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Coronary anatomy: Difference between revisions
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It has become such a common tool in diagnosing coronary artery disease, that it is hard to understand it’s relatively short history. Radner was the first researcher in 1945 to visualize the coronary arteries in humans, through a transsternal puncture <cite>Radner</cite>. In 1958 Sones at the Cleveland Clinic succeeded in injecting small amounts of contrast material directly in the coronary arteries<cite>Sones</cite>. In the late sixties Judkins developed the percutaneous transfemoral approach and used pre-bent catheters to cannulate the coronary ostia. In the seventies Charles Dotter and Andreas Gruntzig extended the catheterization to therapeutic uses. In the nineties, vascular acces via the radial artery became a realistic alternative. | It has become such a common tool in diagnosing coronary artery disease, that it is hard to understand it’s relatively short history. Radner was the first researcher in 1945 to visualize the coronary arteries in humans, through a transsternal puncture <cite>Radner</cite>. In 1958 Sones at the Cleveland Clinic succeeded in injecting small amounts of contrast material directly in the coronary arteries<cite>Sones</cite>. In the late sixties Judkins developed the percutaneous transfemoral approach and used pre-bent catheters to cannulate the coronary ostia. In the seventies Charles Dotter and Andreas Gruntzig extended the catheterization to therapeutic uses. In the nineties, vascular acces via the radial artery became a realistic alternative. | ||
==Indications and Contra-indications== | |||
Cardiac catheterizations were performed 3 million times a year worldwide in 2010. In the Netherlands around 65.000 catheterizations are performed annually. | |||
These are the indications for cardiac catheterization: | |||
*Class I | |||
- High risk acute coronary syndrome, STEMI acute, NSTEMI within 72 hours, depending risk stratification (p.e. Grace risk score) | |||
<br/> | |||
- Angina pectoris CCS III/IV despite medical therapy with high risk of ischemia | |||
<br/> | |||
- After out-of-hospital cardiac arrest (OHCA) with VT/angina pectoris | |||
<br/> | |||
- Pre-cardiac valve surgery (male > 35 years, female > 50 years) | |||
<br/> | |||
*Class IIa | |||
- Decreased left ventricular function, stable angina pectoris CCS I-II/IV with objectified ischemia | |||
<br/> | |||
- Inconclusive or conflicting results after non-invasive stress testing | |||
<br/> | |||
*Class IIb | |||
- Angina pectoris CCS III/IV with improvement on medication | |||
<br/> | |||
*Class III | |||
- Angina pectoris CCS I/II, using medication, without objectified ischemia | |||
<br/> | |||
There are no absolute contra-indications for coronary angiography. Relative contra-indications include: | |||
*Coagulopathy | |||
*Decompensated congestive heart failure | |||
*Uncontrolled hypertension | |||
*Recent CVA | |||
*Refractory arrhytmia | |||
*Renal failure | |||
*Contrast medium allergy | |||
Although coronary angiography, when performed lege artis and for the right indication is a relatively safe procedure, complications do occur in left heart catheterization in 1-2%. Major complications are death (0.1%), myocardial ischemia (0.1%), arrhytmias (0.4%), major bleedings (0.15-2.5%), vascular complications, CVA (0.2%) and contrast reaction. | |||
Patients with older age, diabetes mellitus, chronic renal insufficiency, multivessel disease, low ejection fraction have a higher risk of complications. | |||
==Vascular Access Site== | |||
Before Judkins developed the percutaneous transfemoral approach in the late sixties, brachial arteriotomy was performed to introduce the catheter. This is seldomly used nowadays. In the majority of cases arterial catheters are introduced via the femoral artery or radial artery using the Seldinger technique. | |||
===''Technique of access: femoral artery''=== | |||
The femoral artery is located just below the inguinal ligament. For the femoral artery access, the femoral head provides the best visible landmark. Arterial puncture at this site remains below the inguinal ligament, is generally above the bifurcation of the superfical femoral and deep femoral arteries, and allows for hemostasis. In obese patients the inguinal skin crease is generally too low. | |||
After subcutaneous local anesthesia, a small incision is made and the needle held in a 45 degrees angle to puncture the front wall of the artery. When pulsating blood is obtained, the flexible tip of the guide wire is inserted and advanced in the aorta to the level of the diaphragm. The needle is removed and an introducer plus sheath is inserted<cite>Jukema2</cite>. | |||
<br/> | |||
===''Technique of access: radial artery''=== | |||
The catheter is inserted through the preferably the right radial artery which is punctured 1-2 cm proximal to the styloid process after subcutaneous local anesthesia. To prevent arterial spasm a spasmolytic coctail with nitroglycerin (200mcg) and verapamil (5mg) can be administered intravenously<cite>Jukema3</cite>. Repeated arterial trauma increases the risk for spasm. Arterial puncture can be performed with either a single anterior wall puncture or a double wall through-and-through puncture. A small calibre guidewire is inserted through the plastic cannula to facilitate sheath placement. Introducing sheaths are generally 5-French or 6-French, are hydrophilic and have a tapered tip. Catheter advancement is typically performed with a standard 0.035” J-tipped wire, gently advanced until resistance is met. Common causes of resistance are congenital anatomic variations such as the radial artery loop, tortuosity in the axillary, subclavian or inominate artery, and arterial spasm<cite>Caputo</cite>. | |||
<br/> | |||
===''Which route?''=== | |||
Complications from arterial access include arterial dissection, AV fistula formation, retroperitoneal hemorrhage and pseudoaneurysma formation. The femoral artery has traditionally been the artery of choice for procedures, but has serious limitations in patients with peripheral vascular disease or using anticoagulation. The radial artery has replaced the femoral artery approach as primary choice in most institutions in Europe. Main advantages are the less severe access site bleedings due to good hemostasis technique by p.e. the TR band, possible earlier mobilization of the patient and lower incidence of local bleeding complications. Disadvantages are the possibility of serious arterial spasm and the risk of radial artery occlusion. | |||
<br/> | |||
A randomized trial published in 2008 shower that transradial coronary angiography was safe, feasible and effective with similar results to those of the transfemoral approach. The Access trial performed by Kiemeneij et al showed similar procedural and clinical outcomes of PCI in transradial, transbrachial and transfemoral PCI. Major access site complications were lower in the transradial group, but with higher access failure (coronary cannulation) . Procedural duration and radiation exposure are higher using transradial access, but with significantly lower rate of major vascular complications . In STEMI patients, the HORIZONS-AMI trial showed that the transradial approach was associated with reduced major bleeding and improved event-free survival . | |||
== References == | == References == | ||
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#Sones pmid=13915182 | #Sones pmid=13915182 | ||
#Jukema Jukema JW, Vliegen HW, Bruschke AVG. Coronary angiography: principles, technique and interpretation. 1e druk, Leiden, the Netherlands, 2009. Chapter 1: 7 | #Jukema Jukema JW, Vliegen HW, Bruschke AVG. Coronary angiography: principles, technique and interpretation. 1e druk, Leiden, the Netherlands, 2009. Chapter 1: 7 | ||
#Jukema2 Jukema2 JW, Vliegen HW, Bruschke AVG. Coronary angiography: principles, technique and interpretation. 1e druk, Leiden, the Netherlands, 2009. Chapter 2: 10. | |||
#Jukema3 JW, Vliegen HW, Bruschke AVG. Coronary angiography: principles, technique and interpretation. 1e druk, Leiden, the Netherlands, 2009. Chapter 2: 10. | |||
#Caputo pmid=21544927 | |||
</biblio> | </biblio> | ||