What Is a Femoral Angiogram?

In 1959, when the pediatrician Sones of Cleveland Medical Center performed cardiac angiography for a patient with aortic lesions, he used a special head-shaped curved angiographic catheter to mistakenly retrograde the brachial artery into the aortic root, and the catheter The distal ends were placed at the left and right coronary arteries, respectively, and about 30 ml of contrast agent was directly injected into the left and right coronary arteries to make them clear. Surprisingly, the patient did not develop ventricular fibrillation as expected because Prior to this, the medical community generally believed that the injection of contrast agents into the coronary arteries was very dangerous (causing ventricular fibrillation), and thus initiated selective coronary angiography. In 1964, Sones completed the first coronary angiography via brachial incision. In 1967, Judkins used the femoral artery puncture method for selective coronary angiography, which further perfected this technique and widely applied it ^[1] .

Yuan Jinqing	(Chief physician)	Coronary Heart Disease Diagnosis and Treatment Center of Fuwai Cardiovascular Hospital
Chen Yan	(Chief physician)	Coronary Heart Disease Diagnosis and Treatment Center of Fuwai Cardiovascular Hospital
Tan Xiaoyan	(Deputy Chief Physician)	Coronary Heart Disease Diagnosis and Treatment Center of Fuwai Cardiovascular Hospital

Coronary angiography is a commonly used and effective method for the diagnosis of coronary atherosclerotic heart disease (coronary heart disease). It is a relatively safe and reliable invasive diagnostic technique. It has been widely used in clinical practice and is considered as a diagnostic coronary artery. The "gold standard" of heart disease.

Introduction to coronary angiography

Coronary angiography is currently a common and effective method for the diagnosis of coronary atherosclerotic heart disease (coronary heart disease). Selective coronary angiography uses an angiography machine (Figure 1) to percutaneously puncture the femoral artery of the lower limb through a specially designed cardiac catheter, retrograde along the descending aorta to the root of the ascending aorta, and then explore the left or right coronary artery for insertion , Inject contrast medium to make the coronary arteries develop (Figure 2, Figure 3). In this way, the entire left or right coronary artery and its branches can be clearly displayed, and the presence of stenotic lesions in the blood vessels can be understood, and the location, extent, severity, and condition of the blood vessel wall can be clearly diagnosed. Deciding on a treatment plan (interventional, surgical, or medical treatment) can also be used to judge efficacy. This is a relatively safe and reliable invasive diagnostic technology, which has been widely used in clinical practice and is considered to be the "gold standard" for the diagnosis of coronary heart disease. However, in recent years, intra-coronary ultrasound imaging (IVUS) and optical interference tomography (OCT) have gradually been used in clinical applications. It has been found that in some coronary angiography, there are intimal thickening or plaque in normal vascular segments, but Because IVUS and other inspections are more expensive and the operation is more complicated, they are not routine inspection methods.

Introduction to coronary angiography (3 photos)

Coronary angiography is a very safe surgical method. It currently ranks first in the United States in terms of surgical volume, with an average surgical mortality rate of less than 0.1%.

Coronary Angiography Normal Anatomy of Coronary Artery

The coronary arteries run on the surface of the heart and are distributed around the heart. The three-dimensional shape resembles a tree. There are many branches of different sizes, but there are large individual differences and different walking directions. There are two main branches of normal coronary arteries, namely left coronary arteries and right coronary arteries. The left main coronary artery (LM) originates from the left coronary sinus in the left posterior of the ascending aorta. ) And the left circumflex branch (LCX), and may also issue an intermediate branch between the two. The anterior descending branch usually supplies part of the left ventricle, the anterior wall of the right ventricle, and 2/3 of the anterior ventricular septum, and its branches are issued in three directions, namely the diagonal branch (D), the right ventricular anterior branch, and the ventricular septal branch. The left circumflex branch mainly supplies a part of the left atrium wall, the left ventricular lateral wall, and the left ventricular anterior and posterior walls. The main branch has a blunt margin branch (OM). The right coronary artery (RCA) opens in the right coronary sinus, just to the right of the ascending aorta, and supplies most of the myocardium in the right atrium, the anterior wall of the right ventricle, and the plantar surface of the heart. The main branches are posterior descending branch (PD), left ventricular posterior branch (PL), etc. (Figure 4, Figure 5).

