coronary angiography technique in management of coronary artery disease

1. CENTER FOR PHYSIOTHERAPY AND
REHABILITATION SCIENCE
JAMIA MILLIA ISLAMIA
SUBMITTED TO: DR. JAMAL ALI MOIZ
SUBMITTED BY: FARZANA KHATOON
MPT 3RD SEM

2. coronary angiography technique
in management of coronary
artery disease

3. Coronary Angiography
• Coronary angiography remains the gold standard for
detecting clinically significant atherosclerotic
coronary artery diseas
• The technique was first performed by Dr. Mason
Sones at the Cleveland Clinic in 1958

4. • The American College of Cardiology/American Heart
Association Task Force on Assessment of
Cardiovascular Procedures was formed to make
recommendations regarding appropriate utilization of
technology in the diagnosis and treatment of patients
with cardiovascular disease.
• Coronary angiography is one such important technique.
The uses of coronary angiography have undergone an
extraordinary expansion in the recent past, in part
stimulated by the development of improved techniques
and new forms of treatment, particularly for patients
with atherosclerotic coronary heart disease.

5. • The primary purpose of coronary angiography is
to define the anatomy of the coronary arteries
when such information is needed for patient
management.
• This anatomic definition includes assessment of
the presence, extent and severity of obstructive
atherosclerotic coronary artery disease, coronary
artery size, coronary collateral flow, thrombus
formation, dynamic obstructions (coronary
spasm) or congenital coronary artery anomalies.

6. • Coronary angiography is used not only in diagnosis but also to
assess the appropriateness and feasibility of various forms of
therapy aimed directly at the coronary arteries, such as
percutaneous coronary angioplasty, coronary artery bypass
surgery, thrombolysis or treatments designed to cause
regression of atherosclerosis.
• Information provided by coronary angiography is useful for
assessing the results of therapy and in helping to formulate
prognosis in patients with coronary artery disease.
• It should be emphasized that coronary angiography does not
provide direct information about the patient's functional
capacity and symptoms or the functional significance of a
given coronary lesion.

7. Coronary artery anatomy
• The left and right coronary arteries (LCA, RCA) arise from
the anterior aortic root.
• The LCA divides into the left anterior descending (LAD)
and left circumflex (LCX) arteries.
• The LAD gives rise to two 'diagonal' branches. The left
(obtuse) marginal artery arises from the LCX at the
posterior interventricular sulcus.
• The RCA gives off a right marginal artery branch and in
70% of people supplies the posterior descending artery
(PDA). The LCA supplies mainly the left side of the heart.
The RCA supplies the right heart, 20-30% of the left
ventricle (LV) and in the majority of people the sinoatrial
and atrioventricular nodes.

9. Classification of Applications of
Coronary Angiography
• Class I: Conditions for which there is general
agreement that coronary angiography is justified. A
Class I indication should not be taken to mean that
coronary angiography is the only acceptable diagnostic
procedure.
• Class II: Conditions for which coronary angiography is
frequently performed, but there is a divergence of
opinion with respect to its justification in terms of value
and appropriateness.
• Class III: Conditions for which there is general
agreement that coronary angiography is not ordinarily
justified.

10. What is a cardiac catheterization
• Coronary artery disease is the narrowing or blockage
of the coronary (heart) arteries, After an
interventional procedure, the coronary artery is
opened, increasing blood flow to the heart.
• Cardiac catheterization (also called cardiac cath or
coronary angiogram) is an invasive imaging
procedure that to evaluate heart function

11. • Cardiac catheterization is used to:
• Evaluate or conform the presence of coronary artery
disease, valve disease or disease of the aorta
• Evaluate heart muscle function
• Determine the need for further treatment (such as an
interventional procedure or coronary artery bypass
graft, or CABG, surgery)

12. • During a cardiac catheterization, a long, narrow tube
called a catheter is inserted through a plastic
introducer sheath (a short, hollow tube that is inserted
into a blood vessel in your arm or leg).
• The catheter is guided through the blood vessel to the
coronary arteries with the aid of a special x-ray
machine

13. • Contrast material is injected through the catheter and
x-ray movies are created as the contrast material
moves through the heart’s chambers, valves and
major vessels. This part of the procedure is called a
coronary angiogram (or coronary angiography)
• The digital photographs of the contrast material are
used to identify the site of the narrowing or blockage
in the coronary artery

14. • Additional imaging procedures called intra-vascular
ultrasound (IVUS) and fractional flow reserve (FFR),
may be performed along with cardiac catheterization
in some cases to obtain detailed images of the walls
of the blood vessels.

