Guide To Cathether PDF

78852_FM 25/06/10 10:23 AM Page i
Introductory Guide to
Cardiac Catheterization
Second Edition
Arman T. Askari, MD, FACC

Clinical Associate Professor of Medicine
Case Western Reserve University, Attending Cardiologist
Harrington–McLaughlin Heart & Vascular Institute
University Hospitals Case Medical Center
Cleveland, Ohio
Mehdi H. Shishehbor, DO, MPH

Staff, Vascular Medicine & Interventional Cardiology
Heart & Vascular Institute Cleveland Clinic
Cleveland, Ohio
Adrian W. Messerli, MD, FACC, FSCAI

Co-Director, Cardiac Catheterization Laboratory
St. Joseph Hospital
Lexington, Kentucky
Ronnier J. Aviles, MD, FACC

Staff Interventional Cardiologist
Overlake Hospital Medical Center
Investigator, Hope Heart Institute
Bellevue, Washington
78852_FM 25/06/10 10:23 AM Page ii
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Library of Congress Cataloging-in-Publication Data
Introductory guide to cardiac catheterization/[edited by] Arman T. Askari ... [et al.].—2nd ed.
p. ; cm.
Includes bibliographical references and index.
Summary: “The staff in every catheterization laboratory in the world participates in some form
of hazing. Although largely benign and expected, this ritual can place even more stress on an
already unsettled and insecure newcomer. The first edition of this manual was spearheaded by
cardiology fellows who remembered well what it was like to enter the cath lab for the first time.
Now, several years later, these ‘hazees’ have in many cases become the ‘hazers’ but the additional
experience and responsibility has allowed for a more comprehensive and updated manual.Our
goal is to produce a thoroughly practical and easily accessible manual for physicians, physicians-
in-training, nurses, cath lab x-ray techs, mid-level providers and students. Since we have been
subjected to years of questions, first from our mentors and now from our students, we are
acutely familiar with the most pertinent and necessary data for any student no matter the level
of training. The manual remains specifically designed with an easy-to-read format that includes
highlighted ‘pearls,’ updated American College of Cardiology/American Heart Association
(ACC/AHA) guidelines, numerous visuals including carefully delineated schematics of standard
coronary projections, and special ‘troubleshooting’ notes that provide potential solutions for
frequently encountered problems”—Provided by publisher.
ISBN-13: 978-1-60547-885-2 (alk. paper)
ISBN-10: 1-60547-885-7 (alk. paper)
1. Cardiac catheterization—Handbooks, manuals, etc. I. Askari, Arman T.
[DNLM: 1. Heart Catheterization—methods. 2. Coronary Angiography—methods. WG
141.5.C2 I615 2011]
RC683.5.C25I588 2011
616.1’20754—dc22
2010021076
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78852_FM 25/06/10 10:23 AM Page iii
To our families for their continuous

and faithful support . . .
Jamie, Alexa, Amanda, Jacob,
Ali, Houri, Andrea, Zakarias, Emily,
Mia, Katie, Marco,
Jennifer, and Joshua.
78852_FM 25/06/10 10:23 AM Page iv
CONTENTS
Foreword to the First Edition vi

Foreword to the Second Edition viii
Preface x
Contributing Authors xi
1 Preprocedural Evaluation 1
Bethany A. Austin
2 Setting up the Lab 19
Matthew Kaminski
3 Native Coronary Angiography 41
Stephen Gimple, Niranjan Seshadri, Robert E. Hobbs,

and Sorin Brener
4 Bypass Graft Angiography 59
Kellan E. Ashley
5 Left Ventriculography and Aortography 69
Mateen Akhtar and Frederick A. Heupler, Jr.
6 Cerebral and Peripheral Angiography 85
Inder M. Singh, Steven J. Filby, and Mehdi H. Shishehbor
7 Hemodynamics in the Cath Lab 107
Brian W. Hardaway, Wilson H. Tang, and

Frederick A. Heupler, Jr.
iv
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Contents v
8 Approach to the High-Risk Patient 135
Daniel J. Cantillon
9 Hemostatic Devices 151
James E. Harvey and A. Michael Lincoff
10 Post-Cath Complications 169
Arun Kalyanasundaram and Mehdi H. Shishehbor
11 Study Questions 179
Index 195
78852_FM 25/06/10 10:23 AM Page vi
FOREWORD TO THE
FIRST EDITION
Consider you are a novice to the catheterization laboratory. Apparently,

you got hold of Introductory Guide to Cardiac Catheterization. Now, all
you have to do is retire for an afternoon and study it. You will still be a
novice, but you will be an enlightened and knowledgeable novice.
The authors, primarily cardiology fellows instrumental for the con-
tent and format of the manual, look at the challenging, sometimes frus-
trating, but mostly gratifying work in the cardiac catheterization labora-
tory from the front end. I look at it from the back end, with the
perspective of a lifelong career, and I see things exactly as they do. This
comes as close as anything to guaranteeing that the content of this book
is intelligible, valuable, and lasting.
In a succinct style and a condensed format, the authors report from
the scene. It is apparent that they have been in the midst of the action for
a while; that they have been wide awake while being there; and that they
have been blessed with the particular talent to grasp things, weigh them,
and convey them. Of course, the sedimented experiences of the senior
authors transpire here and there, particularly when pearls are pointed out
that give away the old crack. For instance, the importance of the conus
branch of the right coronary artery is highlighted. The conus branch is
often missed when it takes off separately from the right coronary artery,
and it may be the only contributor to an occluded left anterior descend-
ing coronary artery. Or it is recommended to keep attempts to pass a
stenosed aortic valve in time with systole. In diastole, it is indeed impos-
sible to pass the valve as it is closed; trivial, but blatantly ignored by most
of us.
The manual is made for readers or browsers. The readers will prevail,
as this is one of those books that are hard to put down. Hence, most will
start reading nonchalantly about how to prepare themselves and the pa-
tients for what has to be done in the catheterization laboratory. Then
they will casually settle down more comfortably to learn all they need to
learn, but not a thing more, about radiation protection and the basic ma-
terial, just before diving into some tricks of the trade explained in plain
words and with high-quality photographs and illustrations wherever per-
tinent. By now, they will be practically oblivious to what is going on
around them. Only the lazy ones will skip the somewhat more demand-
ing chapter on hemodynamics, muttering excuses such as “in my place,
vi
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Foreword to the First Edition vii
the computer does this.” This chapter has been the kernel of the thick-
belly books on cardiac catheterization of yesteryear. It still needs to be
there, but it needs to be there in a lean and stripped-down version such
as what is found in Chapter 6. One certainly should resist the temptation
to skip the final short chapter about the aftercare, because this usually is
more important for the patient than the brief intermezzo in the catheter-
ization laboratory, most of which he or she missed anyhow.
I also recommend this compendium for cardiologists in the phase of
only toying with the idea of commencing a career in the catheterization
laboratory. They will be reminded that the video game–like thrill in find-
ing the artery and being able to engage the coronary ostium in a reason-
able time is but the tip of the iceberg. What lies beneath is tough, partly
repetitious, and at times boring routine work with more immediate re-
sponsibility than many of us might care to bear. When pioneers like
Cournand, Sones, and Judkins introduced diagnostic cardiac catheteri-
zation and Rubio-Alvarez, Rashkind, King, and Gruentzig added a ther-
apeutic scent to it, they created a field of action for a new breed of doc-
tor: a mixture between the internist with a big brain and the hands in the
pockets and the gung-ho surgeon with big guts and the hands in every-
thing but the pockets. Introductory Guide to Cardiac Catheterization
will help you to find out whether you are one of that league or whether
it is worth (and safe) for you to try to become one. Enjoy it!
Bernhard Meier, MD
Professor and Head of Cardiology
Swiss Cardiovascular Center Bern
University Hospital
Bern, Switzerland
78852_FM 25/06/10 10:23 AM Page viii
FOREWORD TO THE
SECOND EDITION
The trainee beginning in the cardiac catheterization laboratory (physi-

cian, nurse, tech, or PA) is faced with the daunting task of quickly assim-
ilating a number of foreign concepts, including a new vocabulary, man-
ual skills requiring considerable dexterity, the need to quickly translate
two-dimensional images into three-dimensional anatomy and to relate
these findings to the clinical condition of the person before them, all in
the context of a potentially ill and vulnerable patient. For decades this
has been largely practiced as an apprenticeship. Historically, however,
most apprenticeships didn’t have an immediate risk as harmful to the
consumer (or patient) as this.
There is, therefore, a pressing need to accelerate the learning curve
of the apprentice. The second edition of Introductory Guide to
Catheterization helps achieve this goal. It succinctly presents the basic
concepts and skills in a very readable fashion, from the perspective of an
experienced veteran of the cardiac catheterization laboratory. Vascular
access (femoral, radial, or brachial), closure, the avoidance of errors of
omission (failure to find the errant high anterior right coronary artery
ostium) and commission (too superior an access to the femoral artery
resulting in increased risk of retroperitoneal bleed), and key hemody-
namic interpretations (tips to distinguish constructive vs. restrictive
pathophysiology) are all reviewed. The many illustrations and labeled
angiograms are a particular strength. It can be read in reasonably short
order as a prelude to stepping into the catheterization laboratory, or
as a reference when one has come across or approaches an unfamiliar
clinical situation.
All chapters have been meaningfully updated and new chapters on
peripheral angiography and key study questions have been added.
I wish that I had access to such a text when I began my career in the
cardiac catheterization laboratory nearly 30 years ago. I too readily recall
not knowing what was expected of me next, not understanding why the
same sequence of events wasn’t pursued in every patient, and in particu-
lar why my mentor kept trying to pull the diagnostic catheterization out
of the patient’s groin when I was laboring to torque it into the right
coronary artery (these were the days just before the routine use of vascu-
lar sheaths, and he wanted to make certain that I wouldn’t inadvertently
viii
78852_FM 25/06/10 10:23 AM Page ix
Foreword to the Second Edition ix
let the catheter come out of the femoral artery!). Many things have
changed since then, but the basics remain.
Stephen G. Ellis, MD
Section Head of Invasive/Interventional Cardiology
Robert and Suzanne Tomsich Department of Cardiovascular Medicine
Sydell and Arnold Miller Family Heart & Vascular Institute
Cleveland Clinic
Cleveland, Ohio
78852_FM 25/06/10 10:23 AM Page x
PREFACE
The staff in every catheterization laboratory in the world participate in

some form of hazing. Although largely benign and expected, this ritual
can place even more stress on an already unsettled and insecure new-
comer. The first edition of this manual was spearheaded by cardiology
fellows who remembered well what it was like to enter the cath lab for
the first time. Now, several years later, these “hazees” have in many cases
become the “hazers,” but the additional experience and responsibility
have allowed for a more comprehensive and updated manual.
Our goal is to produce a thoroughly practical and easily accessible man-
ual for physicians, physicians-in-training, nurses, cath lab x-ray techs, mid-
level providers, and students. Since we have been subjected to years of ques-
tions, first from our mentors and now from our students, we are acutely
familiar with the most pertinent and necessary data for any student no mat-
ter the level of training. The manual remains specifically designed with an
easy-to-read format that includes highlighted “pearls,” updated American
College of Cardiology/American Heart Association (ACC/AHA) guide-
lines, numerous visuals including carefully delineated schematics of stan-
dard coronary projections, and special “troubleshooting” notes that pro-
vide potential solutions for frequently encountered problems. Also included
are new chapters on peripheral angiography and study questions. The man-
ual is intended to fit conveniently within a lab coat pocket, so that it may
readily serve as a reference should a bout of hazing demand quick study!
We wish to acknowledge and thank Dr. Stephen Ellis, who spent not
only hundreds of hours teaching each of the editors, but also wrote a
beautiful foreword to our second edition. We remain grateful to Marion
Tomasko, Suzanne Turner, Charlene Surace, and Mary Ann Citraro who
worked tirelessly on the original graphics within this manual. Also, we
thank once again Dr. Bernhard Meier who provided us with a wondrously
supportive foreword to our first edition (enclosed). Finally, a particularly
fond nod of thanks is due each of the cardiology fellows who has con-
tributed to either edition of this manual.
We are grateful for the insightful criticisms we received from readers
on our first edition, and have incorporated many suggestions into this ef-
fort. Hopefully the education provided herein is more comprehensive as
a result! We value further feedback and suggestions. Please email any
comments or thoughts you might have to cathmanual@gmail.com.
Adrian W. Messerli, MD
x
78852_FM 25/06/10 10:23 AM Page xi
CONTRIBUTING
AUTHORS
Mateen Akhtar, MD Steven J. Filby, MD

Cardiologist Invasive Cardiology
Wake Heart & Vascular Associates Pinehurst Medical Center, Inc.
Smithfield, North Carolina Pinehurst, North Carolina
Kellan E. Ashley, MD Stephen Gimple, MD

Interventional Cardiology Fellow Northland Cardiology
Department of Cardiovascular North Kansas City, Missouri
Medicine
Cleveland Clinic Brian W. Hardaway, MD
Cleveland, Ohio Staff, Heart Failure &
Transplantation
Bethany A. Austin, MD HeartPlace at Baylor University
Fellow in Cardiovascular Disease Medical Center
Department of Cardiovascular Dallas, Texas
Medicine
Cleveland Clinic James E. Harvey, MD, MSc
Cleveland, Ohio Fellow of Cardiovascular Medicine
Heart and Vascular Institute
Sorin J. Brener, MD Cleveland Clinic
Professor of Medicine Cleveland, Ohio
Department of Medicine
Ohio State University Frederick A. Heupler, Jr, MD
Columbus, Ohio Department of Cardiovascular Disease
Department of Cardiology Cleveland Clinic
Cleveland Clinic Cleveland, Ohio
Cleveland, Ohio
Robert E. Hobbs, MD
Daniel J. Cantillon, MD Kaufman Center for Heart Failure
Co-chief Fellow Cleveland Clinic
Cardiac Electrophysiology Cleveland, Ohio
Department of Cardiovascular
Medicine Arun Kalyanasundaram, MD, MPH
Cleveland Clinic Interventional Cardiology Fellow
Cleveland, Ohio Cardiovascular Medicine
Cleveland Clinic
Cleveland, Ohio
xi
78852_FM 25/06/10 10:23 AM Page xii
xii Contributing Authors
Matthew Kaminski, MD Niranjan Seshadri, MD

Cardiologist Department of Cardiology
Western Reserve Heart Care Harvard University Medical School
University Hospitals Medical Practices Beth Israel Deaconess Medical Center
Assistant Professor of Medicine Boston, Massachusetts
Case Western Reserve University
Cleveland, Ohio Mehdi H. Shishehbor, DO, MPH
Staff, Interventional Cardiology &
A. Michael Lincoff, MD Vascular Medicine
Director, C5Research (Cleveland Cleveland Clinic
Clinic Coordinating Center Cleveland, Ohio
for Clinical Research)
Director, Center for Clinical Inder M. Singh, MD, MS
Research and Vice Chairman Interventional Cardiology Fellow
for Clinical Research, Lerner Division of Cardiovascular Diseases
Research Institute Mayo Clinic
Vice Chairman, Department of Rochester, Minnesota
Cardiovascular Medicine
Professor of Medicine, Cleveland Wilson H. Tang, MD
Clinic Lerner College of Department of Cardiovascular
Medicine of Case Western Medicine
Reserve University Cleveland Clinic
Cleveland Clinic Cleveland, Ohio
Cleveland, Ohio
78852_ch01 18/06/10 1:06 PM Page 1
CHAPTER 1
Preprocedural Evaluation
Bethany A. Austin
Cardiac catheterization is an invaluable tool for both diagnostic and

therapeutic purposes, with between 2 and 3 million procedures per-
formed annually in the United States. Due to the inherent risks associated
with this invasive procedure, angiographers must be well versed in the indi-
cations, contraindications, and potential complications associated with
this procedure. Thorough preprocedural evaluation facilitates appropriate
selection of candidates for catheterization and identification of those at
highest risk for complications.
Clinical Evaluation
Careful inquiry into a patient’s clinical presentation is an essential com-
ponent of the precatheterization evaluation. In addition to establishing
the indication for catheterization, the clinical syndrome guides the se-
lection of techniques employed during catheterization, including coro-
nary angiography, hemodynamic measurements, left ventriculography,
aortography, cerebral angiography, peripheral angiography, renal an-
giography, right heart catheterization, biopsy, and provocative chemical
challenge.
Concomitant medical conditions should be identified and relevant
comorbidities addressed prior to catheterization (Table 1-1). For example,
severe thrombocytopenia or coagulopathy may render the patient ineli-
gible for catheterization. In those with a prior history of heparin-
induced thrombocytopenia, heparin-free solutions and flushes should be
prepared. Alternate forms of anticoagulation, such as direct thrombin
inhibitors, may be preferable for percutaneous intervention. In patients
with chronic kidney disease (CKD), renal function should be optimized
prior to catheterization (see Troubleshooting and Table 1-6).
Patients with severe lower extremity arterial disease may require
catheterization via the brachial or radial artery. A history of an aortic
aneurysm of significant size or prior aortic dissection may also favor
1
78852_ch01 18/06/10 1:06 PM Page 2
2 Introductory Guide to Cardiac Catheterization
Table 1-1 Relevant Historical Elements
A. Prior cardiac catheterizations and/or cardiac surgeries

B. Results of noninvasive cardiac imaging (echo, stress test, ECG)
C. Comorbid medical conditions
1. Chronic kidney disease
2. Diabetes mellitus
3. Peripheral vascular disease
4. Aortic aneurysm/dissection
5. Valvular heart disease
6. Thrombocytopenia/heparin-induced thrombocytopenia
7. Coagulopathy
8. Anemia
9. Cerebrovascular disease
10. Hypertension
11. Pulmonary disease
12. Liver disease
13. Contrast allergy
brachial or radial artery access. Any history of claudication in conjunc-

tion with the peripheral pulse exam should be taken into account when
selecting the arterial access site.
In patients with known pre-existing coronary artery disease, detailed
knowledge of all prior catheterizations, percutaneous interventions,
and cardiac surgeries is imperative. If possible, films of prior catheter-
izations should be reviewed for comparison. The angiographic location
of prior bypass graft origins should be noted, as should any unusual
catheters previously required. Knowledge of prior peripheral vascular
interventions and surgeries is also useful in planning access.
Medication allergies should be documented prior to the procedure.
In particular, patients with a history of contrast media allergy require
special consideration (see Troubleshooting). Latex allergy is not a con-
traindication to cardiac catheterization; however, the catheterization lab-
oratory should be notified of the allergy and be prepared to use only
latex-free equipment for the case. Particular attention should also be
paid to allergies to medications that are commonly used during the pro-
cedure, such as benzodiazepines and opiates.
A focused physical exam is a prerequisite for cardiac catheterization.
Specifically, there should be an evaluation of any stigmata of congestive
heart failure (CHF) such as rales, jugular venous distension, an S3, or
78852_ch01 18/06/10 1:06 PM Page 3
Chapter 1 • Preprocedural Evaluation 3
peripheral edema. Auscultation of any murmurs, particularly those that

suggest aortic stenosis or mitral regurgitation, should be noted. A careful
examination of peripheral pulses and search for arterial bruits will
influence the choice of arterial access site and serve as a helpful compar-
ison when assessing for postprocedural vascular complications.
Standard laboratory evaluation includes electrolytes, blood urea
nitrogen, serum creatinine, blood glucose, and complete blood
count. A coagulation panel is indicated in any patient on anticoag-
ulant medication or who is at risk for significant hepatic dysfunc-
tion. These laboratory tests should be current (i.e., within 1 month of
the procedure). Similarly, a current electrocardiogram should be assessed.
Evidence of ischemia, prior myocardial infarction (MI), rhythm distur-
bances, and chamber enlargement/hypertrophy should be noted. The
baseline electrocardiogram also provides a comparison for any periproce-
dural changes. If a prior echocardiogram is available, preprocedural
knowledge of left ventricular systolic or diastolic dysfunction, significant
valvular disease, and aortic abnormalities is often helpful. Similarly, if a
prior stress test is available, one should be familiar with areas of ischemia
and scar.
Indications
The decision to proceed with diagnostic cardiac catheterization is
based on a careful assessment of the risk–benefit ratio for the procedure
(Table 1-2). The most current guidelines for diagnostic coronary angiog-
raphy, reported by a joint Task Force of the American College of
Cardiology and the American Heart Association (ACC/AHA), divide
the indications for coronary angiography into three classes. Class I indi-
cations are conditions for which there is evidence and/or general agree-
ment that the procedure is useful and effective. Class II indications are
conditions for which there is conflicting evidence and/or a divergence of
opinion about the usefulness/efficacy of performing the procedure.
Class III indications are conditions for which there is evidence and/or
general agreement that the procedure is not useful/effective and that in
some cases may be harmful.
Cardiac catheterization is a powerful tool for risk stratification during
acute MI and for facilitating revascularization. Emergent coronary angiog-
raphy with the intent to perform primary percutaneous coronary in-
tervention is most applicable to patients presenting within 12 hours
of an acute ST elevation or new left bundle branch block (LBBB) MI.
This strategy can also be applied to patients with non–ST elevation
MI who have persistent or recurrent symptoms despite optimal med-
ical therapy or high-risk features which include elevated troponin,
78852_ch01 18/06/10 1:06 PM Page 4
Table 1-2 Indications for Coronary Angiography

