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Libin Cardiovascular Institute of Alberta

Foothills Interventional Services

Coronary Angiogram (cardiac catheterization or dye test)

Definition:

An invasive imaging procedure that involves inserting a catheter into a blood vessel in the arm or leg, and guiding it to your heart with the aid of a special x-ray machine (fluoroscopy). Contrast dye is injected through the catheter so that x-ray movies of your coronary arteries and heart chambers are taken. Pressures within your blood vessels and heart chambers may also be assessed during this procedure, if needed.

Your doctor uses the coronary angiogram to:

  • evaluate or confirm the presence of heart disease (such as coronary artery disease, valve disease or disease of the blood vessels)
  • evaluate heart muscle function of the main pumping chamber called the ventricle
  • determine the need for further treatment (medications, angioplasty or bypass surgery)

To prepare:

Prior to your procedure, tests may be scheduled such as routine bloodwork, electrocardiogram (ECG), chest x-ray or other special tests.

Although some patients are hospitalized (in-patients) when they undergo catheterization, it is commonly done as an outpatient procedure.

You can wear whatever you like to the hospital. You will wear a hospital gown during the procedure.

Leave money, jewelry, and other valuables at home. If you normally wear dentures, glasses or a hearing assist device, plan to wear them during the procedure to assist with communication.

Your will be informed about what you can and cannot eat or drink in the 12 hours before and after the procedure.

Ask your doctor what medications should be taken on the day of your test. You may be told to stop certain medications, such as Coumadin (warfarin, a blood thinner). Please follow your doctors instructions carefully.

If you have diabetes, ask your physician how to adjust your medications the day of your test and in the days following.

Tell your doctor and/or nurses if you are allergic to anything, especially iodine, shellfish, x-ray dye, penicillin-type medications, latex or rubber products (such as rubber gloves or balloons).

You may or may not return home the day of your procedure. Bring items with you (such as robe, slippers and toothbrush) that may make your stay more comfortable. When you are able to return home, arrange for a companion to bring you home.

What to expect:

Please bring a list of your medications (including over-the-counter) and dosages. When you arrive for your appointment, please tell your nurse if you are taking Coumadin (warfarin), Plavix (clopidogrel), diuretics (water pill) or insulin. Also remind the staff if you are allergic to anything, especially iodine, shellfish, x-ray dye, penicilin-type medications, latex or rubber products (such as rubber gloves or balloons).

You will be given a hospital gown to wear.

A nurse will start one or two intravenous (IV) lines in your arm so that medications and fluids can be administered during the procedure.

The cardiac catheterization room is cool and dimly lit. The air must be kept cool to prevent damage to the x-ray machinery that is used during the procedure. You will be offered warm blankets to make you more comfortable.

You will lie on a special table. The large camera will be above you and will rotate around you during the procedure. If you look to your left, you will see several TV monitors. You may be able to watch your cardiac cath on the monitors depending on the position of the camera.

The nurse will clean your skin at the site where the sheath (narrow plastic tube) will be inserted (arm or groin). The catheter insertion site will be shaved.

Sterile drapes are used to cover the site and help prevent infection. It is important that you keep your arms and hands down at your sides or just below your belly-button, under the sterile drapes.

Electrodes (flat, sticky patches) will be placed on your chest and legs. The electrodes are attached to an electrocardiograph monitor (ECG), which monitors your heart rate and rhythm.

You may be given a mild sedative to relax you, but you will be awake and conscious during the entire procedure.

In some cases, a urinary catheter may be needed during the procedure.

The doctor will use a local anesthetic to numb the site. A plastic introducer sheath (a short, hollow tube through which the catheter is placed) is inserted in a blood vessel in your arm or groin. A catheter will be inserted through the sheath and threaded to the arteries of your heart. You may feel pressure as the introducer sheath or catheter are inserted, but you should not feel pain after the local anesthetic has been introduced. Tell the nurse or doctor if you feel any pain.

When the catheter is in place, the lights will be dimmed and a small amount of contrast material will be injected through the catheters into your arteries and heart chambers. The contrast material outlines the vessels and chambers. You may be asked to hold your breath or move your head from side to side. It is otherwise important that you try to stay still if possible.

When the contrast material is injected into your heart, you may feel hot or flushed for several seconds. This is normal and will go away in a few seconds. Please tell the doctor or nurses if you feel:

  • an allergic reaction (itching, swelling or tightness in the throat)
  • nausea
  • chest discomfort
  • any other symptoms

The x-ray camera will be used to take photographs of the arteries and heart chambers. You may be asked to hold your breath while the x-rays are taken. When all the photos have been taken, the catheter will be removed and the lights will be turned on.

You may have an interventional procedure combined with your cardiac catheterization.

After the procedure:

The catheters and sheath are removed.

  • If the catheter was inserted in the arm: The incision will be bandaged. You will need to keep your arm protected for at least an hour. You will be able to walk around. You will be observed for a few hours to monitor any symptoms or side effects of the procedure. You will be given instructions regarding how to care for your arm when you return home. Tell your nurse if you think you are bleeding (wet, warm sensation) or feel any numbness or tingling in your fingers.
  • If the catheter was inserted at the groin: The incision will be bandaged or may be closed with applied pressure, suture device or a "plug." A "plug" is a material which works with your body's natural healing processes to form a clot in the artery. You will need to lie flat and keep the leg straight for two to six hours to prevent bleeding. Your head cannot be raised more than 30 degrees (2 pillows high). Do not try to sit or stand.
  • A sterile dressing will be placed on the groin area to protect it from infection. The nurse will check your bandage regularly, but call your nurse if you think you are bleeding (have a wet, warm sensation) or if your toes begin to tingle or feel numb.
  • You will need to drink plenty of liquids to clear the contrast material from your body. You may feel the need to urinate more frequently. This is normal. If you are on bed-rest, you will need to use a bedpan or urinal.
  • Your doctor will tell you if you are able to return home or will need to stay overnight. In either case, you mayl be monitored for several hours after the procedure.
  • Treatment, including medications, diet and future procedures, will be discussed with you prior to going home. Care of the wound site, activity and follow-up care will also be discussed.

