Download Diagnostic and Therapeutic Cardiovascular Procedures

Diagnostic and Therapeutic Cardiovascular Procedures
Right Heart Catheterization, Coronary Angiography, and
Percutaneous Coronary Intervention
Sripal Bangalore, MD, MHA; Deepak L. Bhatt, MD, MPH
heparinized saline to ensure an air-free system; stopcocks
should be placed on the end of the ports. The balloon inflation
syringe should be filled with 1.5 mL of air and the balloon
inflated under saline to ensure there are no air leaks in the
balloon. The pressure monitoring system should be prepared
for use according to institutional practice to ensure an air-free
system.
The PA catheter can be inserted either under fluoroscopic
guidance (preferred) or under the guidance of the pressure
waveforms. Fluoroscopic guidance is recommended in patients with a markedly enlarged right atrium or ventricle or
severe tricuspid regurgitation or in those with left bundlebranch block. The catheter should be advanced to the vena
cava/right atrium junction (10 –15 cm from the internal
jugular vein or 25–30 cm from the femoral vein) and the
balloon inflated. The catheter is designed to be flow-directed
and will aid the flow of the catheter along the direction of
blood flow (right atrium to PA). Pressure measurements and
sampling of blood for measurement of oxygen saturation can
be performed as the catheter is advanced through the various
chambers of the heart, although it is sometimes easier to
advance distally to the PA and make measurements on the
way back out (that is, if the PA catheter is not meant to stay
in place). The sequential changes in the pressure waveform
are as shown in Figure 1. Once a pulmonary capillary wedge
pressure tracing is seen, the balloon should be deflated and
the catheter pulled back by 1 to 2 cm to remove any redundant
length or loop in the right atrium or ventricle. The tip should
be maintained in a position where full or near-full inflation
volume is necessary to produce a wedge tracing. The ideal
position of the catheter is the zone 3 region of the lung (lower
zone). For subsequent wedge tracings, the balloon should be
inflated with the minimum amount of air to produce a wedge
tracing. Excess can cause overwedging, in which the pulmonary capillary wedge pressure will be higher because of
transmittal of pressure from the balloon and with loss of
characteristic waveforms. For precautions, please refer to the
accompanying slide set in the online-only Data Supplement.
Right-Sided Heart Catheterization
Flow-directed pulmonary artery catheters, also called SwanGanz catheters after inventors Jeremy Swan and William
Ganz, were initially used to guide therapy after acute myocardial infarction,1 but are now used in a variety of settings.
There is, however, no universally accepted indication for
their use, because right-sided heart (pulmonary artery [PA])
catheterization has not been shown to improve outcome.2
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Indications and Contraindications
PA catheterization is useful in a number of diagnostic
applications. It has been used in the differentiation of various
causes of shock and pulmonary edema; the evaluation of
pulmonary hypertension; the differentiation of pericardial
tamponade from constrictive pericarditis and restrictive cardiomyopathy; the diagnosis of left-to-right intracardiac
shunts; and to guide fluid management and hemodynamic
monitoring of patients after surgery or complicated myocardial infarction and for patients in shock, heart failure, etc.
Although there is no absolute contraindication for use of
PA catheters, care should be taken in patients with severe
pulmonary hypertension and in the elderly. Fluoroscopic
guidance is recommended in patients with preexisting left
bundle-branch block, because it likely reduces the risk of
right bundle-branch damage during catheter insertion and
consequent complete heart block.
PA (Swan-Ganz) Catheter: Insertion Technique
The PA catheter can be inserted via the internal jugular vein,
subclavian vein, antecubital vein, or femoral vein. After the
site is prepped and draped, local anesthesia is administered to
the site with 5 to 10 mL of 2% lidocaine by use of a 25-gauge
needle. The vein is entered with a needle, preferably by
micropuncture and preferably under ultrasound guidance
(especially for the internal jugular vein), and an introducer
catheter is inserted by use of a standard technique. Under
sterile conditions, the PA catheter should be removed from
the packaging and the proximal and distal ports flushed with
From the New York University School of Medicine (S.B.), New York, NY, and the VA Boston Healthcare System, Brigham and Women’s Hospital,
and Harvard Medical School Boston, MA (D.L.B.).