Class Iab
Unstable Coronary Syndromes

Unstable angina/ACS refractory to medical therapy or recurrent symptoms after
initial medical therapy
Unstable angina/ACS with high-risk indicators
Unstable angina/ACS initially at low short-term risk, with subsequent
high-risk noninvasive testing
Prinzmetal angina with ST elevation
Suspected acute or subacute stent thrombosis after PCI
Angina
High-risk noninvasive testing
CCS class III or IV angina on medical therapy
Recurrent angina 9 months after PCI
Acute Myocardial Infarction
Intended PCI in acute ST elevation or new LBBB MI
Within 12 hours of symptom onset
Ischemic symptoms persisting after 12 hours of symptom onset
Cardiogenic shock in candidates for revascularization
Persistent hemodynamic or electrical instability
Angiography in non-ST elevation MI
As part of an early invasive strategy in high-risk patients (+ troponin, ST
changes, CHF, hemodynamic/electrical instability, recent revascularization)
Persistent or recurrent symptomatic ischemia with or without associated
ECG changes despite anti-ischemic therapy
Resting ischemia or ischemia provoked by minimal exertion following
infarction
Prior to surgical repair of a mechanical complication of MI in a sufficiently
stable patient
Perioperative Risk Stratification for Noncardiac Surgery
High-risk noninvasive testing
Unstable angina or angina unresponsive to medical therapy
Equivocal noninvasive test result in patient with high clinical risk undergoing
high-risk surgery
Congestive Heart Failure
Systolic dysfunction associated with angina, regional wall motion
abnormalities, or ischemia on noninvasive testing
78852_ch01 18/06/10 1:06 PM Page 5
Table 1-2 (Continued )
Other Conditions
Valvular surgery in patients with angina, significant risk factor(s) for CAD,
or abnormal noninvasive testing
Valvular surgery in men 35 or older, any postmenopausal woman, and
premenopausal women 35 or older with cardiac risk factors
Correction of congenital heart disease in patients with angina, high-risk non-
invasive testing, form of congenital heart disease frequently associated with
coronary artery anomalies, or in those with known coronary anomalies
After successful resuscitation from sudden cardiac death, sustained monomorphic
ventricular tachycardia, or nonsustained polymorphic ventricular tachycardia
Infective endocarditis with evidence of coronary embolization
Diseases of the aorta necessitating knowledge of concomitant coronary disease
Hypertrophic cardiomyopathy with angina
Class IIac
Angina
CCS class I or II, EF ⬍45%, and abnormal but not high-risk noninvasive testing
Patients with an uncertain diagnosis after noninvasive testing in whom the
benefits of the procedure outweigh the risk
Patient who cannot be risk stratified by other means
Patients in whom nonatherosclerotic causes such as anomalous coronary artery,
radiation vasculopathy, coronary dissection, etc. are suspected
Recurrent angina/symptomatic ischemia within 12 months of CABG
Recurrent angina poorly controlled with medical therapy after revascularization
Patients with CHF who have chest pain, have not had evaluation of their
coronary anatomy, and do not have contraindications to revascularization
Acute Myocardial Infarction
MI suspected to have occurred by a mechanism other than thrombotic occlusion
of atherosclerotic plaque (coronary embolism, arteritis, trauma, coronary spasm)
Failed thrombolysis with planned rescue PCI
Post MI with LVEF ⬍40%, CHF, or malignant arrhythmias
CHF during acute episode with subsequent demonstration of LVEF ⬎40%
Patients with recurrent ACS despite therapy without high-risk features
Planned vascular surgery with multiple intermediate clinical risk factors
Moderate-large region of ischemia on stress test without high-risk features
or decreased EF
(Continued on next page)
78852_ch01 18/06/10 1:06 PM Page 6
Equivocal noninvasive testing in patient with intermediate clinical risk

undergoing high-risk surgery
Urgent noncardiac surgery while recovering from an acute MI
Other Conditions
Systolic LV dysfunction with unexplained cause after noninvasive testing
Episodic CHF with normal LV systolic function with suspicion for ischemia-
mediated LV dysfunction
Before corrective surgery for congenital heart disease in patients whose risk
factors increase likelihood of coronary disease
Recent blunt chest trauma and suspicion for acute MI
Before surgery for aortic dissection/aneurysm
Periodic follow-up after cardiac transplantation or for prospective immediate
cardiac transplant donors
Asymptomatic patients with Kawasaki disease and coronary artery aneurysms
on echocardiography
a
ACC/AHA Guidelines adapted from Scanlon JP, Faxon DP, Audet AM, et al. ACC/AHA
guidelines for coronary angiography: executive summary and recommendations. A report of
the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee on Coronary Angiography). Circulation. 1999;99:2345–2357; and Libby P,
Bonow RO, Mann DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular
Medicine. 8th ed. Philadelphia: W.B. Saunders Company; 2007.
b
Conditions for which there is evidence and/or general agreement that this procedure is
indicated.
c
Conditions for which indications are controversial, but the weight of the evidence is
supportive.
ACS, acute coronary syndrome; CABG, coronary artery bypass graft, CAD, coronary artery dis-
ease, CCS, Canadian Cardiovascular Society, CHF, congestive heart failure, ECG, electrocardio-
gram, LBBB, left bundle branch block; LVEF, left ventricular ejection fraction, MI, myocardial
infarction, PCI, percutaneous coronary intervention.
new ST depression, signs/symptoms of CHF, hemodynamic or elec-

trical instability, and prior revascularization. Ideally, door-to-balloon
time in patients with ST elevation MI should be within 90 minutes.
Urgent angiography should also be performed in those patients younger
than 75 years with ST elevation MI complicated by cardiogenic shock de-
veloping within 36 hours of MI who are candidates for revascularization.
It is reasonable to include patient older than 75 years of age who have
78852_ch01 18/06/10 1:06 PM Page 7
good functional status and who are both suitable and agreeable to revas-
cularization. Patients with persistent chest pain or ST elevation after
fibrinolytic therapy should also have urgent angiography with the intent
to perform primary percutaneous intervention. Additionally, patients
who are successfully resuscitated from sudden cardiac death (without a
readily identifiable cause) have a high probability of underlying coronary
disease and should undergo cardiac catheterization.
During the hospital management phase following all types of MI, re-
current ischemia, malignant arrhythmias, clinical heart failure, and hemo-
dynamic instability all warrant coronary angiography. Coronary angiogra-
phy is indicated following all types of MI in patients with high-risk
findings on stress testing, which include ST depression of ⱖ2 mm in mul-
tiple leads or persisting into recovery 6 minutes, ST elevation of ⱖ2 mm
in leads without Q waves, a drop in blood pressure of 10 mm Hg or more
with exercise, or development of ventricular tachycardia with stress.
High-risk stress imaging findings include left ventricular dilatation, de-
crease in ejection fraction ⱖ10%, and multiple areas of ischemia.
An early invasive strategy with coronary angiography with the goal of
revascularization should be utilized in patients presenting with unstable
angina/non–ST elevation MI with high-risk indicators. This may be as-
sessed using validated risk scoring systems such as the Thrombolysis in
Myocardial Infarction (TIMI) or The Global Registry of Acute Coronary
Events (GRACE) risk scores. Alternatively, clinical variables such as ST
segment changes, positive troponin assays, signs/symptoms of CHF,
new or worsening mitral regurgitation, decreased left ventricular systolic
function ⬍40%, and hemodynamic or electrical instability can be used.
Additionally, patients with previous revascularization, particularly within
the last 6 to 12 months, are considered at high risk. Any patient with
UA/NSTEMI and a high-risk stress test result (see above) should pro-
ceed to coronary angiography. Depending on physician preference, pa-
tients with low-risk features may be further risk stratified with noninvasive
testing prior to consideration of catheterization unless they develop re-
current severe or unstable angina despite medical management.
Development of ischemia after percutaneous coronary intervention
may occur via acute or subacute stent thrombosis (⬍48 hours) or via in-
stent restenosis (3–6 months). Similarly, surgical revascularization may be
complicated by graft obstruction in the immediate perioperative period, or
by graft disease that develops over time. Suspected stent thrombosis
warrants urgent catheterization and possible percutaneous coronary
intervention. Patients with recurrent angina or high-risk features on
noninvasive testing within 9 months of successful percutaneous inter-
vention or 12 months following coronary artery bypass graft surgery are
78852_ch01 18/06/10 1:06 PM Page 8
Table 1-3 Canadian Cardiovascular Society Classification of Angina

Canadian Class Definition
I Ordinary physical activity does not cause angina

II Slight limitation of ordinary activity (walking ⬎2 blocks
or climbing ⬎1 flight of stairs)
III Marked limitation of ordinary physical activity (walking
1–2 blocks or climbing 1 flight of stairs)
IV Inability to carry on any activity without discomfort
also suitable candidates for coronary angiography. A low threshold for an-
giography is appropriate in patients with prior CABG in light of the vari-
ety of anatomic possibilities that can be provoking ischemia.
In patients with known or suspected coronary disease who are experi-
encing typical angina, the Canadian Cardiovascular Society classification of
angina is a useful tool to gauge the severity of symptoms (Table 1-3).
Patients with severe symptoms (CCS class III or IV) despite optimal med-
ical therapy should undergo coronary angiography. Presence of high-risk
criteria on noninvasive testing (see above) should also prompt coronary
angiography in patients with known or suspected coronary disease, regard-
less of symptom severity. Patients with deterioration on serial noninvasive
testing or patients with accelerating (crescendo) angina despite medical
therapy should also be considered for angiography, even if noninvasive
testing does not demonstrate high-risk features. Routine angiography in
asymptomatic patients without evidence of ischemia is not advocated.
Atypical or nonspecific chest pain is infrequently due to myocardial
ischemia. There are, however, several rare causes of ischemia that should
be entertained in the differential diagnosis of atypical chest pain. These
include Prinzmetal angina, cocaine abuse, coronary microvascular dis-
ease, pericarditis, myocarditis, coronary embolus, and aortic dissection.
Noncardiac causes of chest pain include costochondritis, pleuritis, pul-
monary embolus, and esophageal disorders. Due to the broad spectrum
of possible etiologies for atypical chest pain, coronary angiography should
be reserved for patients who demonstrate high-risk findings on noninva-
sive testing including ECG, or those in whom there is a clinical suspicion
of coronary spasm meriting provocative testing.
The presence of left ventricular systolic dysfunction merits considera-
tion of the possibility of concomitant coronary artery disease. Any patient
with CHF in conjunction with reversible ischemia on noninvasive testing
or regional wall motion abnormalities should be evaluated for coronary
78852_ch01 18/06/10 1:06 PM Page 9
disease by angiography unless the patient is not a candidate for revascu-

larization. Systolic dysfunction that is unexplained by noninvasive testing
should also be further investigated by angiography.
In patients undergoing nonemergent surgery for valvular disease,
coronary angiography is recommended for those at increased risk for con-
comitant coronary disease. Presence of chest pain, ischemia on noninva-
sive testing, decreased ejection fraction, or any significant risk factor for
coronary disease all constitute class I indications for catheterization. Men
35 and older should have routine angiography prior to valvular surgery,
as should postmenopausal women and premenopausal women 35 and
older. In addition, patients with infective endocarditis who demonstrate
evidence of coronary embolism should undergo coronary angiography.
In patients with aortic valve endocarditis, particular care must be paid to
catheter manipulation to avoid disrupting the vegetation, which could
result in an embolic episode. Additionally, catheterization is indicated in
those patients with symptomatic valvular lesions who have inconclusive or
discordant noninvasive findings to obtain further diagnostic information
such as hemodynamic measurements, transvalvular gradients, left ventric-
ular pressure, aortography, or ventriculography.
In fact, when a cardiac surgical procedure is planned, patients with
any significant risk factor(s) for coronary artery disease should undergo
preoperative angiography, as should any with possible anginal symptoms.
In preparing for surgical correction of congenital heart disease, those with
chest pain or noninvasive testing suggestive of coronary artery disease
should undergo diagnostic catheterization, as should those with condi-
tions frequently associated with coronary anomalies that may complicate
surgery. Patients in whom there is suspicion for malignant anomalies such
as coronary artery stenosis, coronary arteriovenous fistula, and anom-
alous left coronary artery should also have diagnostic angiography prior
to any correction. Additionally, patients with aortic disease such as dissec-
tion or aneurysm should have diagnostic catheterization prior to surgery
or at any point in their clinical course when knowledge of the presence
and extent of coronary artery disease is needed for management. In
preparation for nonemergent, noncardiac surgery, those patients with
evidence for high risk of adverse outcome based on noninvasive test re-
sults (i.e., suggestive of left main trunk [LMT] or multivessel disease),
those with angina unresponsive to medical therapy and those with unsta-
ble angina should undergo coronary angiography prior to surgery.
It is equally important to be aware of conditions for which angiogra-
phy is not indicated (Table 1-4). Patients who refuse, or who are ineligible
for, revascularization should not undergo coronary angiography. The only
absolute contraindication to coronary angiography is the patient’s
refusal to undergo the procedure. There are, however, several relative
78852_ch01 25/06/10 4:06 PM Page 10
Table 1-4 Class IIIa Indications for Coronary Angiographyb
Unstable Angina
Symptoms suggestive of unstable angina but without objective signs of
ischemia and with a normal coronary angiogram during the past 5 years
Unstable angina in patients who are not revascularization candidates or for
whom revascularization will not improve the quality or duration of life
Unstable angina in a post-bypass patient who is not a revascularization candidate
Patients with extensive comorbidities in whom risks of revascularization likely
outweigh the benefits
Angina and Coronary Artery Disease
Angina in patients who do not desire revascularization
Screening test for CAD in asymptomatic patients
Patients with comorbidity in whom the risk outweighs the benefit of the
procedure
Provocative testing in patients with high-grade obstructive disease
Nonspecific chest pain with normal noninvasive testing
Patients with CCS class I or II responsive to medical therapy with no ischemia
on noninvasive testing
Routine angiography in asymptomatic patients after PCI or CABG (except in
unprotected LMT PCI in which angiographic follow-up in 2–6 months is
reasonable)
Myocardial Infarction: ST Segment Elevation or New LBBB
Patients beyond 12 hours from symptom onset who have no evidence of
ongoing ischemia
After thrombolytic therapy with no evidence of ongoing ischemia
Routine angiography and PCI within 24 hours of thrombolytic therapy
Patients with extensive comorbidities in whom risks of revascularization likely
outweigh benefits
All Myocardial Infarction: Hospital Management and Risk Stratification
Phase
Patients who are not revascularization candidates or do not desire
revascularization
Low-risk surgery with known CAD and no high-risk results on noninvasive
testing
Asymptomatic after revascularization with excellent exercise capacity
(⬎7 metabolic equivalents)
78852_ch01 18/06/10 1:06 PM Page 11
Mild stable angina, good left ventricular function, and not high risk by
noninvasive testing
Patients who are not candidates for revascularization or do not desire
revascularization
Part of work-up for renal, liver, or lung transplant without high-risk noninvasive
test results
Valvular Heart Disease
Prior to surgery for infective endocarditis in patients lacking risk factors for
CAD or evidence for coronary embolization
Routine angiography in patients not being assessed for surgery
a
Conditions in which there is a consensus against the usefulness of the procedure.
b
Adapted from Scanlon PJ, Faxon DP, Audet AM, et al. ACC/AHA guidelines for coronary
angiography: executive summary and recommendations. A report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee
on Coronary Angiography). Circulation. 1999;99:2345–2357; and Libby P, Bonow RO, Mann
DL, et al. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed.
Philadelphia: W.B. Saunders Company; 2007.
CAD, coronary artery disease; CCS, Canadian Cardiovascular Society; PCI, percutaneous
coronary intervention; CABG, coronary artery bypass graft; LMT, left main trunk; LBBB, left
bundle branch block.
contraindications (Table 1-5). These include a history of acute or advanced

chronic renal failure, as contrast-induced or atheroembolic renal failure
incurred during catheterization may significantly worsen pre-existing renal
dysfunction. Gastrointestinal bleeding or unexplained anemia is a concern,
especially if there is potential for percutaneous coronary intervention
following diagnostic angiography, as this requires aggressive anticoagula-
tion. Uncontrolled hypertension increases the risk of local vascular compli-
cations. Those patients with decompensated heart failure may not be
able to tolerate lying flat and may suffer further deterioration from the
contrast load.
Right heart, or pulmonary artery, catheterization can be performed
simultaneously with left heart catheterization or in isolation depending
on the clinical scenario. Indications for right heart catheterization
include: acute MI associated with hemodynamic or mechanical complica-
tions, evaluation of etiology of shock and response to therapy, assessment
of severity and potential reversibility of pulmonary hypertension, diagno-
sis of presence and significance of possible intracardiac shunt, and to
delineate constrictive from restrictive physiology. For those patients with
78852_ch01 18/06/10 1:06 PM Page 12
Table 1-5 Relative Contraindications to Coronary Angiographya
Acute renal failure or advanced chronic renal dysfunction

Active bleeding
Unexplained fever or significant leukocytosis
Untreated active infection
Acute stroke
Malignant hypertension
Significant electrolyte imbalance (i.e., K ⬍3.0)
Patient unable to cooperate or does not desire revascularization
Concomitant severe illness reducing life expectancy
Digitalis toxicity
Decompensated heart failure or acute pulmonary edema precluding adequate
patient positioning or oxygenation
Severe anemia or coagulopathy
Aortic valve endocarditis
a
Adapted from Scanlon PJ, Faxon DP, Audet AM, et al. ACC/AHA guidelines for coronary
angiography: a report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Committee on Coronary Angiography). J Am Coll Cardiol.
1999;33:1756–1824.
severe class IV CHF, right heart catheterization can be used both to

diagnose the hemodynamic significance of their ventricular failure, to risk
stratify them in the process of heart transplant evaluation, and to guide
aggressive therapies such as ionotropic agent and intravenous afterload
reduction. Additionally, right heart catheterization with endomyocardial
biopsy is a routine component of the monitoring of post–heart transplant
patients. Less compelling indications include assessment of volume status
and diagnosis of cardiac tamponade. Right heart catheterization should
not be performed in patients with right-sided thrombus or endocarditis
or in those with mechanical tricuspid or pulmonic valve prostheses.
Angiography of the renal arteries remains the gold standard for eval-
uation of possible renal artery stenosis and should be considered in those
patients with refractory hypertension, those with abrupt onset of hyper-
tension, young patients with hypertension in whom fibromuscular dysplasia
is a clinical consideration, or to confirm findings from a noninvasive study
such as a renal Duplex ultrasound. An additional benefit of renal angiog-
raphy is the ability to measure the gradients across any areas of stenosis.
Similarly, cerebral angiography with digital subtraction angiography can be
performed to definitively evaluate any cerebrovascular disease suspected
78852_ch01 18/06/10 1:06 PM Page 13
clinically or, more typically, based on noninvasive findings. It

allows visualization of the entire carotid circulation, including collateral-
ization, and remains the gold standard. Additionally, cerebral angiogra-
phy may be indicated in patients with infective endocarditis who require
evaluation of possible mycotic aneurysm. However, the potential benefits
must be weighed against the invasive nature of the test and possible neu-
rologic complications, the incidence of which approaches 4%.
Angiography of the peripheral arteries can be performed to establish
definitive diagnosis of peripheral arterial disease or subclavian stenosis.
Indications include: preprocedural evaluation in those patients in whom
revascularization is planned (class I), those who have significant symp-
toms from likely peripheral arterial disease such as rest pain or ulceration
of the extremities, or for definitive diagnosis of peripheral arterial disease
when noninvasive techniques are nondiagnostic.
Complications
The risk of major complications (death, MI, stroke) following diagnostic
coronary angiography is generally less than 1%. However, several comor-
bid conditions significantly increase this baseline risk, including peripheral
arterial disease, CKD, and diabetes mellitus requiring insulin therapy.
Clearly, critically ill patients or those who have recently suffered a cardiac
event are at higher risk than stable patients undergoing an elective proce-
dure. Assessment of the patient’s risk for complications is an important
determinant of whether the procedure can be performed on an outpa-
tient basis. Several factors favor short-term hospitalization after catheteri-
zation, including hydration for patients with chronic renal insufficiency
and heparin bridging for mechanical prosthetic valves.
Obtaining informed consent for the catheterization is an inte-
gral part of preparing the patient. This discussion includes a thorough
explanation of the indication for the procedure, the risks of administer-
ing conscious sedation, and the risks and benefits of the catheterization
procedure. Although the risk of an adverse event for an individual
patient does depend on the patient’s comorbidities, the operator’s expe-
rience, type of procedure, and the clinical setting in which the procedure
is being performed, pooled frequencies of major complications may be
used during an informed consent discussion.
The rate of death complicating coronary angiography has
steadily fallen over the past 15 years and is now approximately 0.1%.
High-risk features for periprocedural mortality include advanced age (age
ⱖ60 years), advanced New York Heart Association functional class, severe
left main coronary artery disease, and left ventricular systolic dysfunc-
tion (ejection fraction ⬍30%). Baseline renal insufficiency, with worsening
78852_ch01 18/06/10 1:06 PM Page 14
of renal function following catheterization, is associated with a particu-

