Routine Diagnostic Coronary Angiography Research Articles

Reference diameter and characteristics of the distal radial artery based on ultrasonographic assessment.

Background/AimsWhile distal radial artery (DRA) access is increasingly being used for diagnostic coronary angiography, limited information is available regarding DRA size. We aimed to determine the DRA reference diameters of Korean patients and identify the predictors of DRA diameter < 2.3 mm.MethodsThe outer bilateral DRA diameters were assessed using a linear ultrasound probe in 1,162 consecutive patients who underwent transthoracic echocardiography. The DRA diameter was measured by the perpendicular angle in the dorsum of the hand, and the average values were compared by sex. DRA diameter < 2.3 mm was defined as unsuitable for routine diagnostic coronary angiography using a 5 Fr introducer sheath.ResultsThe mean DRA diameters were 2.31 ± 0.43 mm (right) and 2.35 ± 0.45 mm (left). The DRA was smaller in women than men (right: 2.15 ± 0.38 mm vs. 2.43 ± 0.44 mm, p < 0.001; left: 2.18 ± 0.39 mm vs. 2.47 ± 0.45 mm, p < 0.001). The DRA diameter was approximately 20% smaller than the radial artery diameter. A total of 630 (54.2%) and 574 (49.4%) patients had DRA diameter < 2.3 mm in the right and left hands, respectively. Female sex, low body mass index (BMI), and low body surface area (BSA) were significant predictors of DRA diameter < 2.3 mm.ConclusionsWe provided reference DRA diameters for Korean patients. Approximately 50% of the studied patients had DRA diameter < 2.3 mm. Female sex, low BMI, and low BSA remained significant predictors of DRA diameter < 2.3 mm.

Feasibility of using ultra-low pulse rate fluoroscopy during routine diagnostic coronary angiography.

IntroductionCoronary angiogram, while a powerful diagnostic tool in coronary artery disease, is not without an associated risk from ionising radiation. There are a number of factors that influence the amount of radiation the patient receives during the procedure, some of which are under the control of the operator. One of these is an adjustment of the fluoroscopic pulse rate. This study aims to assess the feasibility of using ultra‐low pulse rate (3 pulses per second(pps)) fluoroscopy during routine diagnostic coronary angiogram procedures and the effect it has on fluoroscopy time, diagnostic clarity and radiation dose.MethodsA retrospective study of three operators each undertaking 50 coronary angiogram procedures was performed. One of the operators used a pulse rate of 3 pps and 6 pps for fluoroscopic screening while the control groups used the standard 10 pps mode utilised at this centre.ResultsResults demonstrated no reduction of diagnostic clarity, up to a 58% reduction in Dose Area Product and no increase in fluoroscopy time with the 3 pps setting.ConclusionsFindings from this pilot study suggest that utilisation of ultra‐low pulse rate fluoroscopy in routine transfemoral diagnostic coronary angiography in the catheterisation laboratory is feasible.

Efficacy of RADPAD protective drape during coronary angiography

Ionizing radiation is an integral part of percutaneous coronary angiographies. Chronic exposure to low-dose radiation confers arisk for skin damage, eye lens opacities or cataracts, and malignant diseases to staff in the catheter laboratory. The RADPAD is asterile surgical drape that reduces the effect of scatter radiation on the operator. We sought to assess the efficacy of RADPAD shields in reducing radiation dose experienced by operators during routine diagnostic coronary angiography. Sixty consecutive patients due to undergo elective coronary angiography were randomized in a1:1 pattern to have their procedures performed with and without the RADPAD drape in situ. Dosimetry was performed on the left arm of the primary operator. There was no significant difference in the two main determents of radiation exposure in both groups: the screening times (102± 86 s for the RADPAD group vs. 105± 36 s for the control group, p= 0.9) and body mass index (BMI; 27.7± 4.2 kg/m2 for the RADPAD group vs. 27.9± 5.5 kg/m2 for the control group, p= 0.8). Moreover, there was no difference in the dose-area ratio (1337± 582 cGy/cm2 for the RADPAD group vs. 1541± 804 cGy/cm2 for the control group, p= 0.3) between the two patient groups. The primary operator radiation dose was significantly lower in the RADPAD group at 8.0 µSv (Q1: 3.2, Q3: 20.1) compared with 19.6 µSv (Q1: 7.1, Q3: 37.7) for the control group (p= 0.02). The RADPAD significantly reduces radiation exposure to primary operators during routine diagnostic coronary angiography in patients with aBMI> 25 kg/m2. It reduces total radiation exposure toprimary operators by 59%, and the radiation exposure rate by 47%.

