Transcarotid coronary arteriography in man with emphasis on intercoronary arterial anastomosis.

Abstract

At the annual meeting of the Radiological Society of North America in 1957 we demonstrated the technic and the results of transcarotid aortic valvulography based on a series of 51 injections in 49 patients (1). On that occasion, and in subsequent publications, attention was called to the incidental satisfactory, although inconstant, visualization of the normal coronary arteries in these cases (2, 3). It became evident that, after certain modifications, the method (4) could be utilized for the direct visualization of the coronary arteries in those patients in whom clinical findings and electrocardiography failed to establish a diagnosis. Experimental studies, including approximately 300 injections in 50 mongrel dogs, helped us to introduce the changes in the method necessary for constant detailed visualization of both coronary arteries without increasing the risk associated with thoracic aortography. The results of these experimental studies in animals and the associated electrocardiographic and physiologic changes during and following the injection of contrast material have been discussed separately (5, 6). It is the purpose of this paper to describe the technic of coronary arteriography as used clinically in our institution since 1958, and to demonstrate the radiographic detail obtained in visualization of normal and diseased coronary arteries in 50 patients. Selection Of Patients For Transcarotid Coronary Arteriography Selection and preparation of patients for coronary arteriography is important. The disappointing results obtained by other investigators who performed coronary arteriography in old, cachectic individuals (7) and our own previous experiences indicate that the patients should be carefully chosen for the procedure. Inasmuch as most of the candidates for coronary arteriography are between forty and sixty years of age, the cerebral blood circulation should be tested by separate compression of the right and left common carotid arteries for at least ten minutes in the recumbent position. If there is any evidence of carotid or cerebral vascular insufficiency, the transcarotid approach should not be employed. In the presence of a dilated or tortuous innominate artery, the left common carotid artery, rather than the right, should be used for the introduction of the catheter. The presence of a thoracic aortic aneurysm probably increases the risk of cerebral complications. In an earlier series of 26 injections performed to demonstrate aneurysms of the thoracic aorta or of the innominate artery we encountered carotid thrombosis at the site of arteriotomy in 2 cases and temporary hemiparesis in 1, due to cerebral embolus. Although we believe that at least one of these complications can be explained on the basis of our initial technical difficulties, it seems likely that the transcarotid approach is prone to produce cerebral complications in patients with aneurysms.