larly high mortality.
Periprocedural MI is fairly uncommon (ⱕ0.1%). It is reasonable to
check postprocedural cardiac enzymes in those at high risk. In the event of
an ischemic complication during the procedure, it is advantageous to have
cardiac surgical backup available. The patient and his or her family should
be aware of the potential need for emergency coronary artery bypass sur-
gery. Moreover, the patient and his or her family should be counseled
about the potential need for percutaneous coronary intervention or coro-
nary artery bypass graft surgery following the diagnostic procedure.
Periprocedural stroke rates have been quoted as ranging from
0.07% to 0.4%. Strokes are more common in patients with known cere-
brovascular disease, hypertension, and severe aortic atherosclerosis. In
such patients, catheter exchanges may be performed over a wire to min-
imize aortic atheromatous plaque disruption. Undoubtedly, patients
with significant aortic stenosis who undergo retrograde valve catheteri-
zation are at increased risk for stroke. Patients who undergo catheteriza-
tion following administration of thrombolytics or who receive high-dose
anticoagulation, as well as those with advanced age or uncontrolled
hypertension, are at increased risk for hemorrhagic stroke. The occur-
rence of periprocedural stroke has been associated with poor prognosis.
The incidence of vascular complication in diagnostic catheterization
has fallen over the last decade with an incidence generally quoted as less
than 1%. However, local vascular complications continue to be relatively
common. Additionally, they are highly visible and distressing to the
patient and are associated with significant morbidity. Local vascular com-
plications are discussed in greater detail in Chapters 8 and 9.
Malignant arrhythmias such as ventricular tachycardia or ventricular
fibrillation are rare. Minor ectopy and paroxysmal atrial arrhythmias are
more common, but generally represent a benign and self-limited response
to catheter manipulation. Bradycardia is the most common rhythm dis-
turbance during catheterization, either in conjunction with a vasovagal
reaction or in patients with pre-existing conduction disease. In particular,
patients who have underlying LBBB who undergo right heart catheteri-
zation are at risk for advanced heart block.
The most common allergic reactions encountered during catheteriza-
tion result from administration of contrast dye. Contrast dye allergies are
relatively common, with up to 1% of patients developing some adverse
reaction. Patients with known dye allergies should be premedicated with
corticosteroids and antihistamines and should receive noniodinated con-
trast (see Troubleshooting and Table 1-6).
Renal dysfunction can result from administration of contrast agents,
which is reported to occur in approximately 5% patients, or from renal
78852_ch01 18/06/10 1:06 PM Page 15
Troubleshooting
Precatheterization Preparation of Patients with Renal Dysfunction
Patients with any degree of renal impairment need to be well hydrated prior to cardiac
catheterization, but it is essential in patients with a creatinine clearance ⬍60 mL/min
or a creatinine of ⬎1.5. Hydration with 1 mL/kg/hr of either 0.9% or 0.45% saline for
approximately 12 hours before and after the procedure has long been standard of
care. In recent years, an alternative protocol using sodium bicarbonate 3 mL/kg for
1 hour prior to the procedure and 1 mL/kg for 6 hours after the procedure has also
been shown to be at least as efficacious and is an appropriate hydration option as
well. Modifications such as eliminating the bicarbonate bolus or decreasing the infu-
sion rate or duration may be appropriate in patients who have a decreased left ven-
tricular ejection fraction or a tenuous fluid balance.
Use of N-acetylcysteine (Mucomyst) 600 mg orally twice a day for four doses, two
before the procedure and two afterward should also be considered. An increased dose
of 1200 mg is reasonable in high-risk patients (creatinine ⬎2.5 mg/dL or contrast load
⬎140 mL). It is important to make patients with renal dysfunction who may require a
coronary intervention aware of the possibility that a staged procedure may be a neces-
sary precaution to minimize the contrast load.
Precatheterization Preparation of Patients with a Contrast Allergy
Patients with a documented contrast, iodine, or shellfish allergy should be premed-
icated with a regimen of corticosteroids (Prednisone 50–60 mg orally or Hydrocortisone
100 mg intravenously the night prior and the morning of the procedure) and antihista-
mines (Benadryl 25–50 mg orally or IV the night prior and the morning of the procedure)
according to institutional preference (see Chapter 2 for more details).
atheroembolic disease, which is significantly less common. Renal atheroem-

bolic disease complicates approximately 0.15% of cardiac catheterizations
and should be suspected when acute renal failure occurs in conjunction
with other clinical signs of embolization such as discolored toes, livedo
reticularis, systemic or urinary eosinophilia, and abdominal pain.
While infection is generally not a common complication due to ster-
ile technique, patients in whom a brachial approach is used and those in
whom arterial closure devices are used are at a slightly higher risk. Toxic
radiation exposure is also relatively uncommon, particularly in a straight-
forward diagnostic procedure where levels of exposure are often less
than those received from a nuclear stress imaging study. However, spe-
cial care should always be taken to minimize the amount of radiation ex-
posure using the principle of “as low as reasonably achievable” without
undue sacrifice of study quality. Additionally, those patients who have
had recent radiation exposure in other catheterizations or procedures
78852_ch01 18/06/10 1:06 PM Page 16
should receive additional counseling about the potential risk for toxicity
including delayed skin burns.
Medication Considerations Prior to Coronary Angiography

In patients who are candidates for percutaneous coronary intervention
after diagnostic angiography, aspirin 325 mg should be administered on
the day of the procedure (Table 1-6). The use of clopidogrel (600 mg
loading dose) prior to catheterization may be indicated in patients who
are likely to undergo percutaneous coronary intervention. This must be
weighed against the possibility that they will require coronary artery
bypass graft surgery, which often must be postponed for several days after
administration of clopidogrel. Warfarin should be stopped several days
before the procedure. Ideally, the international normalized ratio
Table 1-6 Preprocedural Medication Considerations

Medication Adjustment
Aspirin 325 mg orally prior to the procedure

Clopidogrel 600 mg oral loading dose if there is a high
probability of PCI
Glycoprotein IIb–IIIa Inhibitor Continue if already started; may be started on
arrival to lab if PCI planned
Unfractionated heparin Per discretion of operator, but generally held on
patient transport to catheterization lab
Low molecular weight heparin Per discretion of operator
Warfarin Hold for 2–3 days prior to procedure until INR
⬍1.5–1.8; heparin or low molecular weight
heparin can be used if continued
anticoagulation is essential
Insulin and hypoglycemics Hold on the morning of the procedure
Metformin Hold on the day prior to procedure and resume
2 days after procedure if renal function
remains unchanged
Acetylcysteine (Mucomyst) 600–1200 mg orally twice daily starting the day
prior to the procedure for patients with
chronic renal dysfunction
PCI, percutaneous coronary intervention.
78852_ch01 18/06/10 1:06 PM Page 17
should be less than 1.5 to 1.8 prior to catheterization, depending on

operator comfort and acuity of the indication. Heparin (3,000 to
5,000 units IV) should be considered for patients undergoing cardiac
catheterization via an arm approach.
Metformin is eliminated primarily via the kidneys and therefore accu-
mulates among patients with renal insufficiency (glomerular filtration rate
⬍70 mL/min, or serum creatinine ⬎1.6 mg/dL). Contrast media can
impair renal function and lead to further retention of metformin, which is
known to precipitate the onset of lactic acidosis. The incidence of lactic
acidosis associated with metformin, regardless of exposure to contrast
media, is 0.03 cases per 1,000 patients per year, and 50% result in death.
There is no conclusive evidence to indicate that contrast media precipitates
the development of metformin-induced lactic acidosis among patients
with normal serum creatinine (⬍1.5 mg/dL). This complication is almost
exclusively observed among non–insulin dependent diabetic patients with
abnormal renal function before injection of contrast media. Metformin
should be held the day prior to the procedure and restarted 2 days
after the procedure if renal function remains unchanged.
Long-acting oral hypoglycemics and insulin should be held 12 to
24 hours prior to the procedure depending on their duration of action.
In general, diuretics should be held 12 to 24 hours prior to the proce-
dure in an effort to avoid excessive nephrotoxicity unless of course the
patient’s volume status is tenuous.
General Suggested Reading

Baim DS, Grossman W, eds. Cardiac Catheterization, Angiography, and
Intervention. 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2006.
Kern MJ. The Cardiac Catheterization Handbook. 4th ed. St. Louis: Mosby-Year
Book; 2003.
Libby P, Bonow RO, Mann DL, et al., eds. Braunwald’s Heart Disease:
A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia: W.B. Saunders
Company; 2007.
Topol EJ, ed. Textbook of Interventional Cardiology. 5th ed. Philadelphia: Saunders/
Elsevier; 2008.
Chapter 1 Suggested Reading

Ashley KE, Cho L. Right heart catheterization. In: Griffin BP, Topol EJ, eds.
Manual of Cardiovascular Medicine. 3rd ed. Philadelphia: Lippincott Williams
and Wilkins; 2009:743–756.
Anwarrudin S. Left heart catheterization. In: Griffin BP, Topol EJ, eds. Manual
of Cardiovascular Medicine. 3rd ed. Philadelphia: Lippincott Williams and
Wilkins; 2009:789–813.
78852_ch01 18/06/10 1:06 PM Page 18
Carrozza JP. Complications of diagnostic cardiac catheterization. UpToDate.

2008;Version 16.3.
Davidson CJ, Bonow RO. Cardiac catheterization. In: Libby P, Bonow RO, Mann
DL, et al., eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular
Medicine. 8th ed. Philadelphia: W.B. Saunders Company; 2007:439–464.
Heupler FA, Proudfit WL, Razavi M, et al. Ergonovine maleate provocative test
for coronary arterial spasm. Am J Cardiol. 1978;41:631–640.
Laskey W, Boyle J, Johnson LW. Multivariable model for prediction of risk of sig-
nificant complication during diagnostic cardiac catheterization: the Registry
Committee of the Society for Cardiac Angiography and Interventions. Cathet
Cardiovasc Diagn. 1993;30:185–190.
Maeder M, Klein M, Fehr T, et al. Contrast nephropathy: review focusing on pre-
vention. J Am Coll Cardiol. 2004;44:1763–1771.
Mueller HS, Chatterjee K, Davis KB, et al. ACC Expert Consensus Document:
Present use of Bedside Right Heart Catheterization in patients with cardiac
disease. J Am Coll Cardiol. 1998;32:840–864.
Ryan TJ, Anderson JL, Antman EM, et al. ACC/AHA guidelines for the manage-
ment of patients with acute myocardial infarction: a report of the American
College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee on the Management of Acute Myocardial Infarction).
J Am Coll Cardiol. 1996;28:1328–1428.
Antman EM, Hand M, Armstrong PW, et al. 2007 Focused Update of the
ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation
Myocardial Infarction. A Report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. Circulation.
2008;117:1–34.
Scanlon PJ, Faxon DP, Audet AM, et al. ACC/AHA guidelines for coronary an-
giography: executive summary and recommendations. A report of the
American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee on Coronary Angiography). Circulation.
1999;99:2345–2357.
Scanlon PJ, Faxon DP, Audet AM, et al. ACC/AHA guidelines for coronary an-
giography: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Committee on Coronary
Angiography). J Am Coll Cardiol. 1999;33:1756–1824.
Wilterdink JL, Furie KL, Kistler JP. Evaluation of carotid artery stenosis.
UpToDate. 2008;Version 16.3.
78852_ch02 18/06/10 9:12 AM Page 19
CHAPTER 2
Setting up the Lab

Matthew Kaminski
Prior to arrival of the patient, the catheterization team should verify that
all monitoring, recording, and resuscitation equipment are functioning
properly. Continuous monitoring of the patient’s ECG upon arrival to the
catheterization laboratory is indispensable since it can quickly identify any
arrhythmias, conduction abnormalities, or evidence of ischemia. An auto-
mated blood pressure cuff and continuous pulse oximetry are also neces-
sary. Resuscitation equipment such as intubation trays and defibrillators
should be tested and placed nearby. If a patient is unable to urinate lying
flat or if a long cardiac catheterization is expected, a Foley or Texas urinary
catheter should be placed.
Time-Out Protocol
The concept of preprocedural verification using a verbal “time-out” was
originally developed as a patient-safety measure to prevent wrong-site sur-
gery; however, it has evolved to become standard protocol before any
medical procedure and should be performed before every procedure in the
cardiac catheterization lab. The purpose of the time-out immediately be-
fore starting the procedure is to conduct a final assessment that the correct
patient, site, positioning, and procedure are identified and that all relevant
documents, related information, and necessary equipment are available.
Each catheterization lab should have a standardized time-out protocol.
The time-out should be performed prior to the introduction of local anes-
thesia and sedation, should be initiated by a physician operator, and all
staff participating in the case (nurses, technicians, etc.) should be involved.
It should involve interactive verbal communication between all team
members, and any team member should be able to express concerns about
the procedure verification. During the time-out, other activities are sus-
pended, to the extent possible without compromising patient safety, so that
all relevant members of the team are focused on the active confirmation of
the correct patient, procedure, site, and other critical elements. All time-
outs should address the topics listed in Table 2-1.
19
78852_ch02 18/06/10 9:12 AM Page 20
Table 2-1 Essential Elements of a Preprocedural Time-Out
Patient identification (name and medical record number)

Confirmation of correct site marking (for percutaneous access)
Accuracy of preprocedure consent documentation
Correct patient positioning
Specification of procedure to be performed
Safety precautions based on patient history or medication use (allergies)
Special (nonroutine) equipment or instruments required
Preprocedural Sedation: In nonemergent situations, a detailed discussion

with the patient and family explaining the cardiac catheterization proce-
dure, potential complications, and alternative diagnostic options helps to
alleviate any anxiety prior to the procedure. Prior to administration of
preprocedural sedation, the operator should ascertain that informed
consent has been obtained and that all of the patient’s questions have
been answered.
The objective of preprocedural sedation is to maximize procedure
safety by making the patient cooperative, calm, and relaxed. The goal
should be to achieve conscious sedation: a state where the patient has
a depressed level of consciousness but still maintains the independent
ability to preserve a patent airway and respond appropriately and
quickly to verbal and/or physical stimuli. Prior to administration of
preprocedural sedation, the operator should examine the patient with
special attention to the airway to identify patients who may require addi-
tional caution with the use of sedative agents (e.g., sleep apnea, laryngeal
mass, intrinsic pulmonary disease).
Factors that may influence the selection and dose of sedative include
the patient’s age and weight, anticipated procedure length, comorbid
medical illnesses, level of anxiety, pain threshold, drug allergies, and
potential drug interactions. If preprocedural sedation is initiated with oral
medications, they should be administered at least 1 hour prior to the patient
arriving at the catheterization laboratory. Table 2-2 lists commonly used
medications for preprocedural sedation and their antagonists. A benzodi-
azepine is usually the initial drug of choice since it is not only a sedative
and anxiolytic, but also achieves a limited degree of retrograde amnesia.
Midazolam (Versed) is often the preferred choice because of its rapid
onset of action and relative short duration of effect. Initial doses range
from 0.5 to 1 mg IV, which may be repeated every few minutes until
desired sedation is achieved. If further sedation is needed, administering a
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Chapter 2 • Setting up the Lab 21
Table 2-2 Commonly Used Doses of Preprocedural Sedation

Medications
Medication Oral Dose IV Dose Comments
Benzodiazepines
Diazepam (Valium) 5–10 mg 2–5 mg
Lorazepam (Ativan) 0.5–2 mg 1–2 mg
Midazolam (Versed) N/A 0.5–2 mg
Opioids
Fentanyl N/A 25–50 ␮g
Morphine sulfate 15–30 mg 1–4 mg
Meperidine (Demerol) 50–150 mg 50–100 mg
Antihistamines
Diphenhydramine (Benadryl) 25–50 mg 25–50 mg
Promethazine (Phenergan) 25–50 mg 12.5–25 mg
Antagonists
Naloxone (Narcan) N/A 0.4–2 mg Opioid overdose:
repeat dose every
2–3 minutes to
achieve effect or to
a maximum dose
of 10 mg
Flumazenil (Romazicon) N/A 0.2–0.5 mg Benzodiazepine
overdose: repeat
dose every minute
to achieve effect
or to a maximum
dose of 3 mg
short-acting opioid such as fentanyl (25–50 µg) often results in adequate

patient comfort.
Contrast Agents
Overview of Available Contrast Agents: Iodinated contrast media are
the most frequently used intravascular pharmacologic agents in the
world. More than 70 million injections are administered worldwide
78852_ch02 18/06/10 9:12 AM Page 22
Table 2-3 Contrast Agents

Class Generic Name Trade Name Iodine Osmolality Viscosity
Low osmolar Iohexol Omnipaque 350 844 10.4

Iopamidol Isovue 370 370 796 9.4
Ioversol Optiray 320 320 702 5.8
Ioxilan Oxilan 350 350 695 8.1
Iso-osmolar Iodixanol Visipaque 320 320 290 11.8
Iodine (mg/mL), osmolalility (mOsm/kg H2O), viscosity (37 F).
each year. All intravascular contrast agents contain iodine, which absorbs
x-rays to a greater degree than surrounding tissue and allows for intravas-
cular opacification. Iodine atoms are bound to carbon-based molecules,
making the agent water soluble. Contrast agents are classified based on
their osmolality (high, low, or iso-osmolal). High-osmolar contrast media
(HOCM) were the first intravascular contrast agents developed in the
1950s. They have an osmolality five to eight times greater than that of
plasma (approximately 2,000 mOsm/kg). In the 1980s, low osmolar
contrast media (LOCM) were created, having an osmolality of two to
three times that of plasma (600–800 mOsm/kg). Then, in the 1990s, the
first iso-osmolar contrast media (IOCM), iodixanol, was developed, with
an osmolality of 290 mOsm/kg. Given the substantially higher rates of
adverse effects with use of HOCM, these agents are effectively obsolete
and are no longer used clinically. Thus, all currently available contrast
media are either LOCM or IOCM. Table 2-3 lists examples of the com-
monly used contrast agents used in coronary angiography.
Adverse Effects: Many of the studies that have attempted to differentiate

the various adverse effects of specific LOCM have been contradictory,
making it difficult to make firm recommendations for use of a particular
agent. Selection of a particular LOCM varies among institutions and
operators and is often made based on personal experience and preference.
Some basic guidelines regarding the choice of agent will be presented in
the following sections.
Effect on Myocardial Function: The degree of myocardial depression,

peripheral vasodilation, and elevation of left ventricular filling pressures
seen with contrast agents is more marked with agents that have higher
osmolality. This is even more apparent when larger boluses of contrast
agents are used during ventriculography or aortography. When HOCM
78852_ch02 18/06/10 9:12 AM Page 23
were used routinely, it was not uncommon to have peripheral vasodilation

with a transient reduction in systolic blood pressure of 20 to 50 mm Hg
and corresponding compensatory increase in heart rate with the use of
high osmotic agents. These hemodynamic perturbations could be par-
ticularly catastrophic in patients with relatively low cardiac reserve
such as left main coronary artery disease, severe aortic stenosis, or
severe left ventricular dysfunction (see Chapter 7). In contrast, the
LOCM used today typically only cause a reduction in systolic blood pres-
sure of 5 to 15 mm Hg with no change in heart rate during ventriculog-
raphy or aortography. Despite the more minor hemodynamic effects,
caution must still be used when performing these procedures in poten-
tially unstable patients.
Electrophysiologic Effects: Injection of contrast media into the coro-

nary arteries can rarely cause ventricular fibrillation or sinus bradycardia,
occasionally leading to transient sinus arrest. The incidence of these
events is low. Series with nonionic LOCM found an incidence of 0.1%
for ventricular fibrillation and 0.2% for bradycardia.
Effect on Renal Function: Contrast-induced acute kidney injury

(AKI) is the most common and most serious adverse effect of
intravascular contrast administration. Contrast-induced AKI is typi-
cally defined as an increase in serum creatinine of at least 0.5 mg/dL or
25% increase above baseline that occurs within the first 24 hours after
contrast administration and peaks within the first 5 days. It is estimated
that approximately 7% of patients receiving intravascular contrast will
suffer AKI. It has been shown that these patients have up to a fivefold
increase in the risk of in-hospital death over matched controls who did
not develop contrast-induced AKI. Overall, less than 1% of patients who
suffer contrast-induced nephropathy ultimately require chronic dialysis.
Various factors (Table 2-4) may predispose a patient to deterioration in
renal function after the use of contrast agents. Of these, chronic kidney
disease (CKD) with reduction in estimated glomerular filtration rate (GFR)
Table 2-4 Risk Factors for Contrast-induced Nephropathy
Estimated GFR ⬍60 mL/min/m2