Coronary artery disease in congenital single coronary artery in adults: A Dutch case series.

To assess the current diagnostic and therapeutic management and the clinical implications of congenital single coronary artery (SCA) in adults. We identified 15 patients with a SCA detected from four Dutch angiography centers in the period between 2010 and 2013. Symptomatic patients who underwent routine diagnostic coronary angiography (CAG) for suspected coronary artery disease and who incidentally were found to have isolated SCA were analyzed. Fifteen (7 females) with a mean age of 58.5 ± 13.78 years (range 43-86) had a SCA. Conventional CAG demonstrated congenital isolated SCA originating as a single ostium from the right sinus of Valsalva in 6 patients and originating from the left in 9 patients. Minimal to moderate coronary atherosclerotic changes were found in 4, and severe stenotic lesions in another 4 patients. Seven patients were free of coronary atherosclerosis. Runs of non-sustained ventricular tachycardia were documented in 2 patients, one of whom demonstrated transmural ischemic changes on presentation. Myocardial perfusion scintigraphic evidence of transmural myocardial ischemia was found in 1 patient due to kinking and squeezing of the SCA with an interarterial course between the aorta and pulmonary artery. Multi-slice computed tomography (MSCT) was helpful to delineate the course of the anomalous artery relative to the aorta and pulmonary artery. Percutaneous coronary intervention was successfully performed in 3 patients. Eight patients were managed medically. Arterial bypass graft was performed in 4 patients with the squeezed SCA. SCA may be associated with transient transmural myocardial ischemia and aborted sudden death in the absence of coronary atherosclerosis. The availability and sophistication of MSCT facilitates the delineation of the course of a SCA. We present a Dutch case series and review of the literature.

Exercise Central (Aortic) Blood Pressure Is Predominantly Driven by Forward Traveling Waves, Not Wave Reflection

Exercise hypertension independently predicts cardiovascular mortality, although little is known about exercise central hemodynamics. This study aimed to determine the contribution of arterial wave travel and aortic reservoir characteristics to central blood pressure (BP) during exercise. We hypothesized that exercise central BP would be principally related to forward wave travel and aortic reservoir function. After routine diagnostic coronary angiography, invasive pressure and flow velocity were recorded in the ascending aorta via sensor-tipped intra-arterial wires in 10 participants (age, 55±10 years; 70% men) free of coronary artery disease with normal left ventricular function. Measures were recorded at baseline and during supine cycle ergometry. Using wave intensity analysis, dominant wave types throughout the cardiac cycle were identified (forward and backward, compression, and decompression), and aortic reservoir and excess pressure were calculated. Central systolic BP increased significantly with exercise (Δ=19±12 mm Hg; P<0.001). This was associated with increases in systolic forward compression waves (Δ=12×10(6)±17×10(6) W·m(-2)·s(-1); P=0.045) and forward decompression waves in late systole (Δ=9×10(6)±6×10(6) W·m(-2)·s(-1); P<0.001). Despite significant augmentation in BP (Δ=9±6 mm Hg; P=0.002), reflected waves did not increase in magnitude (Δ=-1×10(6)±3×10(6) W·m(-2)·s(-1); P=0.2). Excess pressure rose significantly with exercise (Δ=16±9 mm Hg; P<0.001), and reservoir pressure integral fell (Δ=-5×10(5)±5×10(5) Pa·s; P=0.010). Change in reflection coefficient negatively correlated with change in central systolic BP (r=-0.68; P=0.03). We conclude that elevation of exercise central BP is principally because of increases in aortic forward traveling waves generated by left ventricular ejection. These findings have relevance to understanding central BP waveform morphology and pathophysiology of exercise hypertension.

