coronary angiography, nicvd

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CORONARY ANGIOGRAPHY DR. MIR JAMAL UDDIN  Associate Professor of Cardiology National Institute of Cardiovascular Diseases

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Page 1: 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