Diabetes mellitus
Hypovolemia
Hypotension or shock
High contrast volumes (greater than 3 mL/kg)
78852_ch02 18/06/10 9:12 AM Page 24
below 60 mL/min/m2 is the most significant. Patients with CKD have a

reduced number of nephrons. The remaining healthy nephrons are suscep-
tible to damage by iodinated contrast, leading to contrast-induced AKI.
After intravascular administration of contrast material, the kidney responds
by releasing potent renal vasoconstrictors, which reduce renal blood flow
by up to 50%. The reduced blood flow leads to concentration of contrast in
the renal tubules and collecting ducts, which allows for direct cellular injury
and death to renal tubular cells. The degree of toxicity to tubular cells is re-
lated to the length of time the cells are exposed to contrast, highlighting
the importance of high urinary flow rates before contrast administration.
Prevention of Contrast-induced AKI: There are several strategies to

reduce the risk of contrast-induced AKI in susceptible patients. Prior to
contrast administration, potentially nephrotoxic drugs such as non-
steroidal anti-inflammatory drugs (NSAIDs), calcineurin inhibitors, high-
dose loop diuretics, and aminoglycosides should be held for several days, if
possible. In addition, volume expansion and treatment of dehydration have
been shown to prevent AKI in clinical studies. There is limited data to rec-
ommend an optimal prehydration strategy, but it appears that isotonic crys-
talloid such as normal saline or sodium bicarbonate are more effective than
half-normal saline. Despite some recent enthusiasm that isotonic bicarbon-
ate may be superior to normal saline in the prevention of contrast-induced
AKI, the largest clinical trial to date showed no clear advantage for bicar-
bonate over saline. There is also little data on the optimum urinary flow
rate. One study found that urinary flow rate of ⬎150 mL/hr in the 6 hours
after the procedure was associated with reduced rates of AKI. To obtain
this, however, isotonic crystalloid needs to be administered at 1.0 to
1.5 mL/kg/min, owing to the loss of some fluid to the interstitial space.
There are currently no approved pharmacologic agents to prevent
contrast-induced AKI. Despite its popularity, N-acetylcysteine (NAC)
has not been consistently shown to be effective in preventing AKI. The
only treatment that has been shown to be effective is high-dose ascorbic
acid. The dose used in the one prospective trial published was 3 g orally
the night before contrast exposure and 2 g orally twice a day for 1 day
after the procedure.
Once contrast is administered, limiting contrast volume for all
patients to less than 5 mL/kg divided by the serum creatinine has
been shown to be associated with lower rates of contrast-induced
AKI. For patients with CKD, use of as little contrast as possible
(⬍30 mL if possible) appears to be related to a reduction in subse-
quent dialysis. It should be noted, however, that even small volumes of
contrast can have adverse effects on renal function in patients at high risk
for AKI. For these patients, there is no safe dosing threshold below
78852_ch02 18/06/10 9:12 AM Page 25
which there is no risk of AKI. It is recommended that contrast volumes

below 100 mL are preferable in patients who have an estimated GFR
⬍60 mL/min/m2.
The choice of contrast agent is also a major factor in determining the
risk of contrast-induced AKI. Use of LOCM confers a significantly lower
risk of AKI compared to HOCM. However, multiple trials have shown that
IOCM has the lowest risk for contrast-induced AKI, especially in patients
with CKD and diabetes mellitus (DM). Currently, iodixanol (Visipaque,
GE Healthcare Biosciences/Amersham Health, Piscataway, NJ) is the only
clinically available IOCM. An expert panel has recommended that in pa-
tients undergoing angiographic procedures with CKD with estimated
glomerular filtration rate (eGFR) ⬍60 mL/min/m2, and particularly those
with DM, iodixanol presents the lowest risk of contrast-induced AKI and
should be the contrast agent of choice. It is also recommended that iodix-
anol be used in renal dialysis patients to minimize the chances of volume
overload and associated complications before the next dialysis session.
Contrast Reactions: Adverse reactions to contrast media are not un-

common. Mild adverse reactions are reported in 3% to 12% of patients
receiving contrast, with mortality rates of less than 1 in 100,000.
Reactions are much more frequent with ionic contrast media, which are
no longer in use in the majority of centers. Adverse reactions are typically
classified as either immediate (occurring within 1 hour of administra-
tion) or delayed (between 1 hour and 1 week later). Immediate reactions
can range from mild to very severe with symptoms of nausea, pruritus,
urticaria and angioedema, to bronchospasm, laryngeal edema, hypoten-
sion, and even death. They account for approximately a quarter of all
contrast reactions. Delayed reactions are usually mild to moderate skin
reactions, which become apparent between 3 hours and 3 days after expo-
sure and resolve without treatment within 1 week. Table 2-5 outlines
common presentation and treatment of immediate contrast reactions.
A great deal of controversy exists regarding the exact mechanism of con-
trast reactions, but it is thought that the majority of reactions are not
mediated by immunoglobin E, and thus are not truly allergic.
Multiple investigators have demonstrated conclusively, however, that im-
mediate reactions involve the granular release of histamine by mast cells
and basophils, producing an anaphylactoid response. Regardless of the
mechanism, the risk of a reaction to contrast is increased twofold in
patients with a strong history of allergy or atopy such as asthma. A com-
mon misconception is that a prior reaction to seafood confers a greatly
elevated risk of an adverse reaction with contrast exposure. In reality, pa-
tients with allergies to seafood have a similar risk of contrast reactions as
those who have a strong history of other allergic reactions. Patients with
26
Table 2-5 Contrast Reactions: Presentation and Treatment
Severity Presentation Onset Treatment
Mild Mild nausea, flushing, bradycardia, Within minutes of exposure Usually self-limited; supportive treatment usually includes
urticaria without hives or tongue observation and/or diphenhydramine 25–50 mg PO; atropine
swelling, transient bradycardia or (0.5–1.0 mg IV) occasionally required
vasovagal episodes
Moderate Persistent nausea with vomiting, Within minutes to hours of Usually requires treatment consisting of IV hydration, antihis-
78852_ch02 25/06/10 4:07 PM Page 26
anaphylactoid reaction (urticaria exposure tamines (diphenhydramine 50 mg IV and famotidine 20 mg

with hives and tongue swelling), IV), steroids (i.e., hydrocortisone 100 mg IV), antiemetics
persistent symptomatic bradycar- (i.e., prochlorperazine 2 mg IV), and atropine (0.5–2.0 mg IV)
dia or vasovagal episodes if persistent bradycardia and/or vasovagal reaction; epi-
nephrine (0.1–0.3 mL of 1:1,000 concentration) SQ or IM to
treat bronchspasm without hypotension
Severe Anaphylaxis-like (bronchospasm, Can occur immediately Life threatening and requires immediate and aggressive
laryngeal edema, and hypotension) after a single dose of treatment; epinephrine (1 mL of 1:10,000 solution)
contrast (0.1 mg/ml) IV q 1 min PRN, steroids (i.e., hydrocortisone
100 mg IV), antihistamines (diphenhydramine 50 mg IV and
famotidine 20 mg IV), and rapid IV fluid expansion; consider
intubation if airway compromised
78852_ch02 18/06/10 9:12 AM Page 27
Troubleshooting
Managing patients with a history of prior contrast reactions: Patients with a
prior moderate or severe reaction to contrast agents should be premedicated with
steroids and antihistamines prior to contrast exposure. Protocols vary widely, but
commonly used regimens include 50 mg of oral prednisone 13, 7, and 1 hour prior to
the procedure (q6 hours) along with diphenhydramine 50 mg IV or PO 1 hour prior to
the procedure. Intravenous steroids can be substituted for oral steroids with hydro-
cortisone 200 mg IV 1 hour prior to contrast administration.
a previous adverse reaction to contrast have about a sixfold increased risk

of an adverse reaction upon repeat exposure to contrast when compared
with individuals without a prior adverse reaction. This elevated risk justi-
fies pharmacologic prophylaxis with steroids and histamine blockade
prior to planned repeat contrast exposure for patients with a history of
moderate or severe reactions, although it should be noted that data is
very limited on the efficacy of these preventive pharmacologic measures
when modern-day nonionic LOCM or IOCM is used. Physicians should
also note that serious, life-threatening reactions have been reported
despite the use of steroid and antihistamine prophylaxis!
Radiation Safety
The main principle regarding radiation safety in cardiology is to
keep exposure to the patient and operator to a level as low as rea-
sonably achievable (ALARA). The principle of ALARA is achieved by
learning the various techniques at reducing radiation exposure and their
possible effects on image quality (Table 2-6). If these techniques are not
learned, radiation exposure to the operator and/or patient may result in
direct tissue injury (deterministic effects) and/or neoplasms and herita-
ble alterations in reproductive cells (stochastic effects).
Operators should wear radiation dosimeter badges whenever they
are working with a source of radiation. They should be worn at collar
level either on the apron or attached to the thyroid shield. These badges
are monitored at periodic intervals (usually monthly). The annual total
effective whole-body dose limit for occupational radiation workers
is 5 rem/year (50 mGy/year).
The main source of radiation exposure for the operator is scat-
ter from the patient. A secondary, less significant, source is escape of
x-rays through the shielding of the x-ray tube. Protection for the opera-
tor consists of shielding, proper positioning from the radiation source,
78852_ch02 18/06/10 9:12 AM Page 28
Table 2-6 Radiation Safety Principles and Corresponding Effects

on Image Quality
Operator Patient Image
Method Dose Dose Quality
Patient and Operator Protection

Lead gown, thyroid collar Reduced Unchanged Unchanged
Leaded glasses Reduced Unchanged Unchanged
Lead shield above, below table Reduced Unchanged Unchanged
Increased distance from operator Reduced Unchanged Unchanged
to table
Femoral vs. brachial approach Reduced Unchanged Unchanged
Operator’s fingers out of Reduced Unchanged Unchanged
radiation beam
Move patient’s arm out of field Reduced Reduced Improved
Radiation Dose Reduction
Shorter fluoroscopy, cine times Reduced Reduced Unchanged
Pulsed fluoroscopy Reduced Reduced Unchanged
Fewer pulses per second Reduced Reduced Worse
Fewer cine frames per second Reduced Reduced Worse
Greater distance from source Variable Reduced Improved
to patient
Shorter distance from image Reduced Reduced Improved
intensifier to patient
Electronic image magnification Variable Higher Improved
Smaller collimator opening Variable Variable Improved
Cranial, caudal angulation Higher Higher Worse
Large patient, pleural effusion Higher Higher Worse
and adjusting the fluoroscopic controls in an attempt to minimize radia-

tion exposure while maintaining a high-quality image.
Personal shielding involves lead aprons, thyroid collars, and lead
glasses. Lead aprons should have shielding properties equivalent to
0.5 mm of lead, which shields the covered areas of the operator
from roughly 90% of scatter radiation. Lead glasses protect the oper-
ator from possible radiation-induced cataracts and should have side
shields to decrease radiation from the lateral direction. Thyroid shields
prevent large cumulative doses of radiation that could lead to thyroid
78852_ch02 18/06/10 9:12 AM Page 29
cancer. These items should be checked annually with fluoroscopy to in-

spect for possible cracks, holes, and other signs of deterioration. The
catheterization table will commonly have two lead shields: one which is
a table side drape that protects the lower body of the operator, and one
that is an adjustable lead acrylic shield which is suspended from the ceil-
ing to aid in the protection of the operator’s head and upper torso.
The inverse square law addresses the important concept that
radiation dose drops rapidly by the inverse square of the relative
increase of distance from the radiation source. Operators can decrease
their radiation exposure by taking a step back from the irradiated
area before engaging in fluoroscopy. Moving the image intensifier,
which is located above the patient, to as close to the patient as possible also
reduces scatter radiation by reducing geometric magnification (radiation
dose usually increases with the square of the magnification). Placing hands
in the direct beam of radiation should only be done in cases of emergency.
Modifying fluoroscopic controls can also decrease radiation exposure
for both the operator and the patient; however, these modifications may
occasionally reduce image quality. One of the “golden rules” for mini-
mizing radiation exposure is keeping beam-on time to an absolute
minimum. Fluoroscopy or cineangiography should not be engaged if the
image on the monitor is not being used. Most fluoroscopic machines
have an option that allows the operator to select the level of image qual-
ity (low, normal, high). Low image quality reduces radiation dose rate,
but often produces a noisy image. These images may be acceptable in cer-
tain situations such as checking position of a guidewire or catheter. Most
fluoroscopic machines have pulsed fluoroscopy which results in x-rays
being produced in short bursts instead of a continuous stream as in con-
ventional fluoroscopy. Reducing the pulse frequency to 15 or 7.5 pulses
of x-rays/second will reduce radiation exposure at the cost of producing
a somewhat flickering, choppy image. A similar result is seen when one
reduces the cine frame rate. Applying collimators (blades outside the x-
ray tube that block x-rays) to the area of interest not only reduces scatter
radiation to the operator, but also improves image quality.
Electronic magnification (field-of-view) size for image intensifiers con-
sists of usually at least three magnifications: 9-in (23-cm), 7-in (17-cm),
and 5-in (13-cm). In general, the least magnification reduces the dose
rate to the patient’s skin. For example, without changing collimators,
changing the field of view from 7 to 5-in results in roughly a doubling in
entrance dose to the patient’s skin, with greater spatial resolution that
may be important in evaluating small coronary arteries. The effect of
increasing magnification on radiation dose rates for the operator and
other personal is variable since it depends on the relative changes in tube
current and kilovoltage.
78852_ch02 18/06/10 9:12 AM Page 30
Increasing the distance between the x-ray source (located beneath

the patient) and the patient also results in improved image quality and a
reduction in entry dose to the skin of the patient. Federal regulations
dictate that a spacer be placed on the x-ray tube to maintain a minimum
distance of 38 cm between the x-ray source and the patient.
Needle, Catheter, Wire, Sheath Selection

Access Needle: Access needles typically consist of two types, an open-
bore needle and a Seldinger-type needle, which has a stylet in place.
Open-bore needles are easier to manage since they signal immediate
blood return when the vessel of interest is punctured. However, they
may have to be flushed periodically if repeated attempts at access are
needed because they can become clogged with subcutaneous tissue, fat,
or blood. The stylet in the Seldinger-type needle prevents blockage of
the lumen of the needle with tissue or blood and is removed once the
operator believes puncture of the artery has occurred.
Most needles have a standard length of between 2.75 and 3 in. A
1.5-in 21-gauge or 22-gauge needle is commonly used for the percuta-
neous radial approach. Needles are conventionally sized by their outer
diameter, which corresponds to an arbitrary gauging system. Increasing
gauge corresponds to a smaller diameter. Typically, an 18-gauge needle
is used for the femoral or brachial approach, while a micropuncture kit
containing a 22-gauge needle is used for the radial approach. When
attempting access for left heart catheterization, the needle should be
held at its hub so that the operator can feel arterial pulsations transmit-
ted from the tip of the needle. Feeling these pulsations aids in guiding
the operator to successful cannulation of the arterial circulation.
Guidewire: Once access is obtained, a guidewire is inserted into the

needle prior to withdrawal of the needle and placement of an arterial
sheath over the guidewire. Guidewires are also used to facilitate passage
of diagnostic coronary catheters to the central aorta. The choice of
guidewire should be made prior to obtaining arterial access. Most
guidewires consist of three major components: a central core (commonly
stainless steel or nitinol), distal flexible spring coil (usually platinum or
tungsten), and an outer coating to decrease friction (silicone, Teflon, or
other hydrophilic coating). If a patient has severely tortuous or athero-
sclerotic vessels, a flexible wire such as a Wholey wire can be used.
Alternatively, a Glidewire (SCIMED) may be of particular benefit be-
cause it has smooth hydrophilic coating and excellent torque control.
Guidewire length varies among different manufacturers, but generally
78852_ch02 18/06/10 9:12 AM Page 31
consists of three major types. Short wires (30–45 cm) are used in placing
sheaths. Medium length wires (125–150 cm) enable the operator to
guide the diagnostic coronary catheter to the aorta. Long length wires
(250–300 cm) are employed when the operator wishes to exchange di-
agnostic coronary catheters without moving the wire tip (“exchange
wire”). Wire tips are universally flexible and are either straight or J-tipped.
For the majority of cases, the J-tipped wire is preferred since it is
less likely to induce vessel dissection and avoids entering small ves-
sel branches. A straight-tipped wire is used mainly in attempting to
cross a severely stenotic aortic valve or in obtaining brachial or radial ar-
terial access.
Guidewire diameters also vary widely. The smaller diameter guidewires
(0.018, 0.021, and 0.025 in) are generally used with a Swan–Ganz
catheter to augment stiffness. The 0.025-in guidewire is also used in ob-
taining radial arterial access. The 0.032-in guidewire is used mostly in
brachial arterial access and intra-aortic balloon placement. The most com-
monly used guidewires are the 0.035 and 0.038-in, used during most rou-
tine diagnostic left heart catheterizations. The 0.035-in wire is usually pre-
ferred because it is more flexible and softer, thus less likely to cause a
dissection. The 0.038-in wire is used when increased stiffness is desired,
such as when attempting dilator placement through calcified arteries or fi-
brotic tissue. Larger diameter guidewires are used predominantly in inter-
ventional cases where larger sheaths and catheter sizes are often necessary.
Dilators and Sheaths: Vascular sheaths generally contain a removable

dilator, a diaphragm that prevents leakage of blood or air into the sheath,
and a side arm that is connected to a three-way stopcock that allows the
operator to record pressure measurements, flush the sheath, and infuse
medications. The dilator is made of stiff plastic (usually Teflon or poly-
ethylene) that allows it to pass through fibrous subcutaneous tissue or
atherosclerotic/calcified vessels. Generally, the sheaths used range from
4 to 8 Fr. (1 Fr. ⫽ 0.33 mm) although larger sized sheaths are sometimes
used in interventional cases. For femoral and brachial diagnostic left
heart catheterizations, 6-Fr. and 5-Fr. sheaths, respectively, are most
commonly used. For radial cases, a 4-Fr. or 5-Fr. dilator is frequently
used prior to insertion of either a 5-Fr. or 6-Fr. sheath. In cases of severe
peripheral vascular disease, a smaller dilator may need to be used initially
prior to inserting a 5-Fr. or 6-Fr. system.
The length of sheaths used routinely varies from as short as 6 cm to
as long as 35 cm. For most cases, an 11-cm sheath is adequate. Longer
sheaths of 25 to 35 cm are selected when one encounters tortuous
femoral and/or iliac arteries in order to facilitate torque control of
78852_ch02 18/06/10 9:12 AM Page 32
the diagnostic coronary catheter. Occasionally, with the radial ap-

proach, a longer 23-cm sheath is used to prevent radial artery spasm.
Catheter Selection: As discussed in Chapter 1, the operator should re-

view, if available, any past coronary angiographic films to observe the
catheters used for diagnostic cardiac angiography and to identify possible
difficulties engaging the native coronary arteries and/or bypass grafts.
The sections of an angiographic catheter include a body (which is
mostly straight throughout its course) and the tip, with various curves.
The curves are classified as primary, secondary, and tertiary starting from
the tip (Figure 2-1). The hub of the catheter has an airtight seal com-
posed of a female Luer-Lok that allows attachment to a syringe or man-
ifold, winged tips to facilitate catheter rotation, and labeling of the size
of the catheter.
Diagnostic coronary catheters are sized by their external diameter,
which is expressed in French sizes (1 Fr. ⫽ 0.33 mm). Most diagnostic
coronary catheterizations will use 6 French (Fr.) catheters, although
catheters as small as 4 Fr. and as large as 8 Fr. may occasionally be used.
Catheter length varies based on the percutaneous approach and its con-
figuration. Most pigtail catheters for ventriculography or aortography
are 110 cm in length, while the commonly used Judkins catheters for
coronary angiography are 100 cm long. Brachial catheters are generally
80 or 100 cm long.
Catheter selection depends upon the percutaneous approach used,
whether bypass grafts are present, and coronary anatomy variations. For
the left femoral, left brachial, and left radial approach, the Judkins
catheters are usually the initial catheters selected. Both the left Judkins
(JL) and right Judkins (JR) catheter have a primary curve of 90⬚. The JL
has a secondary curve of 180°, while the JR has a secondary curve of 30⬚.
The JL catheter comes in various arm (distance between the primary and
secondary curve) sizes. For example, the JL4 catheter has a 4.2 cm length
arm, while the JL5 and JL6 catheters have arm lengths of 5.2 and 6.2 cm,
respectively. For most diagnostic cases, the JL4 catheter is attempted
first. If the patient’s aortic root is dilated, then a longer arm JL catheter
(5 or 6) is frequently used. A smaller arm JL 3.5 catheter is chosen if the
aortic root is smaller than usual, or if the left main is located superiorly.
In cases where a short left main trunk is encountered, a JL4 short tip
catheter usually successfully cannulates the left main ostium. If one is un-
able to engage the left coronary circulation with the Judkins catheters,
the left Amplatz (AL) class of catheters is usually employed.
The AL catheters are particularly good at engaging a short left main
trunk or in cases where the left circumflex coronary artery (LCX) and
left anterior descending artery (LAD) have separate ostia. They can also
78852_ch02 18/06/10 9:12 AM Page 33
Figure 2-1 Commonly used diagnostic catheters. MPA, multipurpose

A; MPB, multipurpose B; PIG, pigtail; LCB, left coronary bypass; RCB, right
coronary bypass; IM, internal mammary; JR, Judkins right; AR, Amplatz right;
AR Mod, Amplatz right modified; JL, Judkins left; AL, Amplatz left.
78852_ch02 18/06/10 9:12 AM Page 34
be used to engage high-anterior right coronary arteries (RCAs) or