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.
111.065219/-/DC1.
Hyperlinked to this article is a video that shows the following 3 procedures: Right-sided heart catheterization, coronary angiography, and percutaneous
coronary intervention. All 3 procedures were performed by Drs Sripal Bangalore and Deepak Bhatt at the VA Boston Healthcare System, West Roxbury Campus.
Correspondence to Deepak L. Bhatt, MD, MPH, FAHA, Chief of Cardiology, VA Boston Healthcare System, Director, Integrated Interventional
Cardiovascular Program, Brigham and Women’s Hospital and the VA Boston Healthcare System, Senior Investigator, TIMI Study Group, Associate
Professor of Medicine, Harvard Medical School, 1400 VFW Parkway, Boston, MA 02132. E-mail [email protected]
(Circulation. 2011;124:e428-e433.)
© 2011 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.111.065219
e428
Bangalore and Bhatt
Cardiac Catheterization and PCI
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Figure 1. Diagram shows sequential pressure waveforms as the pulmonary artery
catheter traverses through the various
chambers of the heart.
Pressure Recordings
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Pressure should always be recorded at end expiration (except
in patients on positive end-expiratory pressure), as under
normal conditions, pressures will be lower in inspiration
because of the decrease in intrathoracic pressure. Before any
pressure measurements are taken, it is imperative to perform
zeroing and referencing of the system. Zeroing is accomplished by opening the system to air so as to equilibrate with
atmospheric pressure and referencing by ensuring that the
air-fluid interface of the transducer is at the level of the
patient’s heart (phlebostatic axis; fourth intercostal space
midway between anterior and posterior chest wall). It is
imperative to ensure that the transducer is at the level of the
heart, because for every inch the heart is offset from the
reference point of the transducer, a 2-mm Hg degree of error
will be introduced. If the heart is lower than the transducer,
the pressure will be erroneously low, and if the heart is
higher, the pressure will be erroneously high. The dynamic
response of the pressure monitoring system should be determined by measuring the resonant frequency and the damping
coefficient of the system by use of the fast-flush test, as
described in Figure 2. Pressure wave interpretations and
differential for the common wave patterns from the right
atrial and pulmonary capillary wedge pressure tracings are
shown in Table 1.
Cardiac Output Measurement
Three indirect methods for cardiac output determinations are
(1) the dye indicator dilution technique, (2) the Fick technique, and (3) the thermodilution technique. The Fick and
thermodilution techniques are the most widely used, and the
former is considered the gold standard for cardiac output
measurement.
The Fick principle is based on the observation that the total
uptake of (or release of) oxygen by the peripheral tissues is
equal to the product of the blood flow to the peripheral tissues
and the arterial-venous concentration difference (gradient) of
oxygen. It is therefore based on measurement of the ratio of
oxygen consumption to oxygen extraction. Oxygen consumption can be measured with an oxygen hood or estimated to be
250 mL/min or 125 mL/min per square meter of body surface
area under resting conditions. Oxygen extraction is measured as the
arteriovenous oxygen difference, which is given by the following
formula: 13.4⫻hemoglobin concentration⫻(SaO2⫺SvO2). SaO2
is the arterial oxygen saturation, whereas SvO2 is the mixed
venous oxygen saturation, measured as (3⫻superior vena
cava saturation⫹inferior vena cava saturation)/4. This is most
accurate in low-output states and is considered the “gold
standard.”
In the thermodilution technique, a known amount of
solution (usually saline) is injected into the proximal port
(right atrium), where it mixes and cools the blood, which is
recorded by a thermistor located at the distal end of the
catheter. Cardiac output is inversely proportional to the area
under the curve. The thermodilution technique is not reliable
in patients with severe tricuspid or pulmonic valve regurgitation, because it results in lower peak and a prolonged
washout phase due to recirculation that results in underestimation of cardiac output. It is also not reliable in patients with
intracardiac shunts (it overestimates cardiac output).