15. • With IVUS a miniature sound-probe (transducer) is
positioned on the tip of a coronary catheter. The
catheter is threaded through the coronary arteries and,
using high-frequency sound waves produces detailed
images of the inside walls of the arteries. IVUS
produces an accurate picture of the location and
extent of plaque.
• With FFR a special wire is threaded through the
artery and a vasodilator medication is given. This test
is functionally performing a very high quality stress
test for a short segment of the artery.

16. What is an interventional procedure
• An interventional procedure is a non-surgical
treatment used to open narrowed coronary arteries to
improve blood ow to the heart.
• An interventional procedure can be performed during
a diagnostic cardiac catheterization when a blockage
is identied, or it may be scheduled after a
catheterization has conrmed the presence of coronary
artery disease

17. • An interventional procedure starts out the same way
as a cardiac catheterization. Once the catheter is in
place, one of these interventional procedures is
performed to open the artery: balloon angioplasty,
stent placement, rotablation or cutting balloon.

18. Balloon angioplasty with stenting:
• In most cases, balloon angioplasty is performed in
combination with the stenting procedure.
• A stent is a small, metal mesh tube that acts as a
scaffold to provide support inside the coronary artery. A
balloon catheter placed over a guide wire is used to
insert the stent into the narrowed artery.
• Once in place, the balloon is inated and the stent
expands to the size of the artery and holds it open.
• The balloon is deated and removed, and the stent stays
in place permanently. During a period of several weeks,
the artery heals around the stent. In this way, restenosis
is somewhat diminished

19. • Angioplasty with stenting is most commonly
recommended for patients who have a blockage in
one or two coronary arteries. If there are blockages in
more than two coronary arteries, coronary artery
bypass graft surgery may be recommended

20. Balloon angioplasty:
• A procedure in which a small balloon at the tip of the
catheter is inserted near the blocked or narrowed area
of the coronary artery.
• The technical name for balloon angioplasty is
percutaneous transluminal coronary angioplasty
(PTCA) or percutaneous coronary intervention (PCI).
• When the balloon is inated, the fatty plaque or blockage
is compressed against the artery walls and the diameter
of the blood vessel is widened (dilated) to increase
blood ow to the heart. This procedure is sometimes
complicated by vessel recoil and restenosis.

21. Goals
• To visualize coronary arteries, branches, collaterals
and anomalies
• Precise localization relative to major and minor side
branches, thrombi and areas of calcification
• To visualize vessel bifurcations, origin of side
branches and specific lesion characteristics (length,
eccentricity, calcium etc)

22. INDICATION
• Diagnosis of CAD in clinically suspected pts.
• Providing peri-interventional information for
percutaneous coronary intervention
• Coronary anomalies
• To exclude stenoses before non-coronary cardiac
surgery (valve surgery after 40 yrs of age)
• Determine patency of coronary artery bypass graft

23. • In patients with non–ST-segment elevation acute
coronary syndromes with high-risk features (e.g.,
ongoing ischemia, heart failure)
• In patients with acute ST-segment elevation
myocardial infarction (STEMI)
• Primary percutaneous intervention (PCI) is usually
performed in the same procedure, immediately after
the diagnostic procedure

24. CONTRAINDICATIONS
• Coagulopathy
• Decompensate congestive heart failure
• Uncontrolled Hypertension
• CVA
• GI Hemorrhage
• Pregnancy
• Inability for patient cooperation
• Active infection
• Renal Failure
• Contrast medium allergy

25. Before the Procedure
• After patient is properly identified, the procedure
must be explained before consent can be signed
• Baseline vital signs will be done and as long as these
are within the doctor’s interest, can proceed with the
procedure
• Blood tests must be done including BUN, creatnine,
PTT, INR, insulin/sugar levels

26. Procedure
Arterial Puncture
• Access is easiest from right side of patient due to
aortic bend
• Puncture is generally done via the femoral artery
• Alternative sites include the radial and brachial
arteries of the arm

27. • After numbing the groin area, the femoral artery is
palpated and a needle is inserted in that direction
• When blood comes out of needle, the artery has been
accessed
• A small, flexible guidewire is then inserted into the
lumen of the needle
• The needle can then be removed but the wire must
maintain position

28. • After removing the needle, a flexible plastic tube can
be placed over the wire and introduced into the artery.
This is called a oneway sheath (allows insertion of
catheters and wires without blood escaping)
• The catheter is then inserted over the guidewire but
through the sheet and advanced into placement to the
aorta.
• MC Catheter used is Judkins.

29. • Movement of catheter is monitored under fluoroscopy
with the cardiologist manipulating its movements
• The fluoroscopic machine is manipulated by a
qualified, scrubbed in, radiologic technologist
• When catheter is in place, wire can be removed and
contrast administered