Shepherd’s Crook RCA. The right Amplatz (AR) catheters are useful for
cannulating RCAs that have an inferior orientation. Amplatz catheters
are classified by the size of their secondary curve (AL1-3; AR1-3).
Alternatively, a 3DRC (No Torque Right) catheter can be attempted in
cases where the RCA ostium cannot be engaged with the JR4. The
three-dimensional curve configuration of the 3DR catheter facilitates
engagement of the RCA.
For the right arm approach (either brachial or radial), either the
Amplatz, multipurpose, or modified brachial or radial catheters are com-
monly used. One advantage of the multipurpose catheter is that it can be
used for both coronary angiography and ventriculography. The multipur-
pose catheter can also be used from the femoral approach, usually in cases
where the RCA or left main has an inferior takeoff. Both the multipur-
pose and Amplatz catheters require experience for proper manipulation.
To minimize the risk of coronary dissection when using the Amplatz
catheters, the operator should rotate the catheter counterclockwise to
disengage it from the coronary ostium prior to removing the catheter.
For bypass grafts, the JR4 catheter is usually successful in engaging
both venous and arterial grafts. For left internal mammary artery (LIMA)
or right internal mammary artery (RIMA) grafts that have a sharply angu-
lated downward takeoff, the IMA catheter is more likely to successfully
engage these grafts since it has a longer tip and less of a primary curve
(80°) than the JR4. The 5-Fr. JoMed catheter is stiffer and more angu-
lated than the IMA catheter and may be used for engaging a LIMA graft
that has a sharp, downward takeoff. However, the JR4 is usually used
first to engage the subclavian artery, and a long J wire is used to exchange
the JR4 for the IMA catheter. For saphenous vein graft (SVG) to RCA
grafts that have a steep downward orientation, the multipurpose, right
bypass, or right modified Amplatz catheters can be attempted if the JR4
approach is unsuccessful. Whenever SVGs to the LAD or LCX cannot be
cannulated with a JR4, one can consider alternative catheters, such as the
left bypass, AL, or multipurpose.
Manifold: A variety of manifold systems exist. One common design is a

three-component manifold that has three stopcocks attached. The first
stopcock is connected to a pressure transducer, the second is attached to
flush solution, and the third is attached to the contrast agent of choice.
When setting up the manifold, it is vital to ensure that the pressure trans-
ducer tubing is flushed adequately with saline to prevent any air bubbles
from interfering with pressure measurements. Shorter and stiffer tubing
between the pressure transducer and catheter optimizes pressure measure-
ments. The pressure transducer is “zeroed” with the aid of an assistant by
78852_ch02 18/06/10 9:12 AM Page 35
placing the transducer at the patient’s mid chest level. The stopcock to the
saline port is then opened to bring down the saline through the connec-
tion tubing into the manifold. Similarly, the stopcock to the contrast agent
of choice is opened and the contrast brought down to the stopcock level.
The manifold is then once again flushed with saline and all tubing inspected
for the presence of any air bubbles.
Vascular Access
Percutaneous Femoral Approach: The femoral approach is the most
common in the United States. The operator should first identify
anatomic landmarks prior to giving local anesthesia such as the inguinal
ligament, which traverses from the anterior superior iliac spine to the
pubic tubercle. The femoral artery generally crosses the inguinal liga-
ment at an imaginary point that is located one third from the medial as-
pect and two thirds from the lateral aspect of the ligament. The femoral
pulse is then palpated approximately 2 finger breadths (2–3 cm) below
the inguinal ligament, marking the site of arterial access (Figure 2-2).
One can also use fluoroscopy to identify femoral head. The optimal ac-
cess location would be at the site over the inferior border of the femoral
head. This approach is especially useful in obese patients where the iden-
tification of the inguinal ligament may be more difficult. Approximately
95% of patients have the femoral bifurcation located below the upper
border of the femoral head. Locating the optimal site of entry is
important since entry sites above the inguinal ligament may lead to
an increased risk of retroperitoneal bleeding, while entry sites that
are too low may result in the development of arteriovenous fistula
or pseudoaneurysm.
After the entry site is determined, the femoral region is scrubbed
with povidone–iodine or chlorhexidine-based solution and surgically
draped. The entry site is again palpated with the index and middle fin-
gers of the left hand either perpendicular or parallel to the artery to con-
firm location of the femoral pulse. With the left index and middle fingers
maintaining constant moderate pressure on the artery, the operator uses
his or her right hand to raise a subcutaneous wheal at the entry site with
a 25-gauge needle containing roughly 3 cc of procaine 1%. A 22-gauge
needle is then used to slowly deliver an additional 6 to 10 cc of local
anesthetic to the deeper subcutaneous tissue. The amount of local anes-
thetic should cover the anticipated needle path from the skin to the ar-
tery. When giving local anesthesia, the operator should monitor the
ECG monitor and the patient for any signs of a possible vagal reaction.
Holding the 18-gauge Cook access needle at the hub with the
thumb and index finger, the operator inserts the needle through the skin
78852_ch02 18/06/10 9:12 AM Page 36
B
Figure 2-2 Femoral access landmarks. A) Diagram of femoral artery land-
marks. B) 30⬚ LAO projection of femoral artery. The LAO projection best displays
the bifurcation of the profunda and the superficial femoral artery.
78852_ch02 18/06/10 9:12 AM Page 37
Troubleshooting
The patient is allergic to procaine: If the patient has a documented allergy to
procaine (ester prototype anesthetics), then lidocaine 2% or other amide prototype
local anesthetic can be given.
at a 30° to 45° angle with the bevel pointed upward. As the needle nears
the femoral artery, the operator should observe the motion of the needle.
A side-to-side motion usually signals that the needle is either lateral or
medial to the artery, and should be repositioned. If the needle motion is
up-and-down, the needle is positioned correctly, and the needle should
be gently advanced. As the needle gets closer to the artery, the operator
may feel arterial pulsations transmitted through the needle hub. Brisk,
pulsatile blood return signals successful arterial puncture. A 45-cm
J-tipped 0.035-cm guidewire is then advanced through the needle. The
needle is removed, and a small nick is made at the level of the skin with
a scalpel to facilitate insertion of the sheath size of choice (usually 6 Fr.)
over the guidewire. The dilator within the sheath and the guidewire are
subsequently removed and the sheath flushed with saline. The arterial
pressure should then be documented by attaching the side port of the
sheath to the manifold.
Arm Approaches: In cases of morbid obesity, severe peripheral vascu-

lar disease, aortic dissection, or aortic aneurysm, the femoral approach
is either very difficult or contraindicated. If coronary angiography is
indicated, the brachial or radial approaches are used. Because the brachial
and radial arteries are smaller caliber vessels, heparin (3,000–5,000 units
IV) should be used to avoid arterial thrombosis. Right brachial or radial
arterial access has the advantage of allowing the operator to remain on
the right side of the catheterization table to manipulate and exchange
catheters and to access the table and fluoroscopy controls. It has the dis-
advantage of often requiring specialized catheters for cannulation of the
coronary ostia, and precludes injection of the left subclavian artery or
LIMA, which is necessary if the LIMA is used as a coronary bypass graft.
Access via the left brachial or radial artery allows the operator to use
standard femoral catheters (such as the Judkins catheters) for cannula-
tion of the coronary ostia and allows selective engagement of the LIMA.
Manipulation and exchange of catheters is more difficult, however,
because of the distance of the access point from the operator.
Percutaneous Brachial Approach: Prior to local anesthesia, the brachial

and radial pulses of both arms should be palpated. The Allen test should
78852_ch02 18/06/10 9:12 AM Page 38
Troubleshooting
Poor blood return: Weak blood flow may signal that the needle may be located
against the vessel wall, subintimally, or in a smaller branch. Gentle forward or back-
ward manipulation or a slight change in the angulation of the needle may improve
blood flow. Alternatively, sluggish blood flow may be secondary to severe periph-
eral vascular disease or low perfusion states.
There is resistance advancing the guidewire: The guidewire should only
be inserted through the needle when brisk, pulsatile blood flow is obtained. If re-
sistance is encountered as the guidewire is passing through the tip of the needle
that is not relieved by reducing the angle of the needle, the guidewire should be re-
moved and brisk pulsatile blood flow should be confirmed. If blood flow is not brisk,
the needle may be gently redirected in an attempt to restore blood flow. If these
maneuvers are unsuccessful, the needle should be removed and pressure held over
the entry site for 5 minutes before reattempting access. If resistance is encountered
or the patient begins to complain of pain after the guidewire has been successfully
advanced a few centimeters, then fluoroscopy should be used to document location
of the guidewire. In this situation, the needle is removed, and a small sheath (5 Fr.)
can be carefully advanced to the point where resistance was encountered. The wire
is then removed and the sheath aspirated to confirm blood return and flushed. Using
a small amount (5 cc) of either nonionic or diluted ionic contrast, the operator then
injects contrast under fluoroscopy to assess for arterial dissection, vessel tortuos-
ity, or severe atherosclerosis.
A retrograde subintimal dissection is found after access is secured:
Subintimal retrograde dissections caused by guidewire insertions rarely cause arte-
rial complications. The patient should be monitored closely for signs and symptoms
of dissection extension (progressive pain, pale extremities, loss of distal pulses).
Either the other femoral artery, or a brachial or radial approach should be accessed
for left heart catheterization.
Severe vessel tortuosity or atherosclerosis is encountered: Reinserting a
softer, more steerable guidewire (Wholey) or hydrophilic-coated guidewire
(Glidewire) may enable passage through the tortuosity or stenosis. A long sheath
(45-cm Arrow or 55-cm Brite Tip long sheath) should be considered to improve
catheter manipulation.
Resistance during sheath placement is encountered: Confirm that an ad-
equate nick has been made at the level of the skin. Resistance may also originate
from severe vessel calcification or scar tissue from prior procedures. Using first a
smaller dilator (4 or 5 Fr.) to predilate along with a stiffer wire (0.038 cm or
Amplatz wire) may facilitate placement of the sheath.
Femoral pulse is not easily palpable: One could attempt using the Smart
Needle device. With this device, the needle is directed to the site where the arte-
rial pulsations are heard best via the Doppler probe.
Patient has prosthetic femoral artery grafts: If the vascular graft is older
than 2 to 3 months, then the percutaneous femoral approach can be considered.
Predilation with a smaller dilator is recommended prior to insertion of the desired
sheath size to prevent the sheath from kinking as it passes through the graft.
78852_ch02 18/06/10 9:12 AM Page 39
also be performed. The brachial artery is approximately 3 to 5 mm in

diameter. The strongest brachial pulse is generally located 1 to 2 cm
above the elbow crease. The antecubital fossa is then sterilized and
draped. Using a 25-gauge needle, a small wheal is raised using approxi-
mately 3 cc of local anesthetic. Injecting larger amounts of local anes-
thetic may make it more difficult to palpate the brachial pulse. One can
use either an 18-gauge needle or a micropuncture needle (22-gauge) to
obtain arterial access using a 45⬚ angle. With the micropuncture needle
kit, a stiffer 0.025 guidewire is used, while the standard 0.035-cm
guidewire is used for the 18-gauge needle. Once the guidewire is
inserted into the artery, a 5-Fr. or 6-Fr. sheath is usually inserted as
described in the percutaneous femoral approach. Heparin 3,000 to
5,000 units IV should be considered to avoid sheath thrombosis.
Percutaneous Radial Approach: As described with the brachial approach, the

Allen test should be performed prior to radial artery catheterization. The
patient’s arm is abducted at a 70⬚ angle and the wrist is hyperextended.
Topical anesthetic cream is then applied over the radial artery to reduce the
amount of local anesthetic needed after the area is cleaned in a sterile fash-
ion and draped. Local anesthesia is then given as depicted in the brachial
approach. Next, either an 18-gauge needle or a micropuncture needle
(22-gauge) is inserted at a 30⬚ to 45⬚ angle approximately 1 cm from the
styloid process. The guidewire is then advanced as described in the brachial
approach. A 4-Fr. or 5-Fr. dilator is then used to predilate the radial artery.
A 5-Fr. or 6-Fr. sheath is then inserted over a standard 0.035-cm
guidewire. A longer sheath (23 cm) may be used in radial cases to decrease
radial artery spasm. Alternatively, standard sheath lengths may be used with
local infusions of nitroglycerine or verapamil. Heparin 3,000 to 5,000 units
IV should be considered to avoid sheath thrombosis.
Suggested Reading
Bashore TM, Bates ER, Berger PB, et al. American College of Cardiology/Society
for Cardiac Angiography and Interventions Clinical Expert Consensus
Document on cardiac catheterization laboratory standards. A report of the
American College of Cardiology Task Force on Clinical Expert Consensus
Documents. J Am Coll Cardiol. 2001;37(8):2170–2214.
Davidson C, Stacul F, McCullough PA, et al. Contrast medium use. Am J
Cardiol. 2006;98(6A):42K–58K.
Denys BG, Uretsky BF, Baughman K, et al. Accessing vascular structures. In:
Uretsky BF, ed. Cardiac Catheterization: Concepts, Techniques and
Applications. Malden: Blackwell Science; 1997:93–118.
Einstein AJ, Moser KW, Thompson RC, et al. Radiation dose to patients from
cardiac diagnostic imaging. Circulation. 2007;116(11):1290–1305.
78852_ch02 18/06/10 9:12 AM Page 40
Limacher MC, Douglas PS, Germano G, et al. ACC expert consensus document.
Radiation safety in the practice of cardiology. American College of Cardiology.
J Am Coll Cardiol. 1998;31(4):892–913.
McCullough PA. Contrast-induced acute kidney injury. J Am Coll Cardiol.
2008;51(15):1419–1428.
Meth MJ, Maibach HI. Current understanding of contrast media reactions and
implications for clinical management. Drug Saf. 2006;29(2):133–141.
Wagner LK, Archer BR. Minimizing Risks from Fluoroscopic X-Rays: Bioeffects,
Instrumentation, and Examination. 3rd ed. Houston: Partners in Radiation
Management; 2000.
Universal Protocol for Disease Specific Care. The Joint Commission. Available at:
http://www.jointcommission.org/PatientSafety/UniversalProtocol/.
Accessed May 2, 2009.
78852_ch03 24/06/10 9:53 AM Page 41
CHAPTER 3
Native Coronary
Angiography
Stephen Gimple, Niranjan Seshadri,
Robert E. Hobbs, and Sorin Brener
The coronary arteries arise from the sinuses of Valsalva. The left main
coronary artery arises from the left sinus. After a short course, the left main
trunk usually bifurcates into the left anterior descending and left circum-
flex coronary arteries. In some instances, it may trifurcate, with the ramus
intermedius being the intermediate vessel in the trifurcation. The current
classification of coronary anatomy is based on the CASS system.
The left anterior descending artery (LAD) follows a course along the
anterior interventricular groove to the apex of the heart, supplying blood
to the anterior wall, the septum via septal perforators and the anterolat-
eral wall via diagonal branches.
The left circumflex coronary artery (LCX) courses along the left
atrioventricular groove supplying the lateral wall of the left ventricle. The
branches arising from the left circumflex are called obtuse marginals, with
the first branch arising from the atrioventricular circumflex called obtuse
marginal 1, the second branch called obtuse marginal 2, and so forth.
The right coronary artery (RCA) arises from the right sinus of
Valsalva and travels along the right atrioventricular groove. The first
branch that arises from the right coronary artery is the conus branch,
which supplies the right ventricular outflow tract. In approximately 50%
of the cases, the conus branch has a separate origin. Localizing the conus
branch may be important in selected cases because it is often a critical
source of collateral circulation to the LAD. Other branches include the
artery to the sinus node, which arises from the RCA in 60% of cases; the
acute marginal branches, which supply the right ventricle; the artery to
the AV node; the diaphragmatic artery; and terminal branches: the pos-
teroventricular branches and the posterior descending artery (PDA) in
most cases.
41
78852_ch03 24/06/10 9:53 AM Page 42
The PDA, which courses in the posterior interventricular

groove, determines coronary dominance. In 85% of the cases, the
PDA arises from the RCA, making the coronary circulation right domi-
nant. In 7% of the cases, the circulation is codominant, with the poste-
rior interventricular groove being supplied by both the RCA and the
LCX. In 8% of the cases, the PDA arises from the left circumflex making
it the dominant artery.
Engaging the Coronary Arteries

For diagnostic coronary angiography, we routinely use 4 or 5 Fr. Judkins
left and right catheters via the femoral approach. However, the use of the
radial approach in appropriately selected patients is increasing and may
soon be the standard for diagnostic angiography. Use of smaller caliber 4
or 5 Fr. systems has some advantages. For example, in patients requiring
only diagnostic angiography prior to heart valve surgery, use of a 4-Fr.
system decreases recovery time and allows faster ambulation after sheath
removal (see Chapter 8). In addition, the use of the radial approach also
fosters shorter recovery times as well as shorter hospitalization times.
Engaging the Left Coronary System: Assuming that the size of the
aorta is within normal limits, a Judkins left 4 (JL4) is routinely used. The
catheters are flushed with heparinized saline and advanced over
a J-tipped guide wire (“J wire”) through the femoral sheath and to the
ascending aorta just above the aortic root. To avoid retrograde dissec-
tion of the aorta, catheters are advanced with the J-tipped guide
wire protruding beyond the proximal end of the catheter. Once the
catheter is just above the sinus of Valsalva, the guide wire is withdrawn and
a few drops of blood are allowed to back bleed from the catheter allowing
for clearance of debris that may have collected during catheter advance-
ment. The catheter is then connected to the manifold, flushed with
saline, and the syringe is loaded with dye. Once an adequate pressure
tracing is seen, the catheter is opacified with 1 to 2 cc of contrast dye and
is ready for selective engagement.
Using the Judkins technique, not much effort is required to cannu-
late the ostium of the left main trunk. The catheter is advanced into the
aortic root, and in the majority of the patients, it will engage the ostium.
The catheter tip should be coaxial with the left main trunk. In cases
where the left main trunk is not easily cannulated, a clockwise or a coun-
terclockwise turn may help engage the ostium.
Once the ostium of the left main trunk is engaged, a good pressure
waveform should be observed before proceeding with coronary arteriog-
raphy.
78852_ch03 24/06/10 9:53 AM Page 43
Troubleshooting
The catheter does not back bleed: If the catheter does not back bleed after re-
moving the guidewire, the tip may be apposed to the wall of the aorta. Gently with-
draw the catheter, and turn it either clockwise or counterclockwise to free the
catheter tip. After discarding a few drops of blood, connect the catheter hub to the
manifold and look at the pressure tracing.
No waveform is observed in the pressure tracing: If no waveform is ob-
served in the pressure tracing, the transducer may not be opened to pressure. This
may be rectified by manipulating the first of the three-way stopcocks on the mani-
fold or by turning the transducer at the side of the table to the on position.
Catheter is NOT engaged and the waveform is dampened: This may be
due to air in the system or the catheter may be partially against the arterial wall. To
eliminate air in the system, first gently withdraw a few drops of blood and flush the
manifold and catheter with saline, taking care not to reintroduce air in the system.
A gentle clockwise or counterclockwise rotation along with pulling back the
catheter will move the tip away from the aortic wall. If the dampened waveform
persists, it may be due to air in the pressure transducer tubing. Flush the transducer
tubing and recheck the pressure. If the problem persists, in rare cases, the catheter
itself may have a kink, in which case it needs to be replaced.
Troubleshooting
The aorta is dilated, and it is difficult to engage the left main trunk with the
JL4: In the case of a dilated aorta, the curve on the JL4 catheter may be too short to
engage the ostium of the left main trunk. Upsizing to a JL5 or even JL6 catheter may
help. Additionally, with a dilated aorta there may not be a hinge point for the arm of
the catheter to rest. In this case, a counterclockwise (moves the catheter anteriorly)
or a clockwise rotation (moves the catheter posteriorly) helps engage the ostium.
The patient is not of average height: The size of the aorta is often propor-
tional to the height of the patient. Some operators start with a JL4 in nearly all pa-
tients. Other operators will start with a JL3.5 if the patient is less than 5‘4” tall, or
a JL5 if the patient is greater than 6’2” tall.
The left main trunk has an unusual takeoff: In some cases, the ostium of the
left main trunk may have a takeoff in a plane that may be out of the reach of the
Judkins catheters (usually a high posterior origin). Switching to an Amplatz system
may be helpful. Amplatz catheters are advanced around the aortic arch over a guide
wire. The catheter is further advanced until the curve rests in the left sinus of
Valsalva with the tip facing the ostium of the left main trunk. Withdrawal and gentle
clockwise and/or counterclockwise rotation brings the tip in plane with the coronary
ostia. To disengage the Amplatz catheter, it is important to first push it gently for-
ward (brings the tip out of the coronary ostium), and rotate before pulling back, all
under fluoroscopic guidance.
78852_ch03 24/06/10 9:53 AM Page 44
Troubleshooting
The catheter is engaged and the waveform is dampened: A dampened pres-
sure waveform (drop in the catheter tip systolic pressure) or a ventricularized pres-
sure waveform (drop in the catheter tip diastolic pressure) usually indicates that the
catheter tip is either deep seated, restricting coronary inflow, or the tip is against
the wall. It also indicates the possibility of significant left main stenosis. This can
be a dangerous situation that needs to be recognized quickly. The catheter tip
should be immediately withdrawn from the ostium. The ostium can be re-engaged
cautiously. If a small injection of dye reveals significant ostial left main stenosis
(another clue may be the absence of dye reflux into the aortic root with the injec-
tion), two short cine runs aimed at visualizing distal targets for bypass surgery
should promptly be performed, and the catheter then immediately pulled back from
the ostium. Care must be taken to avoid multiple engagements of the left main
trunk as this can lead to abrupt vessel closure. In cases where significant left main
trunk stenosis is suspected, the operator can take nonselective angiograms of the
left main trunk by injecting dye with the catheter tip positioned in left sinus.
Catheter damping may also be seen in cases of spasm of the left main trunk. In such
instances, intracoronary nitroglycerin can be injected (200 ␮g) and follow-up pic-
ture can be taken to document relief of spasm.
Engaging the Right Coronary Artery: Engaging the RCA often requires
more skill with catheter manipulation than engaging the left coronary
artery. The Judkins right 4 (JR4) catheter is most commonly used. The
JR4 is advanced to the right coronary cusp, with the tip facing the left
ostium. The catheter is gently pulled back while simultaneously rotating
the catheter clockwise to engage the right ostium (the tip of the catheter
tends to migrate down toward the sinuses with clockwise rotation).
Alternatively, the clockwise rotation may be performed above the plane
of the right coronary ostium without pulling back. This will make the
catheter tip move down toward the sinus while rotating. The ostium is
usually found about 2 cm above the aortic valve. After engaging, the
pressure waveform is visualized, and if satisfactory, coronary arteriogra-
phy may be performed.
Coronary Angiographic Views