Derived Parameters
PA catheter measurements can also be used to calculate
systemic and pulmonary vascular resistance, stroke work
index, shunt fraction, and valve area (Table 2). However, the
vascular resistance obtained is the least accurate (of the
measures obtained from the catheter) and the most sensitive
Figure 2. Fast-flush test/square-wave
testing is performed by briefly opening
and closing the valve in the continuousflush device, which produces a squareware pattern on the oscilloscope: an initial steep rise, followed by a plateau,
followed by a steep fall below baseline,
which is then followed by oscillations. The
pattern determines optimal vs suboptimal
damping.
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Circulation
Table 1.
Pressure Wave Interpretation
Wave Pattern
Cannon ‘a’
wave
Tall ‘a’ wave
October 25, 2011
Mechanism
Condition
AV dissociation
Complete heart block,
ventricular tachycardia,
AVNRT
Increased atrial pressure
Mitral or tricuspid
stenosis
Table 3. Hemodynamic Parameters That Help Differentiate
Constrictive Pericarditis From Restrictive Cardiomyopathy
Parameter
LVEDP-RVEDP, mm Hg
ⱕ50
⬎50
⬎1/3
ⱕ1/3
Atrial fibrillation
Tall ‘v’ wave
Increased volume during
ventricular systole
Mitral or tricuspid
insufficiency, VSD
RV/LV pressure
waveform
Loss of ‘y’
descent
Equalization of diastolic
pressures
Cardiac tamponade
RA pressure waveform
Rapid diastolic filling
Constrictive pericarditis
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to minor inaccuracies in data acquisition. Hemodynamic
parameters that help differentiate constrictive pericarditis
from restrictive cardiomyopathy are outlined in Table 3.
Coronary Angiography
Coronary artery disease is the leading cause of death for both
men and women in the United States. More than 1.5 million
cardiac catheterizations are performed every year in the
United States, primarily to diagnose coronary artery disease.
The indications for diagnostic coronary angiography are
listed in the accompanying slide sets, and more detailed
Table 2. Derived Parameters Using a Pulmonary Artery Catheter
Parameter
Formula
Normal Values
Systemic vascular
resistance
共MAP–RAP兲⫻80
CO
700 to 1600
dyne 䡠 s⫺1 䡠 cm⫺2 (9 –20
Wood units)
Pulmonary vascular
resistance
共MPAP–PCWP兲⫻80
CO
20 to 120
dyne 䡠 s⫺1 䡠 cm⫺2
(0.25–1.5 Wood units)
Stroke work index
共MPAP–LVEDP兲⫻SVI⫻
0.0136
45 to 75
g 䡠 m⫺1 䡠 m⫺2 䡠 beat⫺1 (LV)
5 to 10
g 䡠 m⫺1 䡠 m⫺2 䡠 beat⫺1 (RV)
Shunt fraction
Mitral valve area
(Gorlin’s equation)
Aortic valve area
(Gorlin’s equation)
Aortic valve area
(Hakki equation)
共SaO2⫺MvO2)
(PvO2⫺PaO2)
CO (ml/min)
37.7⫻DFP⫻HR⫻ 冑⌬P
CO (ml/min)
44.3⫻SEP⫻HR⫻ 冑⌬P
CO 共L/min兲
冑⌬P
1
4 to 6 cm2
3 to 4 cm2
3 to 4 cm2
MAP indicates mean arterial pressure; RAP, right atrial pressure; CO, cardiac
output; MPAP, mean pulmonary artery pressure; PCWP, pulmonary capillary
wedge pressure; LVEDP, left ventricular end-diastolic pressure; SVI, stroke
volume index; LV, left ventricle; RV, right ventricle; SaO2, oxygen saturation,
arterial; MvO2, oxygen saturation, mixed venous; PvO2, oxygen saturation,
pulmonary veins; PaO2, oxygen saturation, pulmonary artery; DFP, diastolic
filling period; HR, heart rate; SEP, systolic ejection period; and ⌬P, mean
pressure gradient. Please note for the Hakki equation, peak-to-peak gradient
can be used instead of the mean systolic gradient.