Coronary Angiography, Too Far to be a Gold Standard Technique for Identifying a Vulnerable Plaque

A 79 year-old woman with symptomatic heart failure and severe aortic stenosis was referred to a routine diagnostic coronary angiography previous to surgical aortic valve replacement. Coronary angiography showed severe stenosis in the left circumflex artery and in the ostium of the posterior descending artery. Four days later the patient presented an inferior ST-segment elevation acute coronary syndrome with cardiogenic shock. A rescue angioplasty was performed after failed thrombolysis. Coronary angiography revealed no changes in left coronary artery and a total acute occlusion in the middle segment of the right coronary artery, where only a mild lesion was observed four days before. A rescue angioplasty with a bare-metal stent implantation was performed with an optimal angiographic result. This case highlights the low ability of the conventional x-ray coronary angiography to identify vulnerable plaques. Even knowing the coronary anatomy four days before, we were unable to predict the culprit lesion.

Does biplane imaging reduce contrast load, procedural and screening time compared to single‐plane imaging in routine diagnostic coronary angiography?

AbstractDiagnostic coronary angiography requires radiographic contrast media that can cause complications such as contrast‐induced nephropathy (CIN). Biplane imaging in diagnostic coronary angiography has been assumed to be beneficial to the patient in reducing total radiographic contrast dosage and examination time, yet there are no definitive studies to support this widely held assumption. A retrospective study was conducted to determine if biplane imaging substantially reduces contrast load, procedural time and screening time in routine diagnostic coronary angiography. Radiographic records of 1156 patients were collected over a period of two years from a major Sydney metropolitan hospital. Patients who underwent a routine diagnostic coronary angiogram and left ventriculogram (LV) were selected on predetermined criteria. The mean total contrast volume showed a small but significant reduction with biplane versus single‐plane imaging (117.5 mL v. 124.3mL, P &lt;0.001). There was a small but significant increase in table time with biplane compared to single‐plane imaging (47.3 min v. 45.2 min, P &gt;0.024). Similarly, a small but significant prolongation in screening time was found with biplane compared to single‐plane imaging (4.8 min v. 4.2 min, P &lt;0.003). The mean number of cine angiography runs was 13.6 in biplane and 9.5 in single‐plane (P &lt;0.001).These results contradict the assumption that biplane cine angiography substantially reduces contrast load, procedural and screening time when compared to single‐plane imaging.

Prognostic value of circulating pregnancy-associated plasma protein-A (PAPP-A) and proform of eosinophil major basic protein (pro-MBP) levels in patients with chronic stable angina pectoris

BackgroundPregnancy-associated plasma protein-A (PAPP-A) concentrations predict outcome in patients with acute coronary syndromes. PAPP-A levels and PAPP-A/pro-MBP ratio are increased in chronic stable angina (CSA) patients with complex coronary artery stenoses. Little is known however, about the long-term prognostic value of PAPP-A and pro-MBP in “real-life” CSA patients. We sought to assess whether PAPP-A, the proform of eosinophil major basic protein (pro-MBP) and PAPP-A/pro-MBP levels predict long-term all-cause mortality in patients with CSA. MethodsWe recruited 663 consecutive patients (169 women [25.5%]; mean age 62.9±9.7 years) undergoing routine diagnostic coronary angiography. Samples for PAPP-A and pro-MBP were taken at study entry. Patients were followed for a median of 8.8 years (interquartile range 3 – 10.6 years). Results106 patients (16%) died during follow-up. On a Cox proportional hazards model, increased PAPP-A concentration (>4.8 mIU/L) was an independent predictor of the occurrence of all-cause mortality (HR 1.953, 95% CI 1.135–3.36, p=.016). Neither pro-MBP nor PAPP-A/pro-MBP ratio were markers of all-cause mortality (p=.45 and .54, respectively). ConclusionsHigh PAPP-A levels (>4.8 mIU/L) showed an association with all-cause mortality during long-term follow-up in patients with CSA.