Coronary arteriography provides a silhouette of the epicardial coronary
arteries. The basic views, posteroanterior (PA), left anterior oblique
(LAO), right anterior oblique (RAO) with or without varying degrees of
either cranial or caudal angulation, show the coronaries in orthogonal
views, while minimizing interference by other structures, such as the
78852_ch03 24/06/10 9:53 AM Page 45
Chapter 3 • Native Coronary Angiography 45
Troubleshooting
Difficulty engaging the RCA: The ostium may be high and anterior, posterior, or
angled upwardly. A 3DR catheter may be used if the JR4 catheter fails to engage
the ostium. This catheter is dropped to the aortic valve and gently pulled back with-
out rotating the catheter. For a high and anterior takeoff (frequently seen in trans-
planted hearts due to rotation of the heart), pulling the catheter further back with a
less clockwise turn usually engages the ostium. For a posteriorly directed ostium,
further clockwise rotation may be required. For an upwardly directed ostium or di-
lated ascending aorta, an Amplatz catheter works well. To engage the ostium of the
RCA arising from the left sinus of Valsalva, an Amplatz left (AL 1) catheter may be
used. Other catheters that may be used include an Amplatz right or a multipurpose
catheter.
The pressure waveform is dampened or ventricularized: This usually in-
dicates the catheter tip is either deep seated, restricting coronary inflow; the tip
is against the wall; the conus branch is selectively engaged; or there may be
spasm or severe disease of the ostium. If the catheter tip is too far in the artery,
the catheter is withdrawn gently without disengaging the ostium and a gentle
counter clockwise rotation usually stabilizes the catheter. A gentle clockwise or
counterclockwise rotation moves the tip away from the ostium. If the conus
branch has a separate ostium, then the catheter may need to be slightly reposi-
tioned to avoid this branch, as the main RCA ostium is often very close in proxim-
ity. If spasm is suspected, a gentle test injection is performed. The catheter is dis-
engaged, gently re-engaged, and intracoronary nitroglycerin or a sublingual
nitroglycerin is administered, provided the blood pressure is acceptable and the
image remains suspicious for spasm. If there is true ostial narrowing, a quick in-
jection with just enough dye to fill the artery is done and the catheter is removed
from the ostium. Failure to promptly remove the catheter from the ostium of the
artery, or proceeding with angiography in the presence of a dampened waveform
increases the risk of inducing ventricular fibrillation. Ostial spasm usually occurs
a few seconds after engaging the artery. This helps differentiate it from a fixed
stenosis.
Torque buildup: When a catheter is rotated from outside the sheath, the
torque must be transmitted to the catheter tip before it will rotate. This is best ac-
complished by gently and quickly moving the catheter in and out a few millimeters
while rotating. If torque is allowed to build up within the catheter, the tip can sud-
denly spin, or “helicopter,” which could cause disruption of aortic plaque or poten-
tially even coronary dissection. Torque buildup is often more problematic in patients
with very tortuous iliacs and aortas. Placing a longer sheath can often improve ro-
tational control of the catheter.
78852_ch03 24/06/10 9:53 AM Page 46
spine and the diaphragm. It is important that each segment of coronary

is evaluated in two orthogonal views, with care to avoid significant vessel
overlap and with visualization of all important side branches.
In the LAO projection, the image intensifier (II) is to the left of the
patient. On fluoroscopy, the spine is to the right of the screen in an LAO
view. In the RAO projection, the II is to the right of the patient and
the spine is on the left of the screen in fluoroscopy. In general, cranial
angulation is ideal for visualizing the distal portion of vessels, and caudal
angulation is ideal for visualizing the proximal portion of vessels. The
commonly used views shown in Table 3-1 represent only a guide and
need to be modified for each individual patient.
During cine runs, patients should be instructed to take in and hold a
deep breath, especially with cranial angulations, to move the diaphragm
out of view as far as possible.
Left Coronary System Views: The first view of the left coronary sys-
tem should delineate the course of the left main coronary trunk.
Most operators prefer either a straight PA or a 20° RAO and 20° caudal
angulation (Figure 3-1). The spine should be off the origin of the left
main coronary trunk.
The 20° RAO, 20° caudal view is an ideal view for the proximal cir-
cumflex. In this view, while panning down the circumflex, portions of
the LAD may also be visualized. The operator can also visualize the LCX
artery using a straight PA 30° caudal view.
A straight PA 40° cranial angulation view highlights the mid and dis-
tal portions of the LAD (Figure 3-2). To separate out the diagonals from
Table 3-1 Commonly Used Angiographic Views

Vessel Optimally Viewed
Left Coronary Artery

20⬚ RAO, 20⬚ caudal LMT and LCX
40⬚ PA cranial LAD
45⬚ LAO, 30⬚ cranial LAD and diagonals
30⬚ RAO, 30⬚ cranial LAD
45⬚ LAO, 30⬚ caudal LMT, proximal LAD, and proximal LCX
Right Coronary Artery
40⬚ LAO Proximal and mid RCA
40⬚ PA cranial Distal RCA (PDA and PV branches)
35⬚ RAO Proximal and mid RCA
78852_ch03 24/06/10 9:53 AM Page 47
A B
Figure 3-1 20ⴗ RAO–20ⴗ caudal view of the left coronary artery. A) 3D
diagram of the 20⬚ RAO–20⬚ caudal view. B) Angiogram of the 20⬚ RAO–20⬚ cau-
dal view. This view is optimal for visualization of the left main trunk and the left
circumflex arteries. Note that the left circumflex artery courses posterior to the
heart in this view, a detail best appreciated in the 3D diagram. As in all RAO
views, the spine and the diagnostic catheter lie to the left of the heart.
A B
Figure 3-2 40ⴗ PA cranial view of the left coronary artery. A) 3D diagram
of the 40⬚ PA cranial view. B) Angiogram of the 40⬚ PA cranial view. This view is
optimal for visualization of the mid and distal portion of the left anterior descend-
ing artery and proximal portion of all diagonal branches.
78852_ch03 24/06/10 9:53 AM Page 48
A
B
Figure 3-3 45ⴗ LAO–20ⴗ cranial view of the left coronary artery. A) 3D
diagram of the 45⬚ LAO–20⬚ cranial view. B) Angiogram of the 45⬚ LAO–20⬚ cra-
nial view. This view is optimal for visualization of the left anterior descending
and the entire length of the diagonal branches. As in all LAO views, the catheter
and the spine are to the right of the heart.
the LAD, a 30° RAO with a 25° to 30° cranial angulation is used. The
diagonals are placed above the LAD in this view. Other useful views to
separate the diagonals from the LAD are the 40° to 50° LAO and the
25° to 30° cranial views (Figure 3-3).
The proximal LAD and the left main coronary artery can also be
visualized using the 45° LAO and 30° caudal view (Figure 3-4). This
view is also known as the “spider view.” The origins of the LCX and the
proximal diagonals are also well seen.
In cases where the mid-LAD needs to be visualized in additional
views, such as would be the case for LIMA graft insertions, the straight
lateral view 90° LAO is very useful.
Right Coronary Artery Views: The RCA is viewed in either a straight

RAO or LAO (35–40°) view (Figure 3-5) or a PA view with cranial angu-
lation. The 40° LAO view shows the ostium, proximal, and mid portions
best (Figure 3-6), but the PDA and the posteroventricular branches are
also well visualized.
78852_ch03 24/06/10 9:53 AM Page 49
A B
Figure 3-4 50ⴗ LAO–35ⴗ caudal view of the left coronary artery (“spider
view”). A) 3D diagram of the 50⬚ LAO–35⬚ caudal view. B) Angiogram of the 50⬚
LAO–35⬚ caudal view. This view is optimal for visualization of the left main trunk
and the proximal portions of the left anterior descending and the left circumflex
arteries. In cases of occlusion of the right coronary artery, it is important to main-
tain cine long enough to visualize the extent of potential collaterals to the right
coronary artery.
A
B
Figure 3-5 30ⴗ RAO view of the right coronary artery. A) 3D diagram of
the 35⬚ RAO view. B) Angiogram of the 35⬚ RAO view. This view is best for vi-
sualization of the posterior descending branch of the right coronary artery.
78852_ch03 24/06/10 9:53 AM Page 50
A
Figure 3-6 35ⴗ LAO view of the right coronary artery. A) 3D diagram of the
35⬚ LAO view. B) Angiogram of the 35⬚ LAO view. The posterior descending artery
branch in this view is typically the most inferior vessel arising from the distal right
coronary artery. In cases of severe obstructions of the left anterior descending artery,
it is important to maintain cine long enough to visualize collaterals from the distal
right coronary artery or from the conus branch to the left anterior descending artery.
The bifurcation of the RCA, PDA, and the posteroventricular

branches are best seen in the 40° PA cranial view.
Coronary Anomalies
The various coronary anomalies in order of frequency are listed below:
• Left anterior descending and left circumflex arteries arising from
separate ostia (0.5%) (Figure 3-7)
• Origin of the LCX from the right sinus of Valsalva (0.5%)
(Figure 3-8)
• Origin of the RCA from the ascending aorta above the right sinus
of Valsalva (0.2%) (Figure 3-9)
• Origin of the RCA from the left sinus of Valsalva (0.1%)
(Figure 3-10)
• AV fistula (0.1%) (Figure 3-11)
• Origin of the left main trunk from the right sinus of Valsalva
(0.02%) (Figure 3-12)
78852_ch03 24/06/10 9:53 AM Page 51
B
Figure 3-7 Left anterior descending and left circumflex arteries arise
from separate orifices. Panels A and B show selective engagement of the left
anterior descending and the left circumflex artery. (continued)
78852_ch03 24/06/10 9:53 AM Page 52
Figure 3-8 Left circumflex artery arising from the right sinus of Valsalva.
LAO projection of anomalous circumflex from right sinus of Valsalva passes inferior
and posterior to aorta where it reaches the left atrioventricular groove and distrib-
utes normally over the lateral wall of the heart. In the LAO projection, this anomaly
has the appearance of the letter “S” or “question mark” on its side.
Figure 3-9 Right coronary artery arising from the ascending aorta
above the right sinus of Valsalva. Right coronary artery arises from the as-
cending aorta above the right sinus of Valsalva, RAO projection. Note that the ini-
tial segment of this vessel is vertically oriented.
78852_ch03 24/06/10 9:53 AM Page 53
Figure 3-10 Right coronary artery arising from the left sinus of Valsalva.
Anomalous right coronary artery arises from the left sinus of Valsalva passing
between the aorta and the pulmonary artery and to the right atrioventricular groove
before distributing normally, LAO projection. Patients with this anomaly are at in-
creased risk for sudden death, and it requires surgical correction.
Figure 3-11 AV fistula arising from left circumflex artery draining into
superior vena cava. Serpiginous course of an AV fistula arising from left circum-
flex artery and draining into the superior vena cava, RAO projection.
78852_ch03 24/06/10 9:53 AM Page 54
Figure 3-12 Left main trunk arising from the right sinus of Valsalva.
Anomalous origin of the LMT from the right sinus of Valsalva. Selective visuali-
zation of the left coronary artery, LAO projection. The LMT arises from the right
sinus of Valsalva and passes into the interventricular septum where it gives off a
septal perforator. The vessel then reaches the epicardial surface of the heart
where it divides into the LAD and LCX which distribute normally.
Myocardial Bridging
In myocardial bridging, portions of epicardial coronary arteries (most
commonly the LAD and the diagonals) run within the myocardium
(Figure 3-13). Obliteration of the coronary lumen during systole with res-
olution in diastole may be seen. Because the majority of myocardial blood
flow occurs in diastole, most cases of bridging are clinically benign (98%
11-year survival). However, in rare situations, myocardial bridges may be
associated with angina, myocardial ischemia, myocardial infarction, left
ventricular dysfunction, myocardial stunning, paroxysmal AV blockade,
exercise-induced ventricular tachycardia, or sudden cardiac death.
Effective therapies include beta-blockade, and in severe cases, coronary
stenting or surgical myotomy with or without concomitant bypass surgery.
Image Quality
Due to the invasive nature of the study, and to the important decisions
made with the information, it is vital to obtain high-quality images
when performing coronary angiography. A host of factors are involved
78852_ch03 24/06/10 9:53 AM Page 55
A B
Figure 3-13 Myocardial bridging. Hypertrophied myocardium compress-
ing the mid portion of the left anterior descending artery during A) systole
(arrows). Resolution of arterial compression during B) diastole (arrows).
with the quality of the image, including patient issues and operator
technique.
Patient Factors: Patients who are obese provide lower-quality images

due to difficulty with x-ray penetration. The dose of radiation may be
increased in these patients to improve image quality at the expense of
greater radiation exposure. Bone is dense, and images are of better qual-
ity when the coronaries are not superimposed over the spine. Changing
the amount of lateral angulation can move the spine away from the area
of interest. The density of the diaphragm also creates shadowing which
degrades image quality. Patients should be asked to take and hold a deep
breath, especially during cranial views, to drop the diaphragm out of
view. The lungs are very radiolucent, and look very bright on cine, caus-
ing “washout.” Shielding should be used to cover the lung fields.
Operator Technique: Before a good cineangiogram can be taken, the

vessel must be adequately engaged in a coaxial orientation. A catheter
that does not properly fit in the vessel is either a danger for dissection
or will not allow for adequate filling of the vessel with contrast. The
force with which the contrast is injected is also important. Flow must
be ramped up to avoid blowing the catheter out of the vessel, and in-
jection must be sufficiently strong to prevent streaming within the ar-
tery which will make the angiogram nondiagnostic. The goal of pan-
ning during cineangiography is to visualize the arteries with as little
movement as possible. Cine should begin two cardiac cycles prior to
injection to look for calcification and to see other hardware or foreign
78852_ch03 24/06/10 9:53 AM Page 56
bodies, and cine should continue long enough to evaluate for any late
collateral vessels.
Complications of Native Coronary Angiography

Coronary angiography is a safe procedure. The overall risk of major
complications (death, myocardial infarction, significant embolization) is
less than 0.1%. It is important to understand potential complications so
that they can be avoided when possible.
Vascular complications are the most common complications of
cardiac catheterizations. These include hematoma, pseudoaneurysm,
arteriovenous fistula formation, retroperitoneal bleeding, and vascular
occlusion. Precise placement of the sheath below the inguinal ligament
and above the bifurcation of the femoral artery will decrease retroperi-
toneal bleeds, pseudoanuerysms, and AV fistulas. Meticulous care in inser-
tion and removal of the arterial sheath is necessary to minimize bleeding
and vessel injury (see Chapters 2 and 9 for more information).
Aortic Dissection: Iatrogenic retrograde dissection is largely prevent-

able with careful catheter manipulation. The J-tipped guide wire should
always protrude beyond the tip of the catheter during advancement.
Catheters and wires should never be advanced against resistance. The tip
of the guide wire should be seen by fluoroscopy during advancement to
avoid branch vessel engagement (with special care to avoid the carotid
arteries). Fortunately, most retrograde dissections are non–flow limiting
and self-limited and will seal on their own. However, vascular repair is
occasionally needed.
Coronary Dissection: Injection of contrast when the catheter is

against the wall of the coronary artery (ventricularization of the pres-
sure waveform may give a clue to this) may result in coronary dissec-
tion. With a dissection, contrast is not cleared from the artery wall
after termination of the injection (Figure 3-14). Coronary dissection
can also occur from forceful engagement of the catheter into the coro-
nary ostium. Prompt percutaneous repair or coronary bypass surgery
should be considered.
Coronary spasm can occur anywhere within the coronary tree.
During angiography, spasm may be induced at the coronary ostium due
to mechanical irritation from the catheter tip. The catheter should be dis-
engaged and very gently re-engaged. Intracoronary nitroglycerin should
be injected into the vessel. It is most important to differentiate spasm
from ostial atherosclerotic plaque. Spasm should be suspected if the ves-
sel initially appears normal in caliber, but on subsequent views appears to
78852_ch03 24/06/10 9:53 AM Page 57
Figure 3-14 Iatrogenic dissection of a left internal mammary graft.

A) Dissection of left internal mammary graft showing both the true and false
lumen. The thicker proximal segment represents the true lumen plus the false
lumen (large arrows), and the thinner distal segment represents the false dissect-
ing lumen (small arrows). B) Next run shows thrombosed graft with absence of
blood flow.
be stenotic, or if a severe, smooth, ostial stenosis is seen in an otherwise

normal-appearing coronary.
Air Embolism: While performing coronary arteriography, extreme

caution should be exercised to avoid inadvertently injecting air into
the coronary arteries. To prevent this, all air should be removed from
the manifold and tubing system after each hookup of the catheter. The
manifold should be held at a 45° angle or greater during injection so
that any unrecognized bubbles remain in the syringe. If air is injected
into a coronary artery, the patient may develop chest pain with or
without ST segment elevation on the ECG monitor, or ventricular fib-
rillation as a complication. Saline and intracoronary nitroglycerin
should be repeatedly injected into the coronary artery to clear the air
emboli.
Suggested Reading
Bashore TM, Bates ER, Berger PB, et al. American College of Cardiology/
Society for Cardiac Angiography and Interventions clinical expert consensus
document on cardiac catheterization laboratory standards. J Am Coll Cardiol.
2001;37:2170–2214.
Baum S. Abram’s Angiography. 4th ed. Boston: Little, Brown and Company;
1997:241–252.
78852_ch03 24/06/10 9:53 AM Page 58
Ellis SG. Coronary angiography. In: Fuster V, Ross R, Topol E, eds.

