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A
Arterial and Venous Access
B
Figure 2-22 A, Positioning an obese patient (weighing more than 220 kg)
on a stretcher with the chest and arm on the x-ray table and the body perpendicular to the table. B, Closer view of positioning.
5. Place a pillow under the patient’s head and extend the right arm
90 degrees outward so that the wrist falls approximately where the
groin would normally be.
6. Use sterile drapes to cover both the patient and the wrist to be used
for access.
There are a few ideas to keep in mind when performing this
special procedure. Extra staff will be required because personnel will
be necessary to help move the stretcher during panning. The smoothest way to communicate during panning is to use directional commands (i.e., north, south, east, and west) to ensure that both the
physician and the driver of the stretcher can see the image so that the
path of the coronaries can be panned. If possible, rotate the image
intensifier one-quarter turn so that the images appear on the screen
as they do in a normal catheterization. If one cannot rotate the image
intensifier, a good image will still be obtained if the images are just
rotated. According to how the patient is lying on the table, the camera
angles will be different. RAO cranial becomes LAO cranial, RAO
caudal becomes RAO cranial, and so on.
Using this procedure, the patients and staff are exposed to less
radiation and are more comfortable. It allows for better access and
support of the patient in the event of CPR and makes it possible to
increase the maximum patient weight from 220 to 440 kg. With this
modified method of patient placement on the procedure table, patients
can safely and more effectively be evaluated for coronary artery
disease.
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Arterial and Venous Access 95
C
D
Figure 2-22, cont’d
artery access.
Equipment Used for Access
A variety of needles, guidewires, vessel dilators, and introducer
sheaths are available for use in obtaining vascular access. Because the
components necessary for access come in many different sizes, staff
members must be knowledgeable regarding compatibility of the different components. Certain needles accept only certain sized guidewires. The same is true for compatibility among wires, catheters, and
introducer sheaths. Component package inserts contain information
regarding size and component compatibility. The catheterization team
members should understand the anatomy of the vascular system for
access and catheter placement depending on the clinical presentation
when the patient needs a right-sided, left-sided, or combined right- and
left-sided heart catheterization procedure (see Chapter 4).
Postprocedure Assessment
Prior to arriving in recovery, it is important that the nurse taking the
patient understands what happened during the procedure. He or she
C and D, Two-component needle and sheath for radial
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Arterial and Venous Access
should know what procedure was performed, access used, and drugs
given, and whether there were any complications during the procedure. In addition, knowing the patient’s mental status and vital signs
during the procedure will help in determining if anything has changed
once in recovery.
If radial access was used, the patient should arrive in recovery
with a hemostatic wristband in place. One of the first important steps,
after establishing that the patient is hemodynamically stable, is assessing for patent hemostasis. With the device on the wrist and the pulse
oximetry with plethysmography on the ipsilateral thumb, the nurse
occludes the ulnar artery to determine the Barbeau type. If it is a
Barbeau D, the nurse attempts to let some air out while maintaining
hemostasis. If unsuccessful, another attempt should be made in 15
minutes and every 15 minutes thereafter until there is a Barbeau A, B,
or C, indicating that patent hemostasis has been achieved. Once patent
hemostasis is achieved, it should be confirmed once an hour. If the
nurse is unsuccessful in achieving patent hemostasis by the time the
device is to be removed, the physician should be notified.
Protocols vary, but patients who have had a radial procedure can
be immediately ambulatory as long as they are safe to do so from a
hemodynamic and neurologic (sedation) perspective. In labs that are
accustomed to femoral access, it can be a challenging mental transition for the recovery personnel to move from patients on strict bed
rest to up ad lib. Still, this is one of the benefits of the radial procedure,
and adjusting to the new paradigm is more than worth the effort. There
is a significant reduction in the nursing load when patients can sit up
to engage in activities and ambulate to the restroom on their own. In
addition, one of the main complaints from patients with regard to their
cardiac catheterization is not the procedure itself, but the time afterward, when they have to lie flat for hours and have someone pushing
on their groin. Walking early after the procedure increases patient
satisfaction and also hastens recovery, so that patients leave the hospital sooner. This, in turn, has been shown to reduce medical costs.
Safe and effective vascular access and hemostasis are key components to an overall successful cardiac catheterization procedure.
Key steps must be followed throughout the entire process, from preprocedure to recovery, to make this happen, and it clearly takes the
cooperative effort of the whole team. In addition, as new techniques
continue to be introduced, such as radial and large-bore access, the
entire catheterization laboratory must have a method of quickly educating the staff and seamlessly adapting to change.