⬎5
RVEDP/RVSP, mm Hg
Loss of atrial kick
AV indicates atrioventricular; AVNRT, atrioventricular nodal reentry
tachycardia; and VSD, ventricular septal defect.
ⱕ5
Restrictive
Cardiomyopathy
RV systolic, mm Hg
No ‘a’ wave
Exaggerated ‘y’
descent
Constrictive
Pericarditis
RV/LV interdependence
PCWP/LV respiratory
gradient
Discordance
Concordance
Dip and plateau
(square root sign)
Dip and plateau
(square root sign)
Prominent ‘y’ descent
Prominent ‘y’ descent
ⱖ5
⬍5
LVEDP indicates left ventricular end-diastolic pressure; RVEDP, right ventricular end-diastolic pressure; RV, right ventricular; RVSP, right ventricular
systolic pressure; LV, left ventricular; RA, right atrial; and PCWP, pulmonary
capillary wedge pressure.
information can be obtained from the American College of
Cardiology/American Heart Association guidelines.3
Although there are no absolute contraindications to cardiac
catheterization, relative contraindications include coagulopathy, such as patients taking warfarin or after thrombolytic
therapy (a radial approach can be attempted based on urgency); decompensated congestive heart failure; uncontrolled
hypertension; pregnancy; inability of the patient to cooperate;
active infection; renal failure; and contrast medium allergy.
Coronary Angiography: Technique
After a through history has been obtained, a thorough
physical examination has been performed, and written informed consent has been obtained from the patient, conscious
sedation with a narcotic and a benzodiazepine should be used
before vascular access is attempted. Vascular access can be
either femoral (described by Bangalore and Bhatt3a in the
section on vascular access and closure devices), radial, or
brachial. The selected diagnostic catheter should be flushed
with saline to ensure an air-free system. Once arterial access
is obtained (as described in the section on vascular access and
closure devices), a catheter of appropriate size and configuration is advanced over a 0.035- or 0.038-inch guidewire.
Once it is in the ascending aorta, the guidewire is removed,
and the catheter is allowed to bleed back to remove any
thrombus or atherosclerotic debris. The catheter is then
connected to a manifold assembly connected to a pressure
transducer for continuous central pressure monitoring and is
flushed to ensure an air-free system.
Before any pressure is measured, zeroing and referencing
must be performed. The transducer should be opened to air to
zero out the system. Care must be taken to ensure that the
pressure transducer is at the level of the phlebostatic axis,
which is roughly the midportion between the anterior and
posterior chest wall along the left fourth intercostal space.
The central aortic pressure should be recorded and compared
with the cuff measured brachial pressure. If there is a
considerable difference between the 2, subclavian artery
stenosis should be in the differential. The catheter should then
be filled with 3 to 4 mL of contrast and advanced to engage
Bangalore and Bhatt
the coronary ostium, in the left anterior oblique (LAO)
projection. After ensuring that there is no ventricularization
or damping of the pressure, 2 to 3 mL of contrast should be
injected to confirm the position of the catheter in the coronary
ostium. Coronary angiography should be performed in standard views in orthogonal planes to visualize the lesion and
serve as a roadmap for percutaneous coronary intervention
(PCI). Nonstandard views should be considered on the basis
of the lesion location, orientation of the heart, and patient
body habitus. Before contrast is injected, with every view,
care should be taken to ensure there is no ventricularization or
damping of the pressure waveforms.
Complications
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The overall risk of major complications with coronary angiography is 1% to 2%. This includes death, myocardial
infarction, stroke, bleeding, vascular complications, and contrast reactions.