Activation of coagulation during routine diagnostic coronary angiography

The role of anticoagulation during percutaneous coronary intervention has been well established. However, the role of anticoagulation during diagnostic coronary angiography remains unclear. Prothrombin fragment1+2 (PF1+2) and D-dimer (DD) have been reported to be useful in evaluating thrombotic phenomena. This study was designed to determine whether activation of coagulation occurs during diagnostic coronary angiography as measured by DD and PF1+2. Patients not on anticoagulation (except for aspirin) and with no documented coagulopathy undergoing elective diagnostic coronary angiography were enrolled in this prospective study. Blood samples for DD and PF1+2 were obtained serially after the femoral arterial sheath was placed. Peripheral venous blood was drawn along with an initial arterial blood sample from the sheath; thereafter, arterial blood samples from the sheath were obtained every 10 minutes for a maximum of 60 minutes or until the procedure was completed or when anticoagulation was initiated. A final venous sample was drawn at the end of the procedure. The data were analysed in time interval correlation to the DD and PF1+2 level.Forty-two patients were enrolled in this study, 15 were female (35%). There were 25 (59%) patients with diabetes. The mean fluoroscopic time was 8.8+/-7.81 minutes and the average time for the procedure was 29+/-22.70 minutes. There were 192 blood samples analysed. 67% of patient completed the procedure within 20 minutes and 91% within 30 minutes. Mean venous PF1+2 level was 0.20 nmol/L at baseline and 0.39 nmol/L (p=0.06) at the final interval, while the mean arterial PF1+2 level was significantly elevated. There was an increase of 0.2 nmol/L of arterial PF1+2 every 10 minutes (p<0.001). Mean venous DD at baseline and final levels were 0.41 ug/mL and 0.45 ug/mL respectively (p=0.68). There was a significant change in arterial DD with an increase of 0.02ug/ml every 10 minutes (p=0.023). In diagnostic coronary angiography, there is an early rise in PF1+2 levels in blood drawn through the arterial sheath suggesting that the procedure triggers local activation of coagulation that is not observed systemically. Prophylactic anticoagulation may not be necessary in stable patients without other known risk factors who will be undergoing elective diagnostic coronary angiography for less than 30 minutes. For procedures that are prolonged, or anticipated to be prolonged greater than 30 minutes, it may be advisable to administer anticoagulation to prevent thrombus formation. These findings may not be pertinent to patients with thrombophilia.

Arterial compliance adds to conventional risk factors for prediction of angiographic coronary artery disease

Background Arterial compliance is related to left ventricular hypertrophy and risk for cardiovascular disease events; however, its association with coronary artery stenosis remains uncertain. We sought to assess the relation between lower extremity arterial compliance and presence of angiographically defined coronary artery disease. Methods Lower extremity arterial compliance was measured with the use of a noninvasive air plethysmography technique in 376 subjects undergoing routine diagnostic coronary angiography. Results Measures of calf arterial compliance were significantly associated with the presence of one or more stenoses ≥50% compared with no stenoses, even after adjustment for age, sex, smoking, diabetes, hypertension, hypercholesterolemia, and obesity ( P = .03). Measures of thigh arterial compliance were also lower in subjects with disease, although this association did not reach statistical significance ( P = .07). Receiver operator curves illustrate the incremental predictive ability of calf arterial compliance over and above age, sex, and conventional risk factors. Conclusions Lower extremity arterial compliance is associated with presence of significant coronary stenoses in a cardiac catheterization laboratory referral population. This observation lends support for additional efforts to determine the utility of vascular stiffness measures in both clinical and pre-clinical populations to guide treatment and prevention efforts.

Extent and severity of atherosclerotic vascular disease in patients undergoing coronary angiography--the Kuwait Vascular Study.