Coronary artery anatomy (2 photos)

Indications for coronary angiography

The main role of coronary angiography is to evaluate the course, number and deformity of coronary arteries; to evaluate the presence, severity and extent of coronary artery disease; to evaluate changes in coronary artery function, including coronary spasm and collaterals The presence or absence of circulation; at the same time, left heart function evaluation can be taken into account. On this basis, interventional therapy can be performed according to the degree and scope of coronary artery disease; the effect of coronary artery bypass grafting and interventional therapy can be evaluated; and long-term follow-up and prognostic evaluation can be performed ^[2] .

The main purpose of coronary angiography is diagnosis:

Unexplained chest pain, non-invasive examination can not confirm the diagnosis, clinical suspicion of coronary heart disease.

Arrhythmias of unknown cause, such as stubborn ventricular arrhythmias or new-onset conduction blocks; coronary angiography is sometimes required to exclude coronary heart disease.

Unexplained left ventricular dysfunction is mainly seen in dilated cardiomyopathy or ischemic cardiomyopathy. Differentiation of the two often requires coronary angiography.

Recurrent angina pectoris after percutaneous coronary intervention (PCI) or coronary artery bypass grafting.

Before major surgery such as congenital heart disease and valvular disease, age> 50 years, it is easy to be associated with coronary artery deformity or atherosclerosis, and can be intervened at the same time as surgery.

Asymptomatic but suspected of having coronary heart disease, in high-risk occupations such as pilots, car drivers, police, athletes and firefighters or medical insurance needs.

The main purpose of coronary angiography is treatment:

Clinical diagnosis of coronary heart disease is clear. Coronary angiography can further clarify the scope and extent of coronary artery disease and choose a treatment plan.

Stable angina pectoris or old myocardial infarction, medical treatment is not effective, affecting learning, work and life.

Unstable angina pectoris, first take intensive treatment of internal medicine, once the condition is stable, actively perform coronary angiography; medical drug treatment is not effective, usually emergency angiography is required. For high-risk patients with unstable angina pectoris, spontaneity is predominant, accompanied by significant changes in ST segments of the electrocardiogram and angina pectoris after infarction. Coronary angiography can also be performed directly.

Acute myocardial infarction (AMI) within 6 hours of onset or persistent chest pain that persists for more than 6 hours, emergency PCI is planned; if PCI is performed unconditionally, patients with contraindications after AMI should be transferred as far as possible Conditional hospital. Patients with intravenous thrombolysis who have not reopened after AMI should seek remedial PCI in a timely manner. For patients with no complications of AMI, coronary angiography should be selected at about 1 week after infarction. Complications such as AMI with cardiogenic shock and ventricular septal perforation should be treated as early as possible with the help of auxiliary circulation. For patients with high suspicion of AMI who cannot be diagnosed, especially patients with left bundle branch block, pulmonary embolism, aortic dissection, and pericarditis, coronary angiography can be performed directly to confirm the diagnosis.

Asymptomatic coronary heart disease, coronary angiography should be performed in patients with positive exercise tests and obvious risk factors.

CT and other imaging examinations found or highly suspected that the coronary arteries were moderately narrow or had unstable plaques.

The successful resuscitation of primary cardiac arrest, the possibility of left main trunk disease or near anterior descending branch are more likely to be at high risk. Early intervention with vascular disease should be performed, and the coronary artery needs to be evaluated.

After coronary artery bypass grafting or PCI, angina pectoris relapses, and coronary artery lesions often need to be evaluated again.

Contraindications to coronary angiography

Allergic to iodine or contrast media.

Severe cardiopulmonary insufficiency, can not tolerate surgery.

Uncontrolled serious arrhythmias such as ventricular arrhythmias.

electrolyte disorders.

severe liver and kidney dysfunction.

Preoperative preparation of coronary angiography

The catheter room should be equipped with certain equipment, medicines and staff.

The patient and family members signed the informed consent to the operation.

Improve the examination of echocardiography, X-rays, biochemistry, three routines, and coagulation indicators before surgery.