Catheter Selection
Selecting the right catheter is important, and the choice
depends on the following:
1. Access site: Choice of catheters depends to a certain
degree on the access site (femoral versus radial versus
brachial).
2. Aortic width: Normal aortic width is 3.5 to 4.0 mm,
narrow is ⬍3.5 mm, and dilated is ⬎4.0 mm.
3. Coronary ostial location: High versus low; anterior
versus posterior.
4. Coronary ostial orientation: Superior, inferior, horizontal, or shepherd’s crook (for right coronary artery
only).
It is preferable to use standard workhorse catheters for routine
coronary angiography, such as the Judkins right size 4 (JR4)
and Judkins left size 4 (JL4). It is important to always ensure
coaxial alignment of the catheter. Catheters have 2 main
curves: A primary (distal) curve and a secondary (proximal)
curve. The distance between the 2 curves denotes the length
of the catheter. As a general rule, shorter-curve catheters are
better suited for superior ostial takeoffs, whereas the longercurve catheters are better suited for inferior ostial takeoffs.
Standard Angiographic Views
The standard angiographic views for the left and right
coronary arteries are detailed in the slide set. For the left
coronary artery, many operators follow a standard order of
views, such as starting with the right anterior oblique (RAO)
caudal (RAO 20°, caudal 20°), PA cranial (PA 0°, cranial
30°), shallow RAO cranial (RAO 10°, cranial 40°), LAO
cranial (LAO 50°, cranial 30°), LAO caudal (LAO 50°,
caudal 30°), and PA caudal (PA 0°, caudal 30°) for the left
coronary system. For the right coronary artery, LAO 30°,
RAO 30°, and PA cranial (PA 0°, cranial 30°) are frequently
used. Nonstandard views are used if the standard views are
not clear and if additional information about a lesion is
needed.
Cardiac Catheterization and PCI
e431
Systematic Interpretation of Coronary Angiography
A systematic interpretation of a coronary angiogram would
involve evaluation of the extent and severity of coronary
calcification and lesion quantification in at least 2 orthogonal
views assessing for severity, calcification, presence of ulceration/thrombus, degree of tortuosity, American College of
Cardiology/American Heart Association lesion classification,
and reference vessel size. In addition, grading of the TIMI
(Thrombolysis In Myocardial Infarction) flow and that of the
TIMI myocardial perfusion blush grade should be performed.
Also, it is important to identify and quantify the coronary
collaterals. Some of the definitions are included in Table 4.
Percutaneous Coronary Intervention
It is estimated that more than 1.2 million PCI procedures are
performed every year in the United States. The indications for
PCI are listed in the accompanying slide sets, and more
detailed information can be obtained from the American
College of Cardiology/American Heart Association guidelines on percutaneous coronary intervention and the appropriateness criteria.7–9 The contraindications and cautions are
similar to those described under coronary angiography.
PCI Technique
After the clinician has ensured that the patient understands
the procedure and has provided informed consent, conscious
sedation is administered with a narcotic and a benzodiazepine. As described under the section on coronary angiography, vascular access can be femoral, radial, or brachial.
Antiplatelet therapy with aspirin should be given before the
procedure, and a loading dose of thienopyridine (clopidogrel
or prasugrel) should be given periprocedurally. Antithrombotic
therapy with unfractionated heparin, low-molecular-weight heparin, or bivalirudin should be given and the activated clotting
time maintained at 250 to 300 seconds (for unfractionated
heparin given as monotherapy). Glycoprotein receptor IIb/IIIa
inhibitors can also be used based on the procedure. The selected
guiding catheter (connected to a Y-port) should be flushed with
saline to ensure an air-free system.
Once arterial access is obtained (as described by Bangalore
and Bhatt3a in the section on vascular access and closure
devices), a guiding catheter of appropriate size and configuration is advanced over a 0.035- or 0.038-inch guidewire.
