6.1 Manual of PCI - How to perform coronary angiography

Summary

This video provides a comprehensive, step-by-step guide to performing coronary angiography as part of a percutaneous coronary intervention (PCI). It covers eight critical steps, including ensuring proper pressure waveform, test contrast injection, administering nitroglycerin, optimal patient positioning, and performing the angiogram itself. The video also addresses common challenges, such as catheter disengagement, incomplete artery filling, and difficulties in visualizing coronary segments. Emphasizing the importance of precise technique, this guide offers valuable insights for healthcare professionals to avoid complications and ensure successful outcomes in coronary angiography.

Takeaways

• 😀 Ensure a good pressure waveform before performing coronary angiography to avoid complications like dissection, arrhythmias, or vessel injury.
• 😀 Conduct a small test contrast injection to confirm catheter engagement, check for obstructive disease, and ensure the catheter is properly positioned.
• 😀 Always administer intracoronary nitroglycerin unless the patient is hypotensive, as it helps prevent coronary artery spasm, improving the clarity of the angiogram.
• 😀 Proper positioning of the patient, image receptor, and operator minimizes scatter radiation and optimizes imaging for coronary angiography.
• 😀 Check the pressure waveform and electrocardiogram (EKG) before performing the angiogram to avoid complications during the procedure.
• 😀 Inject contrast while ensuring the syringe is vertical to avoid bubbles, and perform angiography in multiple projections to get a complete view of the coronary arteries.
• 😀 Use proper catheter engagement and strong contrast injection to ensure complete filling of the coronary artery, avoiding incomplete or suboptimal angiograms.
• 😀 Monitor the patient’s EKG and pressure waveform after the angiogram to detect complications such as arrhythmias or vessel occlusion.
• 😀 For accurate interpretation, high-quality angiograms are crucial; poor image quality can lead to incorrect diagnoses or missed lesions.
• 😀 Pay attention to patient factors (e.g., obesity, poor coronary engagement, and high coronary flow) and technical considerations to ensure successful angiography and optimal image quality.

Q & A

Why is it important to ensure a good pressure waveform before performing coronary angiography?

A good pressure waveform is essential before injecting contrast because dampened pressure can cause complications such as vessel dissection, arrhythmias, or other severe issues. Ensuring a clear pressure waveform helps prevent these complications during the procedure.

What is the purpose of a small test contrast injection during coronary angiography?

The test contrast injection serves multiple purposes: it confirms proper catheter engagement, checks for ostial disease, ensures the catheter is coaxial with the vessel, and confirms the catheter isn't too deeply intubated.

How much intra-coronary nitroglycerin should be administered during the procedure, and why is it important?

Intra-coronary nitroglycerin is typically administered at 200 micrograms in normotensive patients, 100 micrograms in patients with a blood pressure between 100-120 mmHg, and 50 micrograms for patients with a systolic pressure below 100 mmHg. It helps prevent coronary spasm, which could interfere with interpreting fixed coronary stenosis.

What are the key factors for optimizing the positioning of the patient, image receptor, and operator during angiography?

To optimize positioning, the table should be as high as possible, the image receptor should be close to the patient, and the operator should be positioned as far back as possible to minimize scatter radiation. Scatter shields should be placed appropriately between the patient and the operator.

Why is it crucial to recheck the pressure waveform and EKG before performing the angiogram?

Rechecking the pressure waveform and EKG ensures there are no changes or abnormalities that could affect the angiography. If any issues, such as dampened pressure or arrhythmias, are detected, contrast injection should not be performed until these are resolved.

What is the role of proper catheter engagement during coronary angiography?

Proper catheter engagement is vital for obtaining high-quality images of the coronary arteries. Poor engagement can lead to suboptimal angiograms, making it difficult to visualize the vessel clearly and potentially miss important diagnostic details.

What are some challenges faced during coronary angiography, and how can they be mitigated?

Challenges include poor catheter engagement, weak contrast injection, and incomplete visualization of coronary segments. These can be addressed by ensuring proper catheter positioning, using sufficient injection pressure, and applying different imaging projections as needed.

What are the common complications that may arise after coronary angiography, and how should they be managed?

Common complications include arrhythmias like ventricular fibrillation or transient EKG changes. Immediate intervention, such as defibrillation for ventricular fibrillation, is necessary. It's also important to ensure there are no issues with coronary flow, such as acute vessel occlusion.

Why is the interpretation of the angiogram dependent on the quality of the images?

The interpretation of the angiogram depends on the clarity and completeness of the images. If the images are of poor quality, such as incomplete coronary artery filling or poor visualization of segments, accurate diagnosis and decision-making may be compromised.

What steps can be taken to ensure the coronary angiogram is of diagnostic quality?

To ensure diagnostic quality, it's important to achieve good catheter engagement, use appropriate contrast injection pressure, and capture the images in multiple projections. Additionally, the patient should be positioned optimally, and the image receptor should be adjusted to capture all relevant coronary segments.