Prepare skin.

Iodine allergy test.

Indwelling needle puncture and so on.

Coronary angiography

Coronary angiography usually takes the arteries of the extremities as the approach, especially the most commonly used percutaneous radial artery, but also the femoral or brachial artery.

Coronary angiography common projection position

The projection position is defined as the position of the image intensifier during coronary angiography, that is, the heart is viewed from the position of the image intensifier, instead of positioning according to the position of the X-ray beam ^[3] .

Coronary angiography Commonly used projection positions for left coronary angiography:

Commonly used projection positions for left coronary angiography (4 photos)

illustrate:

Figure 6 Right anterior oblique + foot position: observe LAD, LCX start, LCX body, OM opening and body

Figure 7 Normal position + head position: Observe the near and middle LAD, where the LAD and the diagonal branch diverge

Figure 8 Left anterior oblique + head position: observe the middle, distal and diagonal branch openings of LAD

Figure 9 Spider position: observation of LM, LAD, LCX opening lesions, LCX body, OM opening and body

Coronary angiography Common projection positions for right coronary angiography:

Commonly used projection positions for right coronary angiography (2 photos)

illustrate:

Figure 10: Left front oblique: RCA is "C" type. Observe the opening of RCA, the beginning to the descending branch.

Figure 11: Rear anterior + head position: RCA is "L" shape, observe the distal branch of RCA and its opening

Routine management after coronary angiography

Monitor patients for discomfort, pay attention to ECG and vital signs.

Make up fluid to prevent vagal reflexes, except those with poor heart function.

The iliac radial artery puncture can remove the compression bandage 4-6 hours after local compression of the puncture site after the sheath is removed. After the femoral artery approach for coronary angiography, the catheter can be immediately removed. After 20 minutes of routine compression of the puncture site, if there is no active bleeding at the puncture site, you can apply braking and pressure bandaging. After 18-24 hours, you can remove the bandage and start Degree activity. If an occluder is used, the patient can begin bed activity 6 hours after supine braking.

Pay attention to whether there is bleeding, redness and murmur at the puncture site, whether the arterial pulse of the punctured limbs, skin color, tension, temperature and activity are abnormal.

Check blood, urine routine, electrolytes, liver and kidney function, myocardial enzymes and myocardial infarction after operation or the next day.

Patients with sacroiliac femoral puncture were discharged on day 3.

Common complications after coronary angiography

Pseudoaneurysm refers to the hematoma formed by the blood flowing out of the puncture of the femoral artery and confined by the adjacent tissue. Blood can flow back and forth between the femoral artery and the tumor through this breach. The difference between a pseudoaneurysm and a true aneurysm is that the tumor wall is composed of blood clots and surrounding tissues, without the tissue structure of normal blood vessel walls. The common symptoms are local pain, sometimes severe. When the tumor is too large, it can also produce symptoms of peripheral neurovascular compression. Subcutaneous hematoma can be found on palpation, pulsation, auscultation and obvious vasoconstrictive murmur. The diagnosis depends on ultrasound Doppler. Most pseudoaneurysms with a diameter of less than 37.5px can heal by themselves without special treatment. The larger diameter can be cured by compression, thrombin injection and surgical repair in the tumor, provided that anticoagulant drugs such as heparin and low molecular weight heparin are stopped.

Iliofemoral arteriovenous fistula refers to the formation of abnormal channels between femoral arteries and veins caused by femoral artery puncture. Most femoral arteriovenous fistulas have no obvious symptoms and do not cause serious complications. Many small arteriovenous fistulas can heal by themselves. In a few cases, due to the large blood flow of arteriovenous fistula, it can lead to venous dilatation and varicose veins, or the patient has severe stenosis of the distal femoral artery. The femoral arteriovenous fistula leads to "blood stealing" and exacerbates lower limb ischemia. There was no subcutaneous hematoma on palpation, and auscultation could be heard with biphasic murmur. Femoral arteriovenous fistulas that fail to heal themselves or have serious complications can be considered for surgical treatment; or closed under pressure with ultrasound guidance.