Once in the ascending aorta, the guidewire is removed, and
the catheter is allowed to bleed back to remove any thrombus
or atherosclerotic debris. The catheter is then connected to a
manifold assembly that is connected to a pressure transducer
for continuous central pressure monitoring. The guiding
catheter is flushed to ensure an air-free system and should
then be filled with 3 to 4 mL of contrast and advanced to
engage the coronary ostium, in the LAO 30° projection. After
ensuring that there is no ventricularization or damping of the
pressure, 2 to 3 mL of contrast should be injected to confirm
the position of the catheter in the coronary ostium.
After adequate antithrombotic agents have been given, a
0.014-inch guidewire with a curve placed at its tip is
advanced through the guide catheter into the coronary artery
and across the lesion. At this stage, in the setting of
thrombotic ST-elevation myocardial infarction lesions, a
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Circulation
October 25, 2011
Table 4.
Standard Definitions for Interpretation of Coronary Angiography
ACC/AHA lesion
classification4
Type A lesion
Minimally complex, discrete (length ⬍10 mm), concentric, readily accessible, nonangulated segment (⬍45°), smooth contour, little
or no calcification, less than totally occlusive, not ostial in location, no major side branch involvement, and absence of thrombus
Type B lesion
Moderately complex, tubular (length 10 to 20 mm), eccentric, moderate tortuosity of proximal segment, moderately angulated
segment (⬎45°, ⬍90°), irregular contour, moderate or heavy calcification, total occlusions ⬍3 mo old, ostial in location, bifurcation
lesions requiring double guidewires, and some thrombus present
Type C lesion
Severely complex, diffuse (length ⬎2 cm), excessive tortuosity of proximal segment, extremely angulated segments ⬎90°, total
occlusions ⬎3 mo old and/or bridging collaterals, inability to protect major side branches, and degenerated vein grafts with friable
lesions
Lesion length, mm
Discrete lesion length
⬍10
Tubular lesion length
10–20
Diffuse lesion length
ⱖ20
Lesion angulation
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Moderate
Lesion angulation ⱖ5°
Severe
Lesion angulation ⱖ90°
Calcification
Moderate
Severe
Densities noted only with cardiac motion before contrast injection
Radiopacities noted without cardiac motion before contrast injection
TIMI flow grades5
0
Absence of any antegrade flow beyond a coronary occlusion
1
(Penetration without perfusion) Faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed
2
(Partial reperfusion) Delayed or sluggish antegrade flow with complete filling of the distal territory
3
(Complete perfusion) Normal flow that fills the distal coronary bed completely
TIMI myocardial perfusion
grades6
0
Either minimal or no ground glass appearance (blush) of the myocardium in the distribution of the culprit artery
1
Dye slowly enters but fails to exit the microvasculature. Ground glass appearance (blush) of the myocardium in the distribution of
the culprit lesion that fails to clear from the microvasculature, and dye staining present on the next injection (approximately 30
seconds between injections)
2
Delayed entry and exit of dye from the microvasculature. There is a ground glass appearance (blush) of the myocardium that is
strongly persistent at the end of the washout phase (ie, dye is strongly persistent after 3 cardiac cycles of the washout phase and
either does not diminish or only minimally diminishes in intensity during washout)
3
Normal entry and exit of dye from the microvasculature. There is a ground glass appearance (blush) of the myocardium that clears
normally and is either gone or only mildly to moderately persistent at the end of the washout phase (ie, dye is gone or is
mildly/moderately persistent after 3 cardiac cycles of the washout phase and noticeably diminishes in intensity during the washout
phase), similar to that in an uninvolved artery
ACC/AHA indicates American College of Cardiology/American Heart Association; TIMI, Thrombolysis In Myocardial Infarction.
manual aspiration catheter can be used to aspirate thrombus.