Atherosclerosis and Coronary Artery Disease. Vol 2. Philadelphia: Lippincott–
Raven Publishers; 1996:1433–1450.
Green CE. Coronary Cinematography. Philadelphia: Lippincott–Raven
Publishers; 1996:39–68.
Heupler FA, Proudfit WL, Razavi M, et al. Ergonovine maleate provocative test
for coronary arterial spasm. Am J Cardiol. 1978;41:631–640.
Manske CL, Sprafka JM, Strony JT, et al. Contrast nephropathy in azotemic
diabetic patients undergoing coronary angiography. Am J Med. 1990;89:
615–620.
Matthai WH, Kussmal WG, Krol J, et al. A comparison of low- with high-osmolar
contrast agents in cardiac angiography: identification of criteria for selective
use. Circulation. 1994;89:291–301.
Tilkian AG, Daily EK. Cardiovascular Procedures: Diagnostic Techniques and
Therapeutic Procedures. St. Louis: Mosby; 1986:117–151.
Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients under-
going coronary arteriography. Catheter Cardiovasc Diagn. 1990;21:28–40.
78852_ch04 18/06/10 9:13 AM Page 59
CHAPTER 4
Bypass Graft Angiography

Kellan E. Ashley
Selective angiography of saphenous vein and arterial bypass grafts is usually

performed immediately after angiography of the native coronary arteries.
The technique for bypass graft opacification is similar to that employed for
native coronary artery angiography. Knowledge of common graft loca-
tions and familiarity with multiple catheter types are essential to perform
a complete study.
Saphenous Vein Grafts

Saphenous veins are the most commonly employed conduits in coronary
revascularization. Approximately 87% of saphenous vein grafts (SVGs)
remain patent at 6 months, with the patency rates dropping to approxi-
mately 63% at 10 years. Because of the high incidence of graft attrition,
repeat revascularization often becomes necessary, requiring coronary
angiography to assess graft patency.
The proximal anastomosis of most aortocoronary SVGs lies on the
anterior surface of the aorta, several centimeters above the sinuses of
Valsalva. Usually, the location of the various grafts in relation to one
another follows a predictable sequence. Grafts to the left circumflex
coronary artery (LCX) are typically placed most superior, followed in
succession inferiorly by grafts to the diagonal branches of the left ante-
rior descending artery (LAD), the LAD itself, and the right coronary
artery (RCA) (Figure 4-1). It should be noted, however, that because of
variations in surgical technique, exceptions to this rule commonly exist. If
prior angiograms are available, they should be reviewed firsthand
prior to diagnostic angiography, as these can be extremely helpful
in locating graft ostia and for selection of catheters.
The Judkins right 4 (JR4) catheter is the most common catheter em-
ployed in pursuit of vein grafts. Typically, grafts to the RCA can be
best visualized and cannulated while in the left anterior oblique
(LAO) projection, while grafts to the left coronary artery (LCA)
59
78852_ch04 18/06/10 9:13 AM Page 60
Figure 4-1 Three-dimensional diagram illustrating the usual surgical

placement of saphenous vein grafts. From superior to inferior in the aorta,
the grafts anastomose to the lateral circumflex (obtuse marginal), diagonal, and
right coronary arteries.
system are most easily found while in the right anterior oblique
(RAO) projection (Table 4-1). The proximal anastomosis sites of these
grafts lie superior to the native coronary ostia. Some surgeons place ostial
graft markers on the outer surface of the aorta at the time of surgery to
facilitate location of the grafts during future catheterizations. Surgical
clips may also provide clues as to the location of grafts.
78852_ch04 18/06/10 9:13 AM Page 61
Chapter 4 • Bypass Graft Angiography 61
Table 4-1 General Graft Views

Graft Ostium and Body Distal Anastomosis Native Artery
LIMA → LAD or Straight LAO and RAO Left lateral view; PA cranial
SVG → LAD LAO cranial
SVG → Diagonal Straight LAO and RAO RAO cranial LAO cranial
SVG → LCX Straight LAO and RAO RAO caudal RAO caudal
SVG → RCA Straight LAO and RAO LAO PA cranial
Steady “up and down” movements of the catheter in the ascending

aorta with slight clockwise or counterclockwise rotations, typically from the
second to the fourth sternal sutures, facilitate engagement of the various
grafts. The catheter tip often “jumps” forward when it cannulates a graft
ostium. Damping of the pressure waveform may indicate that the
catheter tip is lying against the vessel wall or that there is an ostial stenosis.
In this situation, the catheter should be cautiously withdrawn while
simultaneously reversing its torque. Occasionally, the pressure waveform
remains damped, and it may be necessary to perform a ramped injection
of contrast with quick removal of the catheter in order to rule out criti-
cal stenosis or subtotal obstruction of a graft. Remember that injecting
through a deep-seated catheter may not define an ostial stenosis.
Occluded grafts will appear as a “stump” upon selective injection.
If a graft cannot be cannulated, do not assume that the graft is
occluded. Other catheters with different angulation may be necessary. If
further attempts fail, aortography via a pigtail catheter may be helpful
in locating difficult-to-find grafts. To locate bypass grafts to the left
coronary system, an aortogram in LAO projection is recommended.
Conversely, for RCA grafts, an RAO projection should be adequate.
A careful review of native coronary angiograms may also provide
clues regarding graft patency. For instance, if a bypassed native artery
demonstrates competitive distal flow, the graft supplying that artery is
likely patent. Conversely, if normal distal flow is seen in the bypassed native
artery, without competitive filling, the graft is probably occluded.
Once properly engaged, each graft should be visualized in
both the LAO and RAO projections using an injection technique sim-
ilar to that employed for native coronaries. Usually, several views are
needed to fully assess the graft ostium, body, and distal anastomosis.
Additionally, the individual views that are best for evaluating each na-
tive coronary artery can be helpful in evaluating the distal anastomosis
of the graft as well as the distal course of the native vessel.
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Troubleshooting
Cannulating “Difficult” Grafts
SVG to LCX: This graft is usually the most cranially located graft within the ascending
aorta. It is best engaged with a JR4 catheter while in the RAO projection, as are all
grafts to the LCA system. Gentle clockwise rotation of the catheter at a location in the
ascending aorta above the other SVGs will often successfully find the graft ostium.
With all LCA grafts, the operator should strive to position the tip of the catheter so
that it faces toward the right side of the aortic silhouette in the RAO view. Once en-
gaged, the usual LAO and RAO views are subsequently obtained.
SVG to LAD and diagonal branches: The LAD graft is most commonly lo-
cated above the ostium of the native LCA, and just beneath the ostium of the LCX
graft described above. Again, with the JR4 catheter lying in the ascending aorta,
clockwise rotation of the catheter usually locates the ostium of this graft. It often
helps to rotate the catheter slightly above the suspected location of the ostium, as
clockwise rotation usually brings the tip downward slightly. Occasionally, the JR4
catheter is unable to engage left coronary grafts, especially if there is an angulated
takeoff from the aorta. A multipurpose or left coronary bypass (LCB) catheter can be
useful in these settings.
SVG to RCA: This graft is commonly placed just above the native RCA ostium on
the right side of the aorta. Engagement of this graft ostium is best facilitated with the
camera in the LAO projection. Simply withdrawing the JR4 catheter from the RCA will
often cannulate the graft ostium. If this fails, clockwise rotation of the catheter a few
centimeters above the native RCA may bring the catheter into the correct plane.
Sometimes, the takeoff of the RCA graft is at an acute angle from the aorta and is not
easily cannulated with the JR4 catheter. A multipurpose catheter (usually a multipur-
pose B) can be helpful in such circumstances, as it has a more downward angle.
Gentle clockwise rotation as this catheter is first withdrawn then advanced toward
such a downwardly directed graft will usually place the catheter within the ostium.
Right modified Amplatz, right coronary bypass (RCB), and 3-DRC catheters are other
alternatives for cannulation of RCA grafts.
Internal Mammary Artery Grafts

Internal mammary artery (IMA) grafts are used routinely in coronary
artery bypass surgery, as they provide superior patency rates compared
to venous grafts in the long term. Left internal mammary artery
(LIMA) graft patency has been reported to be 93% at 6 months and
90% at 10 years. When these arterial grafts do fail, the culprit stenosis
usually lies at the distal anastomosis or in the artery just beyond
the anastomosis.
78852_ch04 18/06/10 9:13 AM Page 63
In order to successfully cannulate the LIMA, the operator must un-

derstand the anatomy of the left subclavian artery and its branches. The
LIMA is often anastomosed to the mid- or distal LAD, although it
sometimes is grafted to diagonal branches or the left circumflex instead.
It typically arises anteroinferiorly from the left subclavian artery, 1 to
3 cm beyond the vertebral artery (Figure 4-2).
Using the LAO projection, the JR4 catheter is positioned in the aortic
arch just proximal to the origin of the left subclavian artery. The catheter is
Figure 4-2 This schematic depicts the typical anatomy of the left sub-
clavian artery and its most proximal branches. Note that the internal mam-
mary (thoracic) artery (IMA) arises anteroinferiorly. When evaluating a patient
with ischemia in the IMA distribution, it is important to rule out the possibility of
subclavian or innominate stenosis proximal to the IMA origin.
78852_ch04 18/06/10 9:13 AM Page 64
then slowly pulled back as gentle counterclockwise rotation is applied,

thereby moving the tip of the catheter superiorly into the origin of the
left subclavian artery. An alternative technique for subclavian artery can-
nulation involves extending the tip of the JR4 catheter just past the left
subclavian origin, then rotating the catheter clockwise to engage the
artery. An angiogram of this artery in the posteroanterior (PA) projec-
tion enables the operator to locate the ostium of the LIMA and exclude
a significant subclavian stenosis that could be indirectly causing myocar-
dial ischemia by impairing flow down the LIMA. When the subclavian
artery is tortuous, the origin of the LIMA is often better demonstrated
in the RAO projection.
A 0.035-in guidewire (either the J-tipped wire or a Wholey wire) is
then advanced gently through the catheter into the subclavian artery and
out into the axillary artery, well beyond the origin of the LIMA. The
catheter should then be advanced over the wire to a point about halfway
between the sternum and the left shoulder. The guidewire is removed
and the catheter is flushed vigorously. In order to engage the LIMA, the
catheter is slowly withdrawn while simultaneously applying gentle coun-
terclockwise rotation so that the catheter tip faces anteriorly. Because the
LIMA often arises from the subclavian artery at a 90° angle, a catheter
with a sharper curve, such as the IMA or 5-Fr. special IMA catheter, may
be necessary to cannulate the ostium.
Small test injections can be used to orient the operator. Nonionic
contrast is advisable when injecting the subclavian and internal
mammary arteries in order to minimize the risk of hyperosmolar
neurotoxicity, as well as to reduce the burning discomfort to the patient.
Having the patient turn his/her head to the left or right can help engage
the graft by slightly changing the orientation of the catheter.
Once the catheter nears the ostium of the mammary graft, the tip
may “jump” into the ostium. One has to be extremely cautious when
manipulating the catheter near or within the LIMA, as this vessel is espe-
cially delicate and prone to dissection (see Figure 3-7). For this reason,
fine movements are advisable whenever attempting to engage the LIMA.
If pressure damping does occur, the catheter tip should be quickly and
carefully rotated out of the artery by rotating the catheter in an opposite
direction. For example, if pullback and counterclockwise rotation resulted
in a dampen pressure, a clockwise rotation should disengage the catheter
from this position. In general, the catheter should never be advanced
forward without a wire.
Once engaged, the LIMA graft is injected in at least two projec-
tions, paying special attention to the distal anastomotic site. Forceful
injections are discouraged. Straight RAO and LAO projections are the
most commonly employed. Cranial angulation can be added to either
78852_ch04 18/06/10 9:13 AM Page 65
projection to better visualize the distal aspect of the LAD. A cross-table

lateral view is sometimes helpful to gain an additional view of the anas-
tomotic site.
If the LIMA cannot be selectively engaged, a subselective view can
be obtained. In this instance, the catheter should be positioned as close
as possible to the LIMA ostium. A blood pressure cuff inflated on the
left arm will help direct contrast flow preferentially down the LIMA
instead of distally into the brachial artery.
Selective visualization of the right internal mammary artery (RIMA)
is similar to that of the LIMA above, but often is more difficult. A JR4
or IMA catheter (there is no specific RIMA catheter) is advanced into
the proximal aortic arch past the origin of the innominate artery.
Counterclockwise rotation will bring the tip of the catheter into the origin
of the innominate artery, and a guidewire can subsequently be advanced
through the catheter down the right subclavian artery, taking great care
to avoid the right common carotid artery. The catheter is then advanced
over the wire just as in LIMA catheterization. The difference in cannu-
lating the RIMA is that upon pulling back the catheter, slow clockwise
rotation is applied to bring the tip anteriorly to engage the RIMA
ostium. When it is impossible to cannulate the RIMA with this tech-
nique, the operator may elect to configure a JR4 or IMA catheter with
a concave secondary curve proximal to the primary curve in order to
improve engagement of the RIMA ostium.
The RIMA (and occasionally even the LIMA) is often used as a
“free” graft, with its proximal anastomosis in the ascending aorta. In this
case, the procedure for cannulating the graft is the same as that for SVGs.
Radial Artery Grafts

On occasion, the angiographer may encounter a radial artery graft. Data
suggest that short-term patency of radial artery grafts is comparable to
that of SVGs. Long-term patency rates appear to be reasonable for radial
artery grafts, with one study showing 92% patency at 5 to 7 years. Radial
artery grafts are often placed in similar locations as SVGs, and they are
cannulated in much the same way. Angiographically, these grafts have a
smaller caliber and smoother appearance than their SVG counterparts.
Gastroepiploic Artery Grafts

The gastroepiploic artery (Figure 4-3) is a branch of the gastroduode-
nal artery, which originates from the common hepatic artery of the
celiac trunk. It is seldom used but when it is employed as a conduit, it
usually serves as an in situ graft to a vessel along the inferior surface of
78852_ch04 18/06/10 9:13 AM Page 66
Figure 4-3 Schematic diagram depicting normal abdominal aorta

anatomy. Note that the gastroepiploic artery is a branch of the common hepatic
artery, which originates from the celiac trunk. The celiac trunk is typically located
along the anterior aorta just proximal to the twelfth thoracic vertebra.
the heart, such as the posterior descending artery. The graft is usually
cannulated with the use of a standard visceral catheter, such as the
Cobra catheter. Subselective artery cannulation may erroneously lead to
the conclusion that the graft is occluded, so it is important to selectively
engage the artery.
Acknowledgments
The author would like to gratefully acknowledge the contributions of Christopher
Merritt, MD, and Frederick A. Heupler, Jr, MD, to the first edition of this
manuscript.
Suggested Reading
Isshiki T, Yamaguchi T, Nakamura T, et al. Postoperative angiographic evaluation
of gastroepiploic artery grafts. Cathet Cardiovasc Diagn. 1990;21:233–228.
Peterson KL, Nicod P. Cardiac Catheterization: Methods, Diagnosis, and Therapy.
1st ed. Philadelphia: W.B. Saunders Co.; 1997:165–167.
78852_ch04 18/06/10 9:13 AM Page 67
Sabik JF III, Blackstone EH, Gillinov AM, et al. Occurrence and risk factors for
reintervention after coronary artery bypass grafting. Circulation. 2006;114
(1 suppl):454–460.
Sabik JF III, Lytle BW, Blackstone EH, et al. Comparison of saphenous vein and
internal thoracic artery graft patency by coronary system. Ann Thorac Surg.
2005;79(2):544–551.
Tatoulis J, Royse AG, Buxton BF, et al. The radial artery in coronary surgery:
a 5-year experience—clinical and angiographic results. Ann Thorac Surg.
2002;73(1):143–147.
Tatoulis J, Buxton BF, Fuller JA. Patencies of 2127 arterial to coronary conduits
over 15 years. Ann Thorac Surg. 2004;77(1):93–101.
Tatoulis J, Buxton BF, Fuller JA, et al. Long-term patency of 1108 radial arterial-
coronary angiograms over 10 years. Ann Thorac Surg. 2009;88(1):23–29.
78852_ch04 18/06/10 9:13 AM Page 68
78852_ch05 24/06/10 9:54 AM Page 69
CHAPTER 5
Left Ventriculography
and Aortography
Mateen Akhtar and Frederick A. Heupler, Jr.
Left ventriculography provides important anatomic and functional infor-

mation that supplements coronary angiography. Left ventriculography
allows assessment of left ventricular systolic function, degree of mitral re-
gurgitation, and the presence/location of wall motion abnormality or
ventricular septal defect (Table 5-1). Ventriculography should not be
performed when a patient is hemodynamically unstable. Additional con-
traindications are listed in Table 5-2.
Preparation
Single-plane ventriculography is performed in most catheterization labo-
ratories. Some operators prefer biplane ventriculography since it can pro-
vide more information about ventricular anatomy and function. Biplane
ventriculography has limitations such as costly angiographic equipment,
additional radiation exposure to both operator and patient, and longer
angiographic setup time.
The Medrad powered flow injector is connected to extension tubing
and loaded with contrast. During this process, air bubbles should be
purged from the injector. Once appropriate pressure measurements have
been obtained, the pigtail catheter is connected to extension tubing from
the power injector via a blood-contrast interface to minimize the risk of
air embolism with left ventriculography. Usually the left ventricular
cavity is adequately visualized with 30 to 50 mL of contrast.
Table 5-1 Left Ventriculography: Indications
Assess global left ventricular systolic function and regional wall motion
Assess severity of mitral regurgitation
Identify and assess muscular and membranous ventricular septal defects
69
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Table 5-2 Left Ventriculography: Contraindications
Critical left main disease

Critical aortic stenosis
Fresh intracardiac thrombusa
Contrast media reaction
Tilting-disc aortic prosthesis
Decompensated heart failure and/or renal failure
a
Because sessile thrombi more than 6 months old have a lower risk of dislodgement, some
operators will proceed with ventriculography in this circumstance.
The parameters listed in Table 5-3 can serve as a baseline when de-
ciding on the rate and volume of contrast injection. Certain patient char-
acteristics and clinical settings will influence these settings. For instance,
higher volumes of contrast dye (i.e., 50–60 mL) may be necessary to
completely opacify the left atrium in patients with severe mitral regurgi-
tation. Higher rates of contrast injection may be necessary in patients
with increased cardiac output or dilated left ventricular cavity. Conversely,
patients with smaller ventricular cavities such as elderly females or those
with hypertensive heart disease may need only 30 to 36 mL of contrast dye
for adequate imaging. All patients with hemodynamically significant
valvular disease, left ventricular dysfunction, or elevated left ven-
tricular end-diastolic pressure (LVEDP) should receive nonionic
contrast for ventriculography.
Entering the Ventricle

The catheter most commonly used for ventriculography is an angled pig-
tail catheter. The distal segment of this catheter should be angled 145° to
155° in order to facilitate passage into the left ventricle while simultane-
ously preventing the endhole from contacting the endocardium, thereby
reducing the risk of endocardial staining. The multiple side holes help
dissipate the pressure of rapid power contrast injection and prevent ex-
cessive catheter movement.
Table 5-3 Standard Settings for Left Ventriculography
Rate of rise 0–0.4 sec

Rate of injection 10–15 mL/sec
Volume of injection 30–40 cc
Maximum pressure 600–700 psi
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Chapter 5 • Left Ventriculography and Aortography 71
The pigtail catheter is advanced over a 0.035-in J-tipped wire to a

position in the ascending aorta just superior to the aortic valve. The tip
should be pointed toward the orifice of the valve and the catheter
rotated so that the pigtail loop resembles a “6.” In this position, gently
advancing the catheter will usually push it across the valve orifice and
into the ventricle.
Occasionally, the pigtail catheter will prolapse into the ventricle while
the pigtail remains in the ascending aorta. Slowly advancing the guidewire
through the terminal portion of the catheter should provide enough
additional support to allow entry into the ventricle. Once in the ventricle,
the tip of the pigtail should be positioned in the midcavity avoiding con-
tact with the papillary muscles and mitral valve (Figure 5-1).
Figure 5-1 30° RAO ventriculogram demonstrating ideal placement of

the pigtail catheter in the ventricular midcavity. The most common reasons
for ectopy during ventriculography are contact of the catheter with either the
apex or the septum. Gentle counterclockwise rotation and/or pullback of the
catheter should eliminate the ectopy.
78852_ch05 24/06/10 9:54 AM Page 72
Troubleshooting
Ventricular Ectopy
If the pigtail catheter irritates the apex, the risk of ventricular ectopy rises signifi-
cantly. Gentle counterclockwise rotation and pullback should separate the catheter
from the septal and apical walls and the ectopy will usually resolve.
Entrapment in Mitral Valve Apparatus
Occasionally, the catheter tip may become trapped within the mitral valve appara-
tus. If ventriculography is performed under these circumstances, transient but sig-
nificant mitral regurgitation may develop. Gentle clockwise rotation should dislodge
the catheter from the apparatus and place it in the center of the ventricle. If not, the
catheter can be withdrawn from the ventricle and ventricular entry reattempted.
Once the catheter is stabilized within the left ventricle, it is connected

to the pressure manifold, flushed, and used to record intraventricular pres-
sures. Systolic pressure is typically recorded on a 200-mm Hg scale, while
LVEDP is best appreciated on a 40-mm Hg scale. Markedly elevated
LVEDP (⬎30 mm Hg) usually precludes left ventriculography.
Administration of sublingual or intravenous nitroglycerin may reduce
LVEDP to a more acceptable level.
In patients with compromised left ventricular systolic function, elevated
LVEDP, or reduced creatinine clearance, a hand-injection left ventriculo-
gram using digital subtraction angiography (DSA) may be preferred since
Troubleshooting
Crossing a Stenotic Aortic Valve
Crossing a stenotic aortic valve requires patience, experience, and a bit of luck. This
task can be accomplished with a variety of catheters and wires depending on oper-
ator preference, experience, and patient anatomy. Some operators prefer a brief
cine run of aortic valve opening and closing in right anterior oblique (RAO) and left
anterior oblique (LAO) projections in order to identify the angle and plane of the aor-
tic valve orifice prior to crossing it.
Due to the inherent thrombogenicity of guidewires, some operators advise ad-
ministering 5,000 units of intravenous unfractionated heparin before attempting to
cross a stenotic aortic valve. In addition, following every 3 minutes of unsuccessful
wire manipulation, the wire should be removed and wiped, and the catheter should
be flushed vigorously to prevent thrombus formation. Excessive force should never
be used to pass the wire into the left ventricle. Common techniques for crossing a
stenotic aortic valve are reviewed below.
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Wire Selection
The most common wires utilized to cross a severely stenotic aortic valve are a
straight-tipped wire (0.035 or 0.038) or a Rosen exchange J-tipped wire. The Rosen
wire is a J-tipped wire with a J-curve that is narrower (5 mm diameter) than the
usual J-tip (10 mm diameter). The advantage of the Rosen wire is that the J-tip
eliminates the risk of left ventricular perforation, but it may be more difficult to pass
across a very severely stenotic valve. The advantage of a straight-tipped wire is that
it will cross virtually any stenotic aortic valve, but the straight tip can perforate the
left ventricle. The safest procedure is to initially attempt to cross the valve with the
Rosen wire, which can be accomplished in more than 90% of cases.
Catheter Selection
Common catheters utilized to cross the aortic valve are the pigtail, Amplatz left
coronary, Feldman, Judkins right coronary, and multipurpose catheters. The Amplatz
and Feldman catheters are preferred if the aorta is dilated. The length of the sec-
ondary curve of these catheters should be adjusted proportionally to the diameter of
the aorta. The Judkins right coronary and multipurpose catheters are preferred
when the aortic root is narrow.
Technique
Once the selected catheter is positioned in the ascending aorta, the guidewire is
cautiously advanced through the endhole of the catheter in an attempt to cross the
valve orifice. Carefully advancing and rotating the catheter simultaneously should
eventually direct the wire across the aortic valve. The tip of the wire should be di-
rected anteriorly and to the patient’s left. Generally, it is easier to cross the valve in
the RAO projection. The angiographer should only attempt to advance the wire
across the valve during systole. Altering the amount of wire protruding from the pig-
tail catheter may help direct the wire. For instance, more wire protruding from the
pigtail catheter directs the wire toward the right coronary sinus, whereas less wire
protruding directs the wire to the left coronary sinus.
Crossing a Prosthetic Aortic Valve