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Arterial and Venous Access 97
To view Videos 2-1, 2-2, and 2-3, please activate your book on
www.ExpertConsult.Inkling.com using the pincode
on the inside front cover.
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For more information, see Videos 2-1, 2-2, and 2-3.
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Coronary Angiography
and Ventriculography
MORTON J. KERN • ANDREW J. KLEIN •
PRANAV M. PATEL
The leading cause of death worldwide is coronary artery disease
(CAD), and the gold standard for the diagnosis of CAD is catheterbased coronary angiography. The risks and limitations of this technique must be noted, requiring the angiographer to be ever-vigilant.
From preprocedure assessment to the acquisition of images to the
postprocedural follow-up, care must be taken at each step to maximize high-quality data collection with minimal patient risk and discomfort. Angiographic data derived from coronary, ventricular, and
peripheral vascular imaging are the most significant products of
cardiac catheterization, and these assessments often yield the most
critical information for patients with cardiac disease.
Optimal angiographic imaging is the result of a series of linked
steps. Failure of any link breaks the “imaging chain” and may cause
loss of all or part of the data. The chain begins with positioning the
patient on the table, followed by vascular access, catheter placement,
correct imaging views, contrast injection for acquisition of the images,
display of the images for review, and finally the analysis and archiving
of the digital images. The major causes of poor angiograms include
factors specific to the patient (size, hardware), angiographic technique, equipment-related problems, and optical and digital imaging
system issues (Box 3-1).
Indications
All catheterization laboratory personnel should recognize the importance of preprocedure assessment and be aware of indications for
why the patient is having the procedure performed. As a measure of
quality within the laboratory, appropriate documentation should be
provided for each patient to describe the indications for the procedure
and, ideally, the operator should reference the indication category
from the American College of Cardiology/Society for Cardiovascular
Angiography and Interventions (ACC/SCAI) appropriate use criteria
(AUC) document. In this way, patient indications that fall in the uncertain (U) or inappropriate (I) categories can be addressed before
the procedure occurs—because these categories do not address all
individual patient level decision making. Thus, it is important to be
familiar with the AUC document. Furthermore, the SCAI has developed an application that can be downloaded to smartphones and,
after answering a few short questions, can display the indication category for any individual patient (available through the SCAI website,
www.scai.org).
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Box 3-1 Causes of Poor Angiograms
Patient Factors
• Size
• Movement
• Hardware (pacemaker, Harrison rods, multiple surgery with clips, silicone
prosthesis)
• Anatomic conditions (scoliosis, scarred lungs, large heart [fluid])
Angiographer Factors
• Poor catheter seating (wrong catheter shape or size, anomalous origin,
subselective cannulation)
• Poor contrast opacification (weak injection, volume too small, diluted
contrast material)
Equipment Factors
• X-ray generator problems (high heat, quantum mottle, too high
kilovolt age, too short or too long pulse width)
• X-ray tube problems (anode pitting, wrong focal spot, beam geometr y,
proximity to image intensifier, poor collimation)
• Digital imaging program malf unction
Patient Preparation for
Coronary Angiography
Before proceeding with cardiac catheterization, informed consent
must be obtained from all patients and/or family. It is critical to confirm
this documentation prior to the procedure and/or the administration
of conscious sedation to ensure that the correct forms/documents/
procedures are in concordance with the planned procedure and hospital policies.
Medications that are part of a catheterization laboratory routine
for CAD evaluations include administration of aspirin 325 mg prior to
cardiac catheterization. Other drugs for the patient’s clinical conditions are also continued unless they might interfere with the technique
of the procedure (i.e., continuation of warfarin [Coumadin]). The
administration of other antiplatelet medications including clopidogrel,
prasugrel, or ticagrelor before the ascertainment of coronary anatomy
is to be guided by individual laboratory protocols.
Coronary Angiography
The goal of coronary angiography is to visualize the coronary arteries,
branches, collaterals, and anomalies with enough detail to make a
precise diagnosis and plan for the treatment of CAD. With percutaneous coronar y interventions (PCIs; e.g., stents), the coronar y angiographer must demonstrate the precise location of disease relative to
major and minor side branches and the associated vascular anomalies, such as thrombi, calcifications, or aneurysms. For the performance of PCI, visualization of vessel bifurcations, vessel tortuosity,
origin of side branches, the portion of the vessel proximal to a significant lesion, and specific lesion characteristics (e.g., length, eccentricity and calcium) is crucial. In the case of a total vessel occlusion (also
called chronic total occlusion [CTO]), the distal vessel should be visual-
ized as clearly as possible by opacifying the contralateral coronary
artery and collateral vessel pathways. CTO angiograms require
extended cineangiographic imaging runs that are long enough to visualize late collateral vessel filling with appropriate panning across the
heart. The features of the proximal segment, the distal cap, and length
of the occluded segment help determine the suitability for CTO revascularization strategy.