For saphenous vein graft interventions, an embolic protection
device should be deployed before any angioplasty or stenting
(if feasible, as described in the upcoming article and section
by Bangalore and Bhatt10 on embolic protection devices). An
appropriate-size compliant balloon may now be advanced
over this guidewire to the region of the stenosis and the
balloon inflated with a mixture of 50:50 heparinized saline
and contrast to predilate the lesion. The balloon is then
removed. Predilation should be avoided in saphenous vein
graft grafts (if possible) to reduce the risk of distal embolization. Once adequate predilation is performed, a stent of
suitable type, size, and length is taken and is flushed to ensure
an air-free system. This is advanced over the guidewire across
the lesion and deployed by inflating the balloon-mounted
stent to appropriate pressures. The stent balloon is now
removed, and coronary angiography is performed to ensure
no complications and to assess for adequate stent expansion. Some laboratories believe in routine postdilation of
all stents (except saphenous vein graft interventions) to
ensure adequate strut expansion. If desired, this is accomplished by use of a noncompliant balloon of appropriate
size and length. The balloon is removed and coronary angiography performed in 2 orthogonal views to assess the following:
Stent expansion; the proximal and distal stent edges, to ensure no
dissections or perforation; the distal wire site, to ensure no
perforation; and the ostium, to ensure no dissection caused by
the guiding catheter.
The guidewire is then removed, and further angiography is
performed to confirm adequate stent deployment and no
complications, as described above. The guiding catheter
should then be removed and intravenous antithrombotic
Bangalore and Bhatt
therapy stopped unless further continuation is required because of heavy thrombus burden.
Coronary Guide Catheter Selection
For routine stenting of noncomplex lesions, a coronary guide
catheter of 4F to 6F size is generally recommended. Larger
guide catheters (7F to 8F) are needed for more complex
procedures (bifurcation stenting, rotational atherectomy, or to
provide extra support for chronic total occlusions, tortuous, or
calcified lesions). The choice of guide catheter (standard versus
support versus extra support) depends on the complexity of the
lesion, presence of chronic total occlusions, vessel tortuosity,
and calcification, as well as on operator preference.
Coronary Guidewire Selection
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The types of guidewires are listed in the accompanying slide
set. Some general principles of guidewire selection will be
described. It is preferable to always start with the least
traumatic wire (workhorse wire) and to always advance the
wire under fluoroscopic guidance, ensuring that the guidewire
tip does not buckle (more prone to dissection) and that the
wire tip is always free. If frequent premature ventricular
contractions are noted on wire advancement, the wire tip
might have perforated; the wire should be withdrawn slightly.
If the wire becomes trapped and is difficult to retrieve
(especially in calcified arteries) even with gentle traction, it is
best to use a low-profile balloon or small-caliber catheter and
advance until the hinge point and then withdraw both as a
unit. For stenting over a bifurcation, if a wire is placed in the side
branch to protect the branch vessel, the stent can be deployed at
low pressures, with withdrawal of the wire in the branch,
recrossing through the stent strut, and postdilation to higher
pressures. If the wire tip breaks off and embolizes, it potentially
can be retrieved with a snare, and if that fails, the embolized tip
may be plastered against the wall by use of a stent.
Complications
Apart from the complications listed under diagnostic
coronary angiography in the accompanying slide set, those
related to PCI include abrupt closure, dissection, perforation, intramural hematoma, side-branch occlusion, distal
embolization, ventricular arrhythmia, acute renal failure,
radiation injury, myocardial infarction, stroke, emergent
coronary artery bypass grafting, and death. Most of these
complications can be minimized by appropriate patient
selection and with the use of proper catheterization techniques, although they cannot be eliminated entirely. Therefore, great care must always be exercised in deciding to
proceed with catheterization and PCI.
Acknowledgments
We would like to thank the nurses in the VA Boston Catheterization
Laboratory, who helped with the filming of the cases: Diane Lapsley,
RN, Scott Sandstrum RN, and Kimberly Shattuck, RN.
Disclosures
Dr Bhatt receives research grants (significant) from Astra Zeneca,
Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi-aventis, and
Cardiac Catheterization and PCI
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The Medicines Company. Dr Bangalore serves on the advisory board
for Daiichi Sankyo.
