Coronary anatomy: Difference between revisions

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Coronary anatomy (view source)

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Patients with older age, diabetes mellitus, chronic renal insufficiency, multivessel disease, low ejection fraction have a higher risk of complications.
Patients with older age, diabetes mellitus, chronic renal insufficiency, multivessel disease, low ejection fraction have a higher risk of complications.


=Time-out procedure=
In surgery, the use of a pre-operative checklist has improved the outcome. Implementation of a 19-item surgical safety checklist improved team communication and reduced rates of death and complications in patients undergoing noncardiac surgery<cite>Haynes</cite>. Implementation of a comprehensive preoperative checklist targeting the entire surgical pathway (including items such as medication, marking of operative side and the use of postoperatieve instructions) was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care<cite>deVries</cite>.
Although the goal of most procedures in interventional cardiology is to access the heart and its associated vasculature (making wrong site procedures less of a concern), a preprocedure checklist is also recommended in the catheterization laboratory<cite>Naidu</cite>. Information obtained preprocedural should include procedural indication, patients history, informed consent, a review of medication (in particular antiplatelet therapies and metformin) and a risk of bleeding assessment. Renal function should be less than 90 days old. If the patient is using VKA an INR is obtained < 24 preprocedural.  Images of prior catheterizations are obtained and procedural reports of any coronary or peripheral bypass surgery reviewed. The history should be reviewed for previous heparin-induced thrombocytopenia (HIT). Allergies should be checked, especially contrast allergies or allergies to medication used periprocedural (p.e. heparin). Each laboratory has a protocol for preventing contrast allergic reaction (using p.e. Prednison and an antihistaminic).
Before procedure a time-out procedure is performed by all team members before vascular access is obtained. Patient identification should be checked and confirmed and agreement on the right procedure obtained. Figure 1 shows a sample of a time-out checklist.
Figure 1
<br/>
Sample ‘‘Time Out’’ Preprocedure Checklist
The physician taking ultimate responsibility for the procedure should lead the Time Out and ensure each of the following items is announced:
#Patient’s name and medical record number
#Procedure to be performed (e.g., left heart catheterization, coronary angiography, right heart catheterization)
#Route to be used (e.g., right femoral artery)
#Confirm that the equipment needed is available or alternatives are available including intended stent type for PCI or cath-possible patients
#Patient’s allergies and premedication if appropriate (e.g., heparin-induced thrombocytopenia, contrast allergy)
#Special laboratory or medical conditions (e.g., elevated INR, chronic kidney disease)
=Vascular Access Site=
=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.
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.
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For collateral connections, it is necessary to make longer angiographic projections. In a RCA obstruction, intercoronary collaterals can form between the septal branches of the LAD and the RDP through the interventricular septum. Collaterals connecting distal portions of two arteries are frequently observed, p.e. connections between the distal RCx and RCA in the interventricular groove and between diagonal branches of the LAD. A collateral between the conus branch of the RCA to the proximal LAD is called a ring of Vieussens. Atrial branches from the RCA or the Kugel’s artery (mostly an small artery arising from proximal RCA anastomosing with branches of sinus node artery) can form connections between the proximal and distal RCA.
For collateral connections, it is necessary to make longer angiographic projections. In a RCA obstruction, intercoronary collaterals can form between the septal branches of the LAD and the RDP through the interventricular septum. Collaterals connecting distal portions of two arteries are frequently observed, p.e. connections between the distal RCx and RCA in the interventricular groove and between diagonal branches of the LAD. A collateral between the conus branch of the RCA to the proximal LAD is called a ring of Vieussens. Atrial branches from the RCA or the Kugel’s artery (mostly an small artery arising from proximal RCA anastomosing with branches of sinus node artery) can form connections between the proximal and distal RCA.
=Time-out procedure=
In surgery, the use of a pre-operative checklist has improved the outcome. Implementation of a 19-item surgical safety checklist improved team communication and reduced rates of death and complications in patients undergoing noncardiac surgery<cite>Haynes</cite>. Implementation of a comprehensive preoperative checklist targeting the entire surgical pathway (including items such as medication, marking of operative side and the use of postoperatieve instructions) was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care<cite>deVries</cite>.
Although the goal of most procedures in interventional cardiology is to access the heart and its associated vasculature (making wrong site procedures less of a concern), a preprocedure checklist is also recommended in the catheterization laboratory<cite>Naidu</cite>. Information obtained preprocedural should include procedural indication, patients history, informed consent, a review of medication (in particular antiplatelet therapies and metformin) and a risk of bleeding assessment. Renal function should be less than 90 days old. If the patient is using VKA an INR is obtained < 24 preprocedural.  Images of prior catheterizations are obtained and procedural reports of any coronary or peripheral bypass surgery reviewed. The history should be reviewed for previous heparin-induced thrombocytopenia (HIT). Allergies should be checked, especially contrast allergies or allergies to medication used periprocedural (p.e. heparin). Each laboratory has a protocol for preventing contrast allergic reaction (using p.e. Prednison and an antihistaminic).
Before procedure a time-out procedure is performed by all team members before vascular access is obtained. Patient identification should be checked and confirmed and agreement on the right procedure obtained. Figure 1 shows a sample of a time-out checklist.
Figure 1
<br/>
Sample ‘‘Time Out’’ Preprocedure Checklist
The physician taking ultimate responsibility for the procedure should lead the Time Out and ensure each of the following items is announced:
#Patient’s name and medical record number
#Procedure to be performed (e.g., left heart catheterization, coronary angiography, right heart catheterization)
#Route to be used (e.g., right femoral artery)
#Confirm that the equipment needed is available or alternatives are available including intended stent type for PCI or cath-possible patients
#Patient’s allergies and premedication if appropriate (e.g., heparin-induced thrombocytopenia, contrast allergy)
#Special laboratory or medical conditions (e.g., elevated INR, chronic kidney disease)


=Left ventriculography=
=Left ventriculography=
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