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The routine coronary angiographic views should visualize the
origin and course of the three major vessels and their branches in at
least two different planes. Because coronary anatomy varies widely,
appropriately angiographic projections must be modified for each
patient.
The choice of catheters for coronary angiography depends on
the approach (radial or femoral access) and physician preferences.
Regardless of approach, the angiographic catheter is advanced over a
J-wire to the aortic root under fluoroscopic guidance. Engagement of
the left main coronary artery (LMCA) can be performed in anteriorposterior (AP) or left anterior oblique (LAO), whereas engagement of
the right coronary artery (RCA) is performed in LAO. Regardless of the
catheter or the artery, coaxial alignment of the catheter with the artery
should be obtained by subtle movement of the catheter while carefully
observing the catheter tip pressure waveform on the hemodynamic
monitor. Before contrast injection through the catheter, operators must
pay careful attention to the invasive pressure waveform either as
dampening or showing ventricularization, which may indicate that the
catheter is into a small side branch (e.g., conus) or up against a plaque
or left main (LM) roof where injection might lead to ventricular fibrillation and/or dissection. Care also must be taken to notice “deep
seating” of the catheter, which may lead an operator to miss an ostial
lesion beyond which the catheter has moved. During contrast injection into the coronary tree, the operator should note an adequate
reflux of contrast back into the aorta to ensure that an ostial lesion
is not present. It is routine in many laboratories to administer intracoronary nitroglycerin to combat catheter-induced spasm that can
mimic stenosis. Catheter-induced spasm is typically more common in
the RCA.
For all catheterization laboratories, the x-ray source is under the
table, and the image intensifier (II) is directly above the patient. The
source and II (also known as a flat-panel detector in fully digital laboratories) move in opposite directions in an imaginary circle around
the patient who is positioned in the center. The body surface of the
patient facing the observer determines the specific view. This relationship holds true regardless of whether the patient is supine, standing,
or rotated (Fig. 3-1).
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Coronary Angiography and Ventriculography 101
Angiographic Nomenclature
AP position: The II is directly over the patient with the beam traveling
perpendicularly back to front (i.e., from posterior to anterior) to the
patient lying flat on the x-ray table.
RAO position: The II is on the right side of the patient. A, Anterior; O,
oblique.
LAO position: The II is on the left side of the patient.
Note: Think of the oblique view as turning the left or right shoulder
forward (anterior) to the camera (II).
Cranial: The II is tilted toward the head of the patient.
Caudal: The II is tilted toward the feet of the patient.
Angiographic Projections Made
Simple: An Easy Way to
Understand Oblique Views
Trainees in the catheterization laboratory need to understand coronary angiograms and how the arteries change position with specific
angulations. The following section illustrates how the heart and
the coronary arteries move in the different projections. The changing
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Anterior
view
Posterior
view
Right left
lateral
Left anterior
oblique
Right anterior
oblique
A
P
L
LAO
RAO
A
Caudo-cranial
CRANIAL
Cranio-caudal
B
Figure 3 -1 Nomenclature for radiographic projections. Small black arrows,
Directions of the x-ray beam. A, Anterior, posterior, lateral, and oblique.
B, If the intensifier is tilted toward the feet of the patient, a caudal view is
produced. If the intensifier is tilted toward the head of the patient, a cranial
view is produced.
CAUDAL
positions can be easily remembered by using the left hand as a representation of the coronary tree as it sits over the heart and changes
position with different angulations as the right or left shoulder is
rotated toward the II to duplicate LAO and RAO views.
The Cardiac Silhouette in Left Anterior
Oblique and Right Anterior Oblique
The heart is the size of one’s fist (Fig. 3-2) and is shaped like an ice
cream cone, with the tip toward the sternum. The open hand is positioned as it would be seen in an AP projection. When the left shoulder
is moved forward (LAO projection), the hand is seen more on end;
that is, the heart is made shorter and rounder in the LAO (Fig. 3-3, A).
When the right shoulder is moved forward (RAO projection), the hand
is seen in profile; that is, the heart is made longer with the tip extending to the left chest wall. These two movements of the hand in the
LAO and RAO remind you how the heart should look in each
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