coronary angiography, nicvd
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7/27/2019 CORONARY ANGIOGRAPHY, NICVD
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CORONARY ANGIOGRAPHY
DR. MIR JAMAL UDDIN Associate Professor of CardiologyNational Institute of Cardiovascular Diseases
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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 followingPCI or pharmacological therapy as aresearch tool.
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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.
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Details description:
Class I
1. Asymptomatic/Stable angina CCS class iii-iv onmedical therapy non invasive testing irrespectivehigh 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 capacityc) Stress imaging demonstrates moderate or large
perfusion defect
- Multiple defects
- Large fixed perfusion defect with LV dilatation
- Increased lung uptake.
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d) Dobutamin induced wall motion abnormality
e) Successfully resuscitated from sudden cardiac death
with sustained monomorphic VT or nonsustainedpolymorphic VT.
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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 thatprecludes risk stratification.
CCS class I or II angina with intolerance to
medical therapy Individnals whose occupation affects the safety
of others.
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2. Unstable angina
Class I:
High or intermediate risk for adverse outcome inpatients refractory to medical therapy.
High or intermediate risk that stabilizes after medicaltherapy.
Initially low risk but that is high risk on non-invasivetesting.
Suspected prinizmetal variant angina
High risk features includes.
i) Prolonged ongoing (>20 minutes) chest painii) Pulmonary edema
iii) Worsening MR
iv) Dynamic ST seg. Depression 1mm
v) Hypotension
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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.
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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
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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.
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4. Postrevascularisation
ischemia
Class I Suspected abrupt closure or subacute
stent thrombosis after PCI.
Recurrent angina and high risk criteria onnoninvasive evaluation within 9 months
of PCI.
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Class IIa
Recurrent symptomatic ischemia within
12 months of CABG.
Non-invasive evidence of high riskcriteria occuring any time after CABG.
Recurrent angina inadequately controlled
by medications.
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5. Nonspecific chest pain
Class I
High risk features on non-invasive testing
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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 withcorticosteroids.
Ongoing stroke
Acute renal failure
Decompensated CHF
Severe inrinsic or iatrogenic congulopathy (INR >2.0)
Active endocarditis
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Complication:
1. Vascular access site complication
2. Myocardial infarction
3. Cerebravascular accident
4. Arrhythmia
5. Contrast reaction
6. Hemodynamic complications
7. Perforation of heart chamber 8. Radiodrematitis related to prolonged x-rayexposure
9. Mortality
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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
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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 hematocritLess severe vascular access site bleeding
is defined as insignificant.
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e roper onea ee ngPrimary cause-Arterial puncture above the
inguinal ligament
Sign sumptoms- Suprainguinal tenderness & fullness in
100% cases.
Severe back & lower quadrant pain 64%.
Femoral neuropoathy 36%
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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.
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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
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Diagnosis-Pulsatile mass & an audible to & fro
murmur Treatment- i) Manual compression
ii) Ultrasonic compression
iii) Surgical repair
iv) Thrombin injection
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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:
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Treatment-
1) Manual compression
2) Coil embolization
3) Covered stent
4) Surgical repair is the sold stranded
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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.
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Proximal path – RAO caudal
LAO Cranial
RAO cranialMid path - LAO cranial
RAO cranial
AP cranialLateral
Distal path – LAO cranial
RAO cranialDiagnosis – Ostium by RAO cranial
LAO cranial
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Left circumflex artery :
Ostium by LAO Caudal
Proximal path – RAO Caudal
AP Caudal
Distal path –
LAO caudalLAO cranial
Lex PD – LAO cranial view
Obtuse marginalsBy RAO caudal
LAO caudal
AP caudal
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Ratnus intermedias-
Ostium – LAO caudal
Rest by AP caudal
RAO caudal
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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