Na HCo3
• Oral N-Acetylcysteine (? Controversial Data )

Extra Caution in Impaired Renal function :

- Biplane
- Ultra-low Contrast usage ( just for Adequate opacification )
- Low or iso- osmolar contrast
- Smaller diameter catheters
- Staged procedures

* Complex CTO w Retrograde approach ( just < 10 – 15 ml contrast used !!)

( IVUS guidance; Previous Angiogram references; Co-registration etc )
Maximum Allowable Contrast Dose - MACD
• Healthy adult individuals, the maximum allowable volume of
intravenous iodine contrast is:
≤300mL (with Iodide concentration 300mg /mL)
• Patients with renal insufficiency - As low as reasonable
( ALARA ) principle
Should not exceed
440 x Bwt (kg) / creatinine (µmol/L) mL
5 x Bwt [kg] / creatinine (mg/dL) mL
( with concentration 300mg Iodine /mL )

Others :

Use Ratio of Contrast Volume/ Cr CL : ( Should be < 3 ) for PCI

procedures
- The Lower ; The Better
Ajay Kirsten; USA
Pitfalls of Coronary Angiogram
Patient of Atypical Chest pain , borderline treadmill

ANGIOGRAM : Severe Ostial LMN diseases

CABG done
No improvement of symptoms and SVG Grafts closed very quickly

IVUS – LMN : No significant plaque burden seen !! !

ONLY mild diffuse atheroma
IVUS- Severe plaque burden in LMN
EJ Topol et al. Circulation 95:92; 2333-342
Diagnostic Coronary Angiogram
 Coronary Angiogram

Use Different catheter

 Tips and Tricks For Poor Opacification
• Identify Causes
• Proper configuration catheters
• COXIAL Alignment - most important
• Huge coronaries - change catheters
( even Guide catheters )
• Proper/ Constant hand injection techniques
( FOCUS on Pressure Tracing )
• Automatic injector
• Others: IVUS ; OCT etc in special cases
 ENDING the Procedure
• Proper DISENGAGE the Catheter ; Pressure Tracing recorded

• MUST CAREFULLY REVIEW ALL Images FIRST

• DECISION MAKING --- ARE you Going to do CABG or PCI for the patient
based on these Images ???
– Quality of Images
– Lesions Severity
– Separate LMN Origin
– Anomalous origin
– Conus branches supplying collaterals to occluded vessels
– Anomaly ; AV fistula etc
– Formulate Management Plan

• Patient Counselling / Explanation / Postop Care / Report

 KNOW the Other Alternative Tests
• Anatomy : CT Coronary
MRI Heart
• Functional Tests :
Stress Echocardiography
Radioactive studies - Sestamibi; thallium
CT perfusion
MRI perfusion
Invasive FFR, iFR
 CT Coronary Angiogram
• Minimal invasive test
• Sensitivity and specificity of 95 % and 98%
respectively
• ? Take over invasive angiogram in diagnostic
situations :
- preop coronary angiogram for valve surgery
- dilated CMP
- atypical chest pain with equivocal noninvasive
tests
• New Modalities : CT-FFR ; CT Perfusion studies
 FINAL ADVICE
• Stay Foolish; Stay Hungry
- by Steve Jobbs; in 2005 -Standford University
Graduation ceremony
• Stay Happy ; Stay Humble ( by KTChan at HK )

• Being Independent Means : You are (独立)

Responsible; Accountable; Proficient; Professional;
Self- Confident; Respectable …………………
Act as a “TEAM ”- Know When to ASK x HELP
Not ACT arbitrarily !
(不是獨断獨行 !! )
Thank You very much
•ADDITIONAL SLIDES
Rotational Angiogram
C. Von
Birgelen
TCT 2009
EJ Topo; et al. Circul;ation 1995; 922333-2342
 A Word about Radiation Safety
Terms for RADAIATION MEASUREMENT
Patients Exposure in VARIOUS
Procedures
RADIATION- Deterministic and Stochastic
Effect
PRINCIPLE in RADIATION PROTECTION

ALARA
AS
CAUTION
LOW
AS
Reasonably
Achievable
 NCRP Staff Exposure Limits
(National Council of Radiation Protection- USA)
• Whole Body*
5 rem (50 mSv)/yr
• Eyes*
15 rem (150 mSv)/ yr
• Pregnant Women
50 mrem (0.5 mSv)/month
• Public
100 mrem (1.0 mSv)/yr
Cataract in eye of interventionist after
repeated use of over table x-ray tube
*ICRP movement to 20 mSv/yr
www.ircp.org
1 rem = 10 mSv (0.001 Sv)
www. SCAI.org
Measures : eg.
- use of low/ iso-osmolar contrast
- lower profile diagnostic catheters
- measures to reduce bleeding Etc
 CHOLESTEROL EMBOLI
• Cholesterol crystals from friable vascular plaques
• Distal embolization of cholesterol crystals after angiography, major
vessel surgery, or thrombolysis causes a systemic syndrome (1 )
• Diagnosis is suggested clinically :
– discoloration of extremities in a mottled purple pattern of
livedo reticularis,
OR digital cyanosis or gangrene, or neurological or renal
involvement
• Renal involvement is characteristically slowly progressing over a
two to four week period following angiography
• Diagnosis is confirmed by biopsy of affected tissues showing
deposition of cholesterol crystals
• Accompanying eosinophilia and elevated C-reactive protein are
common laboratory features
• Incidence reported in prospective studies is generally less than 2%
(2)
 Cholesterol Emboli
• Autopsy reported a much higher incidence = (25-30%)
• many of these events are asymptomatic ( 3)
• further supported by the discovery of plaque debris from > 50% of
all guiding catheters in a prospective study of 1,000 patients (4 )
• No significant difference in the risk of atheroembolism between
brachial and femoral approaches exists, suggesting that the
ascending aorta is the predominant source
• Major risk factors include advanced age, repeat procedures, diffuse
atherosclerotic disease, and elevated pre-procedure C-reactive
protein. Treatment is mostly supportive but one retrospective
study reported decreased incidence of cholesterol emboli with pre-
procedural use of simvastatin.( Woolfson & Lachmann, 1998)
• Besides statins, management with steroids and prostaglandins has
not resulted in significant benefit
1. (Keeley & Grines, 1998).
2 Fukumoto, Tsutsui, Tsuchihashi, Masumoto, & Takeshita, 2003; Saklayen, Gupta, Suryaprasad, & Azmeh, 1997)
3. (Fukumoto et al., 2003; Ramirez, O’Neill, Lambert, & Bloomer, 1978)
4. ) (Keeley & Grines, 1998).