Only a few angiographic studies have correlated the presence and severity of coronary artery disease with atherosclerosis in other arteries. The presence of disease in more than 1 area clearly has important implications on management. One hundred and seventy eight patients had angiographic evaluation of their peripheral arteries and abdominal aorta after routine diagnostic coronary angiography. The extent and severity of vascular disease was correlated with those of coronary artery disease. Of the 178 patients, 73.6% were men (mean age +/- sd was 52.93 +/- 10.12 years). Hypercholesterolemia (59%), systemic hypertension (56.7%) and diabetes mellitus (50.6%) were the major risk factors. Triple-vessel coronary artery disease was present in 48.9%, and 13.5% had normal coronaries. A new atherosclerotic vascular disease score, which reflects the presence and severity of atherosclerotic vascular disease elsewhere, was seen to correlate significantly with the extent of coronary artery disease. Of particular interest was the involvement of the first part of the vertebral artery in 41.6% of patients. The combined involvement of the abdominal aorta, renal artery, and iliac artery segments (together referred to as the lower body segment) was seen almost exclusively in those with 2- or 3-vessel coronary artery disease. Also there was a direct correlation between the extent of coronary artery disease and the score in the lower body segment as opposed to the upper body segment (subclavian, vertebral, and internal mammary arteries). The presence of atherosclerotic vascular disease correlated with the severity of coronary artery disease, particularly in respect to disease in the lower body segment. Thus early detection of such disease in the iliac or femoral arteries has a potential for early diagnosis of significant coronary artery disease.

Time Course of Endothelin-1 Plasma Level in Patients with Acute Coronary Syndromes

An elevated plasma level of endothelin-1 was reported in several cardiovascular conditions including unstable angina pectoris and myocardial infarction. The present study was designed to evaluate the time course of the endothelin-1 release in unstable angina pectoris and to assess its relationship to the development of myocardial infarction and coronary vessel occlusion. The cohort studied included 32 patients with the clinical diagnosis of unstable angina pectoris who had been admitted to the coronary care unit and subsequently underwent coronary angiography (group A). Fourteen patients with chronic stable angina pectoris referred to routine diagnostic coronary angiography served as the control group (group B). A significant difference in the endothelin-1 plasma level was found between both groups, the values being 10.2 ± 5.3 and 6.0 ± 3.1 pg/ml (p < 0.01), respectively. There were, however, no significant differences between the following subdivisions of group A: patients with and without subsequent myocardial infarction; those with angiographically documented occlusion of at least one major branch of the coronary artery and no occlusion; and finally, those with persisting symptoms of angina pectoris and with favorable response to treatment. Neither was there any difference found among the subgroups differing in the time interval between the onset of chest pain and blood sampling. The time course of endothelin plasma concentrations showed elevated values lasting for more than 96 h after the index episode of prolonged chest pain. No correlation with the subsequent clinical course could be inferred. Thus, plasma endothelin level was elevated in patients with unstable angina pectoris and myocardial infarction and the increase persisted for several days after the onset of symptoms.

Estrogen Acutely Abolishes Abnormal Cold-Induced Coronary Constriction in Men

Ambient cold exposure may induce myocardial ischemia by precipitating coronary artery constriction and a decrease in coronary blood flow. Estrogen has vasoactive properties that may prevent abnormal coronary constriction in a sex-independent manner. The purpose of this study is to determine whether estrogen acutely abolishes abnormal coronary responses to cold exposure in men. Randomized, double-blinded placebo-controlled clinical trial. Cardiac catheterization laboratory. Men referred for routine diagnostic coronary angiography who exhibit abnormal coronary artery constriction in response to a 90-s cold pressor test (CPT). Intravenous conjugated estrogens (1.25 mg) vs. placebo. Rate-pressure product, coronary cross-sectional area (CSA), and coronary blood flow responses to the CPT were measured before and 15 min after intervention. In 12 men with CPT-induced coronary constriction who were assigned to estrogen, CPT induced a mean 21.8% decrease in coronary CSA (p < 0.01) and a nonsignificant change in coronary flow. After estrogen, the repeated CPT induced a 16.3% increase in CSA (p < 0.01) and a 54.9% increase in flow (p < 0.01). CSA and coronary flow responses to CPT were significantly different before and after estrogen (p < 0.01). In contrast, placebo was not associated with changes in CSA or coronary flow responses to CPT in eight men. In men, conjugated estrogens acutely abolish abnormal coronary constriction and improve coronary blood flow responses to an exogenous cold stimulus. These results suggest that estrogen favorably alters coronary vasoreactivity in men.