The cardiac cath procedure only takes about 30-60 minutes, but plan to spend about 5 to 9 hours from the preparation through the recovery time.

Please ask your doctor if you have any questions about cardiac catheterization.

Percutaneous Coronary Intervention (PCI)

A percutaneous coronary intervention (PCI) is a non-surgical treatment used to open narrowed coronary arteries to improve blood flow to the heart. A PCI may be performed during a diagnostic cardiac catheterization when a blockage is identified, or it may be scheduled after a catheterization has confirmed the presence of coronary artery disease. It is also used to treat patients having heart attacks (primary PCI).

A PCI starts out the same way as a cardiac catheterization. Once the catheter is in place, one of these interventional procedures is performed to open the artery: balloon angioplasty or stent placement.

Balloon angioplasty: [Percutaneous Transluminal Coronary Angioplasty (PTCA) or Plain Old Balloon Angioplasty (POBA)]

A procedure in which a small balloon at the tip of the catheter is inserted near the blocked or narrowed area of the coronary artery. The technical name for balloon angioplasty is percutaneous transluminal coronary angioplasty (PTCA). When the balloon is inflated, the fatty plaque or blockage is compressed against the artery walls and the diameter of the blood vessel is widened (dilated) to increase blood flow to the heart.

Balloon Angioplasty with Stenting

In most cases, balloon angioplasty is performed in combination with the stenting procedure. A stent is a small, metal mesh tube that acts as a scaffold to provide support inside the coronary artery. A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed artery. Once in place, the balloon is inflated and the stent expands to the size of the artery and holds it open. The balloon is deflated and removed, and the stent stays in place permanently. During a period of several weeks, the artery heals around the stent.

Angioplasty with stenting is most commonly recommended for patients who have specific blockages in their arteries. If there are many blockages with extensive disease or blockages difficult to fix with PCI, coronary artery bypass graft surgery may be recommended.

A note about drug eluting stents (DES): Drug-eluting stents contain a medication that is actively released at the stent implantation site. Drug-eluting stents have a thin surface of medication to reduce the risk of restenosis. Concern was raised in 2006 regarding the safety of drug eluting stents. The Food and Drug Administration (FDA) continues to feel that DES, when used according to approved indications, are safe and effective. [Update to FDA Statement on Coronary Drug-Eluting Stents (January 4, 2007), http://www.fda.gov/cdrh/news/010407.html*] If you receive a drug-eluting stent, your doctor will prescribe certain medications (clopedogrel) for at least a year after your procedure, to prevent the risk of clotting in the stent. It is extremely important to keep taking the medication until your doctor tells you otherwise. If you have concerns about drug eluting stents, please speak to your physician.

Balloon Angioplasty

Balloon Angioplasty

balloon is inflated to compress
fatty matter

Stent

Balloon Angioplasty with Stent

stent stays in place after
catheter is removed

Fractional Flow Reserve Assessment (Pressure Wire)

Myocardial fractional flow reserve (FFR) is an index of the functional severity of a coronary blockage. It involves placing a special wire down the artery in question and taking pressure measurements to find out if that artery needs to be fixed or not. It is often used in cases where the doctor is unable to tell by the angiogram alone if the blockage is bad enough to be causing problems.

Intravascular Ultrasound (IVUS)

Intravascular ultrasound (IVUS) is a medical imaging procedure using a specially designed catheter with a miniaturized ultrasound probe attached to the end of it. The other end of the catheter is attached to computerized ultrasound equipment. It allows the application of ultrasound technology to see from inside blood vessels out through the surrounding blood column, visualizing the inner wall of blood vessels during an interventional procedure.

IVUS is used in the coronary arteries to determine the amount of atheromatous plaque built up at any particular point in the coronary artery. This build up of plaque leads to stenosis (narrowing) of the artery (known as coronary artery lesions). IVUS is of particular use to determine the degree of stenosis in situations in which angiographic imaging is considered unreliable, such as for ostial lesions and when angiography cannot visualize the segment adequately, particularly if there are a lot of overlapping arteries.

Peripheral Vascular Disease Intervention

Peripheral arterial disease (PAD) affects many Canadians, most of whom are not aware that they have the disease. PAD interferes with one's lifestyle by decreasing walking ability (it affects the limbs) and affecting cardiovascular health. Left untreated, PAD increases the risk of heart attack, stroke, amputation of lower extremity limbs, and death. A patient with PAD has about five times the risk of dying of a heart attack or stroke over the next ten years as the patient who does not have peripheral arterial disease.

Like coronary artery disease (CAD), peripheral arterial disease is a form of atherosclerosis - a progressive disease that involves the hardening and narrowing of the arteries due to a gradual build-up of plaque (fatty deposits). Whereas CAD involves the coronary arteries, PAD occurs in the hundreds of arteries outside of the heart (called peripheral arteries).

If patients have symptoms of PAD they may require assessment by a specialist and further investigations including a peripheral angiogram and possible intervention.

Download the Canadian Cardiovascular Society Consensus Conference on peripheral arterial disease