References
1. Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D.
Catheterization of the heart in man with use of a flow-directed balloontipped catheter. N Engl J Med. 1970;283:447– 451.
2. Sandham JD, Hull RD, Brant RF, Knox L, Pineo GF, Doig CJ, Laporta
DP, Viner S, Passerini L, Devitt H, Kirby A, Jacka M. A randomized,
controlled trial of the use of pulmonary-artery catheters in high-risk
surgical patients. N Engl J Med. 2003;348:5–14.
3. Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA,
Legako RD, Leon DF, Murray JA, Nissen SE, Pepine CJ, Watson RM,
Ritchie JL, Gibbons RJ, Cheitlin MD, Gardner TJ, Garson A Jr, Russell
RO Jr, Ryan TJ, Smith SC Jr. ACC/AHA guidelines for coronary angiography: executive summary and recommendations: a report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Committee on Coronary Angiography)
developed in collaboration with the Society for Cardiac Angiography
and Interventions. Circulation. 1999;99:2345–2357.
3a. Bangalore S, Bhatt DL. Femoral arterial access and closure. Circulation.
2011;124:e147– e156.
4. Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB 3rd, Loop FD,
Peterson KL, Reeves TJ, Williams DO, Winters WL Jr, et al. Guidelines
for percutaneous transluminal coronary angioplasty: a report of the
American College of Cardiology/American Heart Association Task Force
on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures
(Subcommittee on Percutaneous Transluminal Coronary Angioplasty).
Circulation. 1988;78:486 –502.
5. Gibson CM, Ryan KA, Kelley M, Rizzo MJ, Mesley R, Murphy S,
Swanson J, Marble SJ, Dodge JT, Giugliano RP, Cannon CP, Antman
EM; TIMI Study Group. Methodologic drift in the assessment of TIMI
grade 3 flow and its implications with respect to the reporting of angiographic trial results. Am Heart J. 1999;137:1179 –1184.
6. Gibson CM, Cannon CP, Murphy SA, Ryan KA, Mesley R, Marble SJ,
McCabe CH, Van De Werf F, Braunwald E. Relationship of TIMI
myocardial perfusion grade to mortality after administration of
thrombolytic drugs. Circulation. 2000;101:125–130.
7. Kushner FG, Hand M, Smith SC Jr, King SB 3rd, Anderson JL, Antman
EM, Bailey SR, Bates ER, Blankenship JC, Casey DE Jr, Green LA,
Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle
DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. 2009 Focused
updates: ACC/AHA guidelines for the management of patients with
ST-elevation myocardial infarction (updating the 2004 guideline and
2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous
coronary intervention (updating the 2005 guideline and 2007 focused
update): a report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines. J Am
Coll Cardiol. 2009;54:2205–2241.
8. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/
SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for
coronary revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for
Cardiovascular Angiography and Interventions, Society of Thoracic
Surgeons, American Association for Thoracic Surgery, American Heart
Association, and the American Society of Nuclear Cardiology: endorsed
by the American Society of Echocardiography, the Heart Failure Society
of America, and the Society of Cardiovascular Computed Tomography.
J Am Coll Cardiol. 2009;53:530 –553.
9. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern MJ, King
SB 3rd, Morrison DA, O’Neil WW, Schaff HV, Whitlow PL, Williams
DO, Antman EM, Adams CD, Anderson JL, Faxon DP, Fuster V,
Halperin JL, Hiratzka LF, Hunt SA, Nishimura R, Ornato JP, Page RL,
Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous
coronary intervention: a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines (ACC/
AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006;113:e166 – e286.
10. Bangalore S, Bhatt DL. Embolic protection devices. Circulation. In press.
Right Heart Catheterization, Coronary Angiography, and Percutaneous Coronary
Intervention
Sripal Bangalore and Deepak L. Bhatt
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Circulation. 2011;124:e428-e433
doi: 10.1161/CIRCULATIONAHA.111.065219
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