Coronary and Graft Angiography via the Femoral Approach

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • To determine the presence and/or extent of obstructive coronary artery disease (CAD) in a variety of clinical settings:
    • Acute coronary syndrome (ACS)
    • Positive stress test result
    • Congenital heart disease
    • Equivocal noninvasive test results with underlying high clinical index of suspicion for CAD
    • Pre-operative evaluation for cardiovascular surgery where knowledge of coronary anatomy may affect treatment plan (e.g., valve replacement surgery, aortic root replacement surgery, etc.)
    • Pre-operative evaluation for solid organ transplantation where index of suspicion for underlying CAD is high or where noninvasive stress testing yields equivocal results
CONTRAINDICATIONS
  • Absolute contraindications
    • Refusal by a competent patient
  • Relative contraindications
    • Coagulopathy, including anticoagulation with INR > 1.8
    • Decompensated congestive heart failure
    • Uncontrolled hypertension
    • Active stroke
    • Refractory arrhythmia
    • Active gastrointestinal bleeding
    • Pregnancy
    • Inability of patient to cooperate
    • Active infection
    • Acute renal failure or severe chronic nondialysis-dependent kidney disease
    • Contrast allergy in the absence of premedication
    • Uncorrected digitalis toxicity
    • Unexplained fever or untreated infection
    • Severe uncorrected anemia
EQUIPMENT
  • Patient monitors: ECG, pulse oximeter, blood pressure cuff
  • Sterile mask, cap, gown, gloves
  • Sterile drape over patient
  • Sterile prep solution for arterial access site
  • Crash cart with resuscitation equipment, drugs, and defibrillator
  • Manifold setup and/or power contrast injector
  • 1% lidocaine
  • 21-gauge needle and syringe for local anesthesia
  • 18-gauge Seldinger-Cook needle
  • Sterile vascular introducer sheath (various French sizes) with J-tipped wire
  • Sterile 180" or longer 0.035" J-tipped guidewire
  • Sterile diagnostic coronary catheters (eg, Judkins, Amplatz) including pigtail catheter
  • Sterile diagnostic bypass graft catheters – if graft angiography performed (eg, Judkins, IMA, LCB, RCB)
  • Oxygen source and delivery system (nasal cannula, face mask)
  • Sedative drugs such as midazolam, IV analgesic medications such as fentanyl
  • Ultrasound for vascular access (optional)
  • Fluoroscopy system
  • ECG recording system
  • Equipment for starting a peripheral IV:
    • IV catheter (20-gauge)
    • Alcohol or other sterile prep solution
    • Tape or transparent sterile dressing for securing IV
    • Heparin lock for IV
    • Gauze or bandage for IV site
  • Pressure dressing for femoral access site
ANATOMY
  • Vascular access for catheter ablation via the femoral artery is described here. The femoral artery is located in the groin just medial to the femoral pulsation below the inguinal ligament. The vein is accessed medial to the pulsation of the femoral artery. Alternative sites may also be used and are discussed elsewhere (see Radial Artery Access for Coronary Catheterization).
    • The common femoral artery travels medial to the femoral head, with the bifurcation of the common femoral artery distal to the middle third of the femoral head. The femoral artery should be punctured several centimeters distal to the inguinal ligament but proximal to the bifurcation of the superficial femoral and profunda arterial branches.
  • Coronary Artery Anatomy
    • The right and left coronary arteries arise from the ascending aorta in its anterior and left posterior sinuses.
    • The term “dominant” is used to refer to the coronary artery giving off the posterior interventricular (descending) branch, supplying the posterior part of the ventricular septum and posterolateral wall of the left ventricle (LV). In 60% of patients, the right coronary artery is dominant.
    • The right coronary artery
      • Arises from the anterior aortic sinus. It passes anteriorly and to the right between the right auricle and pulmonary trunk, where it reaches the atrioventricular (AV) groove and descends to the right cardiac border, curving around posteriorly.
      • Branches of the right coronary artery supply the right atrium and ventricle and variable parts of the left chambers and AV septum.
    • The left coronary artery
      • Arises from the left posterior aortic sinus.
      • Is larger in caliber than the right coronary artery and supplies a greater volume of myocardium, including almost all of the LV and LA and most of the interventricular septum.
      • It has a short initial portion (left main) and divides into two or three main branches near or in the interventricular groove. The anterior descending artery (LAD) is the continuation of the main artery, and the circumflex artery represents a branch turning to the left at the bifurcation in the interventricular groove. In 90% of cases, a large ventricular branch, the left marginal artery, arises from the circumflex and supplies much of the adjacent LV.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Patients should remain on bed rest for 2 to 6 hours to prevent bleeding at femoral access sites and should refrain from significant physical activity for 5 to 14 days afterward.
  • Patients should be cautioned to watch for swelling or bleeding at the femoral puncture site and to report these immediately to the nursing staff.
  • Patients who take metformin should be advised not to resume taking it for at least 48 hours after the procedure.
COMPLICATIONS
  • Bleeding
  • Vascular injury (eg, femoral artery dissection)
  • Iatrogenic coronary artery dissection
  • Air embolism
  • Stroke
  • Arrhythmia
  • Cardiac arrest
  • Myocardial infarction
  • Death
RESULT ANALYSIS
  • Errors in image acquisition and interpretation may affect patient management strategies after coronary angiography.
  • Inadequate coronary opacification can cause misinterpretation of the degree of coronary disease and may result in overestimation of the amount of coronary thrombosis or stenosis. Inadequate opacification can result from improper “nonaxial” catheter positioning during contrast injection, dislodgement of the catheter during injection, the presence of significant aortic valve insufficiency, and other issues.
  • Eccentric or slit-like coronary lesions can be difficult to evaluate, and it may be difficult to estimate the hemodynamic significance of such lesions.
  • Superimposition of major branches of the coronary arteries can result in failure to detect narrowing or occlusion of such branches. Such problems may be overcome by changing the angulation of the imaging device.
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