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Unit 6 Cardiac Catheterization and Angiography

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Unit 6 Cardiac Catheterization and Angiography UNIT 6 CARDIAC CATHETERIZATION AND ANGIOGRAPHY Structure 6.0 Objectives 6.1 Introduction 6.2 Ventriculography 6.3 Aortography 6.4 Pulmonary Angiography 6.5 Intracardiac Pressures 6.6 Shunts 6.7 Coronary Angiography 6.8 Stenotic and Regurgitant Lesions 6.9 Percutaneous Interventions 6.10 Let Us Sum Up 6.11 Answers to Check Your Progress 6.0 OBJECTIVES After reading this unit, you will be able to: • enumerate the various types angiography such as coronary angiography, pulmonary angiography, ventriculography and aortography; • enlist the indicators, contraindication of various types of angiography; and • give a description of techniques of percutaneous intervention techniques. 6.1 INTRODUCTION In the previous block we have discussed about the echocardiography. Here, we shall discuss about the special investigation techniques such as cardiac catheterization and angiography. The purpose of this unit is to give you an overview and insight into the world of Cardiac Catheterization and Angiography. This write up will enable you to assess the magnitude and importance of shunt lesions as well as stenotic and regurgitant lesions. Above all, it will open up a Pandora’s Box of the ever expanding horizon of interventional cardiology including coronary interventions and valvuloplasties. 1 6.2 VENTRICULOGRAPHY Cardiac ventriculography is a diagnostic test, i.e., used to define the anatomy and function of the ventricles (left and right) and related structures. Left Ventriculography Left ventriculography is helpful in the assessment of the following parameters: 1) Segmental and global LV function 2) Mitral valve regurgitation 3) Ventricular septal defect–their presence, location and severity 4) Hypertrophic cardiomyopathy Right Ventriculography Rarely performed in adults. Useful in assessment of: 1) Segmental and global RV function 2) Assessment of RV in Congenital heart disease. Choice of Catheters for Ventriculography 1) Pigtail Catheter: This catheter developed by Judkins has end hole and side holes. The end hole permits insertion of the catheter over a J-tipped guide wire so that it can be safely advanced into the ventricle. The loop keeps the end hole away from direct contact with the endocardium. The multiple side holes permit simultaneous exit routes for the contrast and help to stabilize the catheter and prevent recoil. 2) Sones Catheter 3) NIH and Eppendorf Catheters 4) Lehman Catheter Injection Site This is best achieved by injecting directly into the ventricular chamber. Midcavitary position of the catheter ensures that there is no ventricular ectopy; sufficient contrast is delivered to chamber and apex, valve function is not interfered with and there is no endocardial staining. Injection Rate and Volume A pressure injector or flow injector can be used to deliver contrast material into the ventricle. Most laboratories follow a pressure cut-off of 1000 psi. For the pigtail and most of the other catheters, an injection rate of 10 to16 ml/sec and a volume of 30 to 55 ml is desirable. Care should be taken to avoid air embolism. Filming Projection and Technique Biplane ventriculography is preferred over single plane ventriculography because it gives more information without additional risk to the patient. Whether it is biplane or single plane ventriculography, one should use a view that gives maximum information of the area of interest with minimal overlapping of adjacent structures. For biplane ventriculography, the preferred view is 30° right anterior oblique (RAO) and 60° left anterior oblique (LAO). For single plane it is 30° RAO and 45° to 60° LAO views. For routine ventriculography, cineangiography at 30 frames/sec using a 9 inch field of view is recommended. 2 Analysis of the Ventriculogram The Ventriculogram should be assessed for: — global and regional systolic ventricular function. — degree of valvular regurgitation. — any other specific area of interest. Complications of Ventriculography Complications of Injection 1) Arrhythmias 2) Endocardial staining 3) Fascicular block 4) Embolism–Air or thrombus Alternatives to Contrast Ventriculography 1) Echocardiography 2) Magnetic Resonance Imaging 3) Electromechanical mapping 6.3 AORTOGRAPHY Visualization of the aorta and its branches is possible by several modalities today. Apart from angiography, aorta can also be visualized non-invasively by echocardiography, CT scan imaging and by MR Angiography imaging techniques. For aortography, radiographic imaging techniques are used. These techniques have evolved over the years and have reached a high level of sophistication. Further Digital Subtraction Angiography (DSA) has been added to the armamentarium to enhance the quality of images and information