Retroperitoneal hemorrhage refers to blood flowing through the femoral artery puncture, usually along the psoas muscle edge into the retroperitoneal space. Because the retroperitoneal space has more space, it can store a large amount of blood; retroperitoneal hematomas are hidden, and when there are obvious symptoms, such as hypotension, it usually indicates that there is severe bleeding. If the diagnosis and treatment is not timely, it will lead to Patient death is the most dangerous complication associated with the femoral artery pathway. The main symptoms and signs are anemia, hypotension, abdominal tension, and lower abdominal pain and sweating. The diagnosis depends on CT. Treatment includes the following principles: Immediately discontinue anticoagulants. Use vasoactive drugs to boost blood pressure, quickly replenish blood volume, transfusion, infusion, infusion volume and speed with the goal of continuously stabilizing blood pressure. (3) Closely monitor blood pressure and heart rate, regularly check blood images, determine whether there is continued bleeding, and give targeted treatment. Patients should be absolutely bedridden. Intervention of occlusion or surgical treatment as early as possible for patients who cannot effectively stop bleeding.

Forearm hematoma and forearm osteofascial compartment syndrome forearm hematoma are caused by rupture and bleeding in the radial artery away from the puncture point. The common reason is that it is easy to enter the radial artery branch or radial return when the ultra-sliding guide wire is pushed The artery caused its rupture and perforation; or due to radial spasm, the guide catheter was pushed accidentally and excessively when it encountered resistance, resulting in its rupture. The symptoms are mainly forearm pain and high palpation tension. Because bleeding can be limited by surrounding tissues, most forearm hematomas are self-limiting. However, if the radial artery is ruptured and perforated, and the amount of bleeding is large, it can lead to forearm osteofascial compartment syndrome, which is an extreme manifestation of forearm hematoma. The main symptoms are pain, dyskinesia, sensory disturbance, passive stretch pain, swelling of the limbs, weakened or disappeared pulsations of blood vessels, and increased pressure in the osteofascial compartment. Forearm hematoma can use elastic bandage to bandage the forearm, but pay attention to bandaging strength. Forearm osteofascial compartment syndrome should emphasize early diagnosis and early treatment. Once diagnosed, the deep fascia is opened in time (within 6 hours), and the pressure is completely reduced. The incision should be large enough to completely relieve the pressure in the osteofascial chamber. Surgery should be kept sterile to prevent infection, and any muscle necrosis should be removed together.

Hemoma of the neck and mediastinum is a unique complication of radial artery intervention. The main reason is that the guidewire is mistakenly inserted into the small branch of the carotid and thoracic artery and the distal rupture is caused. Wait. Mainly manifested as pain and hypotension in the corresponding area. If bleeding is self-limiting, the prognosis is good. If tracheal compression occurs, breathing is often difficult, and the performance is dangerous, tracheal intubation should be performed.

Vascular vagal response and treatment often occur during or after coronary angiography, when the vascular sheath is removed, the hemostasis (femoral artery) is compressed, or the puncture site is severely painful. The main manifestations are pale, sweating, dizziness or altered consciousness. In severe cases, consciousness can be lost. Some patients may feel shortness of breath, palpitations, and extreme weakness. The most important manifestations are sinus bradycardia and hypotension. Treatment measures include intravenous atropine, rapid volume expansion, and application of booster drugs such as dopamine.

Coronary artery perforation and pericardial tamponade Occasionally, a strong push of a wire under resistance causes vascular perforation to rupture, resulting in pericardial tamponade. Often manifested as: mental anxiety, more need to sit, difficulty breathing, more common in superficial, cold skin, reduced pulse pressure, decreased blood pressure, increased heart rate and so on. The diagnostic tests for acute pericardial tamponade are cardiac ultrasound and coronary angiography. Emphasize early diagnosis and early treatment. General treatment principle: Heparinization is quickly reversed, and the balloon seals the rupture of the vessel 15-20 minutes when the guide wire is in the true cavity. If pericardial tamponade occurs, pericardial puncture and drainage, anti-shock therapy or surgical intervention should be performed immediately. Anti-shock therapy includes anesthesia machine inhalation of oxygen, dopamine and other intravenous booster drugs and intravenous fluid replacement.

Implantation of important organs such as cerebral embolism and pulmonary embolism.