Endothelial-dependent coronary vasomotor responsiveness in postmenopausal women with and without estrogen replacement therapy

Recently, Williams et al’ reported that acute administration of estrogen attenuates the coronary vasoconstrictor response to acetylcholine in atherosclerotic cynomolgus monkeys. These observations suggest that estrogen plays a fundamentally important role in the relationship between coronary vascular endothelium and vascular smooth muscle. This study examines the influence of current estrogen replacement therapy in postmenopausal women on endothelial-dependent and independent vasomotor responsiveness to acetylcholine. Ten postmenopausal women with exertional angina undergoing routine diagnostic coronary angiography or percutaneous transluminal coronary angioplasty were studied. The protocol was approved by the Clinical Research Practices Committee and each subject gave informed consent before the study, Four women were taking estrogen replacement therapy (PremarinB 0.625 to 1.25 mglday or topical estradiol 0.1 mg). None of the women were taking progesterone. All of the women had minimal coronary artery narrowings in the proximal portion of the left anterior descending or a nondominant circumflex coronary artery. Vasoactive medications were withheld for 12-24 hours before the procedure. A 3Fr infusion catheter was positioned in the proximal left anterior descending or proximal circumflex artery through the guiding catheter. After the baseline angiogram was recorded, 3 consecutive 2-minute infusions of acetylcholine were administered into the proximal coronary artery. The$ow rate (0.8 mllmin) was calculated to deliver a final estimated blood concentration of 10s, 10m7 and 10m6 M. After each acetylcholine infusion, repeat angiography was performed in an identical fashion to baseline. After the third acetylcholine in& sion and angiogram, a 50 pg bolus of nitroglycerin was administered and a final coronary angiogram was recorded. Heart rate, blood pressure and appropriate electrocardiographic leads were monitored during the infusions to verify the absence of any changes in hemodynamic status or evidence of &hernia. Proximal and midvessel segments of the coronary artery distal to the tip of the infusion catheter were analyzed without knowledge of the estrogen status using a quantitative coronary angiography method (Gammasonits, Chicago, Illinois). When possible, coronary segments from the noninfused half of the left coronary distribution

Does the use of new intracoronary interventional devices prolong radiation exposure in the cardiac catheterization laboratory?

Objectives. The aim of this study was to the duration of radiation exposure associated with new percutaneous coronary interventional devices with that associated with convention balloon angioplasty.Background. Radiation exposure levels has been documented to be higher with coronary balloon angioplasty than with routine diagnostic coronary angiography. However, the effect of new interventional devices on radiation exposure has not been studied.Methods. Fluoroscopic and cineangiographic data from the Mayo Clinic cardiac catheterization laboratory data base of patients having single-segment coronary intervention during a recent 46-month period were retrospectively analyzed. Of 897 patients studied, 646 underwent balloon angioplasty, 138 directional coronary atherectomy (42 with adjunctive balloon angioplasty), 76 excimer laser angioplasty (50 with adjunctive balloon angioplasty) and 37 placement of an intracoronary stent (16 emergencies).Results. Duration of fluoroscopy during balloon angioplasty was 24 ± 18 min, which was longer than with directional atherectomy (18 ± 8 min; p = 0.001). Fluoroscopy time was 25 ± 17 min with laser angioplasty and 29 ± 15 min with elective stent placement (neither time was significantly different from that with balloon angioplasty). When atherectomy or laser angioplasty was performed with adjunctive balloon angioplasty or if emergency intracoronary stent placement was performed, the duration of fluoroscopy was significantly prolonged compared with balloon angioplasty alone.Conclusions. Fluoroscopy duration is not prolonged with the use of new interventional coronary devices compared with conventional angioplasty unless adjunctive balloon angioplasty is used or emergency stent placement is required.