obtained from this procedure. Catheters and Guide Wires The commonly used guide wires vary in diameter from 0.012 to 0.052; with 0.035 or 0.038 being the most commonly used sizes. The standard length varies from 100 to 180 cm. The exchange length catheters vary from 260 to 300 cm and help to keep the wire tip in a particular position during catheter exchange. Catheter tip configurations include straight, angled or J-tip. Catheters sizes most commonly used are 5F, 6F or 7F. They may be only end-hole, end hole and side hole or only side-hole systems. Thoracic aorta visualization requires 100-120 cm length while abdominal aorta requires 60-80 cm length. Several catheters have been used for aortography, namely, straight catheter, pigtail or tennis racquet catheter, simple curved catheter and complex reverse curve catheter. The pigtail catheter is by far the most commonly used catheter. Contrast Agents Low osmolar contrast agents are preferred because of they deliver less osmotic load, cause less local pain, less intravascular volume augmentation and less allergic reactions. CO2 and Gadolinium are emerging as useful alternative contrast agents. 3 Vascular Access Femoral and brachial arteries are still the commonest routes of access for aortography. Thoracic Aorta A sound knowledge of the anatomy of the aorta is essential prior to performing aortography. The common disorders of thoracic aorta which can be diagnosed by aortography are: 1) Coarctation of aorta 2) Patent ductus arteriosus 3) Aortic aneurysms 4) Aortic dissection 5) Vasculitides–inflammatory diseases of aorta 6) Connective tissue disorders Thoracic Aortography Aortic arch angiography has been used to assess aortic valve or aortic root disease. Thoracic aortography is helpful for assessment of aneurysms, dissection, vascular rings, coarctation, patent ductus arteriosus as well as assessment of stenoses of origin of great vessels. It is also helpful in assessment of aorta after blunt or penetrating injuries to chest wall. Abdominal Aortography The abdominal aorta starts at the level of diaphragm (T12). Here too, prior to performing an abdominal aortogram, a sound knowledge of its anatomy is absolutely essential. Abdominal aortography is performed by femoral approach using a 5F, 6F or 7F pigtail or tennis racquet catheter. If femoral access is not possible, translumbar, axillary, brachial or radial approaches may be helpful. The catheter tip is kept at T12 or L1 level. About 30 to 60 ml of contrast is injected at a rate of 15 to 30ml/sec. At least two views of aorta-AP and lateral are often enough to provide necessary information. Abdominal aortography is useful in assessment of Abdominal Aortic Aneurysms (AAA), Atherosclerotic occlusive disease (ASO), Thrombotic occlusions, Leriche syndrome, Congenital coarctation syndromes, Renal artery involvement, Middle aortic syndrome (Abdominal aortic coarctation), and stenosis/occlusion of the various branches arising from abdominal aorta. Treatment options for the various disorders include: 1) Percutaneous transluminal Angioplasty 2) Surgical Bypass grafting 3) Endovascular stenting for Abdominal aortic aneurysms 6.4 PULMONARY ANGIOGRAPHY Pulmonary angiography is the angiographic opacification of the main and pulmonary artery and its branches. By radiographic techniques, it is possible to picturize up to seventh order pulmonary arteries. Newer imaging modalities like CT and MR angiography are fast emerging as superior 4 alternatives to angiography but there is a need to hold on to this modality in view of its therapeutic potential. Indications 1) Pulmonary embolism — In view of the limited ability of CT and MRA to detect sub segmental emboli, pulmonary angiography with direct super selective injections may offer better resolution. 2) Vasculitis 3) Congenital abnormalities of pulmonary arteries 4) Acquired abnormalities of pulmonary arteries 5) Tumour encasement 6) Pulmonary vascular malformation Technical Requirements Digital subtraction pulmonary angiography with selective pulmonary arterial injections is vastly superior to conventional cut film angiography in all aspects except in resolution. Contraindications Absolute: None Relative 1) Individuals with LBBB may develop complete heart block due to catheter trauma 2) Pulmonary hypertension 3) Anaphylactoid reaction to intravenous contrast 4) Patients on amiodarone Venous Access The femoral vein is the preferred venous access site. However, if there is proximal thrombus, then the alternative venous access sites are right or left internal jugular vein, right or left basilic vein in the antecubital fossa. Pulmonary Catheterization A 6F or 7F pulmonary catheter is placed over the wire in the pulmonary artery. A sidearm sheath can be left in place if it is intended to follow the study with thrombolytic therapy. The commonly used catheters for
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