Crossing a prosthetic stenotic aortic valve is typically not clinically necessary but
may be considered when echocardiography provides suboptimal image quality,
when echocardiographic and clinical findings do not correlate, or when there is se-
vere left ventricular dysfunction with low cardiac output. It is absolutely contraindi-
cated to cross a tilting-disc aortic valve prosthesis (St. Jude, Medtronic-Hall, Bjork-
Shiley). Attempts at catheter or wire passage across these prostheses can result in
entrapment and/or disc dislodgement. Bioprosthetic porcine and pericardial valves
may be crossed. In theory, Starr–Edwards prosthetic valves may also be crossed,
but smaller sized catheters are usually necessary. Avoid crossing a metal pros-
thesis unless absolutely necessary.
78852_ch05 24/06/10 9:54 AM Page 74
Figure 5-2 Left ventriculogram in a 30° RAO view.
only 10 mL of contrast is needed. Patients should be instructed to cease

respiration and avoid any motion during cine acquisition in order to mini-
mize artifact.
Views
The most common views for left ventriculography are the 30° RAO and
60° LAO projections. The optimal magnification is a 9-in field because
it allows for complete visualization of the entire left ventricle, including
the mitral and aortic valves, without the need for panning.
30° RAO View: The 30° RAO view is particularly helpful because it
projects the left ventricle off the spine, thus producing a higher quality
picture (Figure 5-2). Positioning the wedge filter into the upper right
hand corner improves image quality. The walls best visualized with the
30° RAO view include the anterior, apical, and inferior walls. Also, from
this angle the mitral valve is seen in profile, allowing for evaluation of
mitral valve disease. One limitation of this view is that it places the left
atrium over the spine and descending aorta, thus impairing the opera-
tor’s ability to evaluate the severity of mitral regurgitation. Adding
steeper RAO angulation (45°) will help the operator quantify mitral re-
gurgitation since this view positions the left atrium to the right of the
spine.
60° LAO View: The 60° LAO view is most useful for functional assessment
of the ventricular septum, lateral wall, and posterior walls (Figure 5-3).
78852_ch05 25/06/10 4:09 PM Page 75
Figure 5-3 Left ventriculogram in a 60° LAO view.
Also, the aortic valve is well visualized. Adding 25° of cranial angulation
reduces any foreshortening of the ventricular septum and therefore is ideal
for assessing the left ventricular outflow tract and for presence of a muscu-
lar ventricular septal defect. Cranial angulation also provides improved visu-
alization of the left atrium because it positions the left atrium away from the
spine, the left ventricle, and the descending aorta.
Left Lateral View (70° to 80°): A lateral view is particularly useful to

assess for a membranous ventricular septal defect.
Analysis
Left Ventricular Systolic Function: In most laboratories, a qualitative as-
sessment of left ventricular systolic function, mitral regurgitation severity,
and regional wall motion is performed. When describing regional wall
motion, the walls are commonly classified as either normal, hypokinetic,
akinetic, or dyskinetic (Table 5-4). Once all the ventricular walls have
Table 5-4 Classification of Regional Wall Motion

Classification Definition
Hypokinesia Reduction of inward motion during systole

Akinesia Absence of inward motion during systole
Dyskinesia Paradoxical outward motion during systole
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Table 5-5 Semiquantitative Assessment of LV Systolic Function

LV Systolic Function Ejection Fraction
Normal ⱖ55–60%
Low normal 50%
Mildly impaired 40–49%
Moderately impaired 30–39%
Severely impaired ⱕ30%
been studied, an estimation of global left ventricular systolic function is

made. This estimation is typically done semiquantitatively (Table 5-5).
A quantitative assessment of left ventricular systolic function may be cal-
culated by comparing end-systolic to end-diastolic left ventricular vol-
ume. However, these calculations are rarely done on a routine basis.
Valvular Anatomy and Function: During left ventriculography, both

aortic and mitral valve function should be grossly assessed. Table 5-6
classifies degrees of mitral regurgitation. Leaflet mobility, thickening,
and calcification can each be evaluated. Mitral annular calcification, if
present, should be noted and quantified. Bicuspid aortic valves and
mitral valve prolapse may also be observed.
Prosthetic Valves: The ideal angulation for either the RAO or LAO
view places the annulus of the prosthesis perpendicular to the imaging
plane. The best angle for evaluating mitral valve function is an RAO
Table 5-6 Angiographic Assessment of Mitral Regurgitation

Grade Angiographic Appearance
Mild (1⫹) Faint LA opacification that clears with each

beat does not opacify the entire LA
Moderate (2⫹) Complete LA opacification after several beats
Opacification intensity: LA ⬍⬍ LV
Moderately severe (3⫹) Complete LA opacification
Opacification intensity: LA ⫽ LV
Severe (4⫹) Complete LA opacification after one beat
Opacification intensity: LA ⬎⬎ LV
Opacification of pulmonary veins
78852_ch05 24/06/10 9:54 AM Page 77
Figure 5-4 An RAO projection of a normally functioning bileaflet tilting-disc

(St. Jude’s) mitral valve prosthesis. (Courtesy of Mario Garcia, MD.)
view (Figure 5-4). The best angle for evaluating aortic valve function
is an LAO view (Figure 5-5).
A complete fluoroscopic evaluation includes assessment of valvular
motion and structural integrity. Some prosthetic valve companies, such
as St. Jude’s and Bjork-Shiley, publish what they consider to be normal
parameters for opening and closing angles. These angles can be meas-
ured fluoroscopically to determine if a specific valve is functioning
properly. However, the availability of multiplane transesophageal
echocardiography (TEE) obviates the need for angiographic assess-
ment of prosthetic valve function in most cases.
Complications
Potential complications of left ventriculography are listed in Table 5-7.
78852_ch05 24/06/10 9:54 AM Page 78
Figure 5-5 An LAO projection of a normally functioning bileaflet tilting-disc

aortic valve prosthesis. (Courtesy of Mario Garcia, MD.)
Table 5-7 Complications of Left Ventriculography

Complication Caveats
Ventricular arrhythmias Most common complication

Sustained VT is an indication for immediate wire/catheter
removal
Complete heart block Complete heart block may occur due to trauma from the
catheter as it enters the left ventricle or during
ventriculography. Particular caution should be used in
patients with baseline RBBB and left posterior hemiblock
Endocardial staining Refers to accumulation of contrast within endocardium
Larger stains may result in VT or VF
Air embolism Potentially catastrophic complication which may result
in CVA or MI
Cardiac tamponade Catastrophic complication which occurs if ventricle is
punctured during aggressive wire manipulation; rare
with reported incidence of 0.3%
VT, ventricular tachycardia; VF, ventricular fibrillation; RBBB, right bundle branch block;
CVA, cerebrovascular accident; MI, myocardial infarction.
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Table 5-8 Aortography: Common Indications and Contraindications

Indications
Assess severity of aortic regurgitation

Assess aneurysm size
Identify the location and extent of aortic dissection
Opacify difficult-to-find bypass grafts or anomalous coronary arteries
Localize coarctation of the aorta
Contraindications
Decompensated heart failure

Renal failure
Contrast media reaction
Aortography
Introduction: Aortography is not routinely performed during diagnostic
cardiac catheterization. However, in certain circumstances (Table 5-8),
aortography can be useful to better define aortic root anatomy (Table 5-9)
and aortic valve function (Table 5-10).
Preparation: A 6-French pigtail catheter is most commonly employed

because its multiple side holes reduce the risk for aortic dissection dur-
ing power injection. The pigtail is advanced to a location just above the
Table 5-9 Normal Aortic Anatomy

Location Description
Aortic root or bulb Formed by the three sinuses of Valsalva: right, left,
and posterior
Ascending aorta Measures 2.2–3.8 cm in normal adults
Aortic arch Gives rise to the great vessels including the
brachiocephalic, left common carotid, and left
subclavian artery
Descending aorta Continuation of aorta distal to left subclavian artery
Typically measures ~2.5 cm
Anatomic landmark used to distinguish type A from
type B dissections
78852_ch05 24/06/10 9:54 AM Page 80
Table 5-10 Angiographic Assessment of Aortic Insufficiency

Grade Angiographic Appearance
Mild (1⫹) Faint, incomplete LV opacification that clears

with each beat
Moderate (2⫹) Opacification of entire LV ⬍⬍ aorta
Moderately severe (3⫹) Progressive opacification of entire LV ⫽ aorta
Severe (4⫹) Dense LV opacification after one beat ⬎⬎ aorta
sinotubular junction. Standard injection volume is 40 to 60 mL at a rate

of 20 mL/sec.
Views: The most useful view is a 60° LAO view because both the
aortic root anatomy and the severity of aortic insufficiency can be
evaluated (Figure 5-6).
Figure 5-6 60° LAO aortography demonstrating a normal aorta.

78852_ch05 24/06/10 9:54 AM Page 81
Figure 5-7 An object with a predefined diameter may be placed in the

fluoroscopic field and used as a reference when measuring aortic aneurysms, for
instance.
Analysis: In order to measure aortic root dimensions, image acquisition

of a radiopaque standard-sized object is used as a reference (Figure 5-7).
The diameter of this object is measured during angiography and then
used to calculate the diameter of the aortic root. Once an image of the
object has been obtained, aortic root angiography must be performed
using the same angulation and magnification.
Assessment of Aortic Dissection: Aortography may help identify the origin

and proximal and/or distal extension of an aortic dissection (Figure 5-8).
In addition, the severity of aortic regurgitation, the patency of the proxi-
mal coronary arteries, and location of an intimal flap may also be evalu-
ated. It is important never to inject into the false lumen of an aortic dis-
section. With advances in noninvasive imaging modalities such as
78852_ch05 24/06/10 9:54 AM Page 82
Figure 5-8 An example of an ascending aortic dissection in LAO pro-

jection. Note the “flap” visualized (arrows).
TEE, cardiac CT, and MRI, aortography is no longer the initial im-
aging modality of choice in the diagnosis of aortic dissection.
Locating Bypass Grafts: Aortography is sometimes performed to help

locate difficult-to-find bypass grafts. It is important to remember,
however, that lack of bypass graft opacification by aortography does not
completely rule out the presence of patent grafts.
Coarctation of the Aorta: Aortic coarctation is best identified from a lat-

eral view (Figure 5-9). Aortography determines the site of obstruction
and extent of pre and/or poststenotic dilatation. A pressure gradient
⬎20 mm Hg across the coarctation is considered to be hemodynamically
significant, while a gradient ⬎50 mm Hg warrants intervention.
78852_ch05 24/06/10 9:54 AM Page 83
Figure 5-9 Example of coarctation of the aorta in steep RAO projection.
Suggested Reading
Arciniegas JG, Soto B, Little WC, et al. Cineangiographs in the diagnosis of
aortic dissection. Am J Cardiol. 1981;47:890–894.
Baltaxe HA. Imaging of the left ventricle in patients with ischemic heart disease:
role of the contrast angiogram. Cardiovasc Intervent Radiol. 1982;5:
137–144.
Bhargava V, Warren S, Vieweg WVR, et al. Quantitation of left ventricular wall
motion in normal subjects: comparison of various methods. Cathet Cardiovasc
Diagn. 1980;6:7–16.
Chaitman BR, DeMots H, Bristow JD, et al. Objective and subjective analysis of
left ventricular angiograms. Circulation. 1975;52:420–425.
Sanders C. Current role of conventional and digital aortography in the diagnosis
of aortic disease. J Thorac Imaging. 1990;5:48–59.
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78852_ch06 18/06/10 9:14 AM Page 85
CHAPTER 6
Cerebral and Peripheral

Angiography
Inder M. Singh, Steven J. Filby,
and Mehdi H. Shishehbor
Noncoronary angiography, often generalized as “peripheral” angiography,

has become an increasingly common part of the invasive cardiologist’s
repertoire. Prior to gaining a sound working knowledge of peripheral
angiography, it is important to recognize several associated salient tech-
nical features. It is also prudent to have a sound knowledge of the key
elements that distinguish peripheral from coronary angiography.
1. The diameter of the image intensifier used for peripheral angiography
is 14 to 16 in compared to 9 in used in most cardiac catheterization
laboratories. This provides a larger imaging window when viewing
the aorta and lower extremities.
2. The frame rate for peripheral angiography is usually 2 to 3 frames
per second compared to 15 to 30 frames per second for coronary
angiography.
3. Digital subtraction angiography (DSA) is the preferred imaging
modality for peripheral angiography. DSA literally subtracts the sur-
rounding radio structures (such as bone) and shows only the contrast-
filled arterial bed of interest. This technique greatly enhances image
quality but requires the patient to be completely still (including tem-
porary cessation of respiration or swallowing for carotid angiography)
during image acquisition. The radiation exposure for DSA is signifi-
cantly greater than standard cardiac cineangiography.
4. Trace subtract fluoroscopy or “road mapping” is frequently used in-
stead of standard fluoroscopy during peripheral angiography. Like
DSA, “road mapping” also enables visualization of contrast-filled
vessels without the surrounding tissues or bone.
5. Arterial access for peripheral angiography may require retrograde
common femoral artery (CFA) cannulation. However, depending on
the nature of disease, antegrade CFA cannulation or brachial/radial
85
78852_ch06 18/06/10 9:14 AM Page 86
access may be required. Prior to upper extremity access, an Allen

test should be performed to confirm intact dual vascular supply
of the hand. Familiarity with the micropuncture system is essential
for all physicians performing peripheral angiography.
6. Ionic contrast is not used for peripheral angiography as it has been
associated with transient vision loss during cerebrovascular angiog-
raphy and is extremely painful when used for limb angiography. A
nonionic iso-osmolar agent such as iodixanol is the preferred con-
trast agent.
Similarities in the periprocedural evaluation of patients undergoing
coronary or peripheral angiography are enumerated below.
1. Knowledge of presenting symptoms is essential for clinical and tech-
nical decision making.
2. Knowledge of comorbid medical conditions is important for per-
forming the procedure safely.
3. Knowledge of angiography and prior revascularization in any vascular
bed is imperative. Reviewing noninvasive data from peripheral
computed tomography and magnetic resonance angiography can
be extremely helpful for planning access and strategy. This becomes
especially important in cases of complete occlusion and also in cases
of prior bypass grafting. It is also important to note the timing of
bypass grafts, as direct cannulation of grafts less than 6 months
old should be avoided when possible.
4. A focused physical examination pre- and post-procedure is manda-
tory and should include access site examination and a full assessment
of all relevant vascular beds proximally and distally for pulses, bruit,
thrills, or presence of hematoma. Additionally, a pre- and postfocused
neurologic examination should be performed for carotid and cerebral
angiography.
5. Standard preangiography laboratory evaluation is necessary for patient
safety.
6. Medications such as warfarin and metformin should be held prior to
peripheral angiography in a manner similar to coronary angiography.
Cerebrovascular
Anatomy: The aortic arch is the major conduit that gives rise to the
entire cerebrovascular system (Figure 6-1). The aortic arch is classified as
type 1, 2, or 3 based on plane and angle of takeoff of its major branches.
As part of the aging process, the aortic arch can remodel from type 1
(horizontal plane) to type 3 (C-shaped plane) as the arch sinks into the
thoracic cavity. Traditionally, the arterial branches arise off the arch in
78852_ch06 18/06/10 9:14 AM Page 87
Chapter 6 • Cerebral and Peripheral Angiography 87
Figure 6-1 Aortic arch and great vessels. 1: aortic arch; 2: innominate;
3: right common carotid; 4: right subclavian; 5: right vertebral; 6: left common
carotid; 7: left subclavian; 8: left vertebral.
the following order: (1) innominate artery, (2) left common carotid
artery (CCA), and (3) left subclavian artery (SCA). The innominate
bifurcates into the right SCA and the right CCA. The right and left SCA
give rise to their respective vertebral arteries. A more detailed description
of the SCA and its branches is presented in the “Upper Extremity/
Thorax” section later in this chapter.
The right CCA usually arises from the bifurcation of the innominate
artery (Figure 6-1). Occasionally, the right CCA may arise independ-
ently from the aortic arch. Rarely, the right and left CCA may arise as
a common carotid trunk from the arch. The left CCA has significant
variation in its anatomy. In 75% of individuals, it is the second great
vessel arising from the aortic arch, posterior to the innominate. In the
remaining cases, the origin of the left CCA is via a shared origin with
78852_ch06 18/06/10 9:14 AM Page 88
the innominate off the aortic arch or as a branch off the innominate
proper (also known as a “bovine arch”). Although there is significant
variation, the CCA typically bifurcates into the external carotid artery
(ECA) and the internal carotid artery (ICA), at the upper border of the
thyroid cartilage (Figure 6-2). The CCA usually does not give off any
significant branches until it bifurcates into the ICA and ECA.
Figure 6-2 Left carotid. 1: common carotid; 2: internal carotid; 3: external

carotid; 4: superior thyroid; 5: facial; 6: lingual; 7: occipital; 8: maxillary; 9: superfi-
cial temporal. The ascending pharyngeal and posterior auricular branches of the
external carotid are not clearly appreciated.
78852_ch06 18/06/10 9:14 AM Page 89
The ECA is readily recognized due to its eight extracranial branches.

These arterial branches arise in the following order—superior thyroid,
ascending pharyngeal, lingual, occipital, facial, posterior auricular, max-
illary, and superficial temporal (Figure 6-2).
The ICA is recognized by the bulbous carotid sinus at its origin.
This region houses the mechano- and chrono-regulatory receptors for
the body. Conventionally, the ICA is divided into four segments—
cervical, petrosal, cavernous, and supraclinoid (sometimes also referred
to as subarachnoid).
1. Cervical segment: The segment between the CCA bifurcation and
the petrous bone. This segment does not give off any arterial
branches. The ostial and proximal portions of this segment are often
involved in carotid atherosclerotic disease.
2. Petrosal segment: The segment that courses through the petrous bone
to the cavernous sinus. This segment has the shape of an inverted
hockey stick. This segment also does not give off any arterial branches.
3. Cavernous segment: The segment that courses through the cavernous
sinus giving off the meningiohypophyseal and the inferior cavernous
sinus arterial branch.
4. Supraclinoid segment: The segment begins after the ICA exits the
cavernous sinus. Several key branches that originate from this seg-
ment include the ophthalmic, posterior communicating, and anterior
choroidal. The ICA terminates after this segment in the anterior and
middle cerebral artery. Thus, the main area of the brain supplied
by the anterior and middle cerebral arteries is referred to as the
carotid territory. The classical finding of amaurosis fugax results from
ophthalmic artery ischemia.
Other important extracranial vessels include the bilateral vertebral
arteries that anastamose at the base of the pons to give rise to a single
basilar artery, which lies intracranially. The largest branches of the verte-
bral arteries are the bilateral posterior inferior cerebellar arteries, while
the basilar artery gives off bilateral anterior inferior cerebellar arteries,
superior cerebellar arteries, and the posterior cerebral arteries. These
arteries form the posterior circulation of the brain including the cerebel-
lar blood supply. Usually, the left vertebral circulation is dominant and
provides the majority of the arterial supply to this region.
The intracranial circulation is formed by the anterior cerebral artery,
anterior communicating artery, middle cerebral artery, posterior cerebral
artery, and posterior communicating artery (Figure 6-3). The circle of
Willis is formed by these vessels but a “normal ring” is found only in 50%
of individuals. Description of the anatomic variations is beyond the scope
of this text.
78852_ch06 09/07/10 12:23 PM Page 90
A B
Figure 6-3 A) Right intracranial circulation (anteroposterior projec-
tion). 1: anterior cerebral; 2: middle cerebral. B) Right intracranial circulation
(lateral projection). 1: anterior cerebral; 2: middle cerebral; 3: posterior cerebral.
Angiography: Aortic arch angiography is the recommended first step

prior to selective angiography of the cerebrovascular system (Figure 6-1).
This allows for assessment of arch type, detection of anomalous vessel
origin or takeoff, and estimation of proximal vessel atherosclerosis and
tortuosity. Arch angiography is generally performed with a power
contrast injection (20 mL per second for 40 mL total) using a standard
multihole pigtail catheter approximately 40° left anterior oblique (LAO).
For arch angiography, the patient should be asked to turn his or her head
to the right in an extended position.
Carotid angiography and catheter selection is determined by aortic
arch type. In type 1 and most type 2 arches, the carotids can be success-
fully engaged using a JR4 diagnostic catheter. For type 2 arches with
bovine left CCA origin or type 3 arches, a Vitek catheter is usually
required. A heparin bolus of 2,000 to 3,000 units should be admin-
istered prior to selective angiography of the cerebrovascular system.
Before engaging the great vessels, the arch angiogram should be used as
a reference view on the monitor. For the right CCA, the innominate is
first engaged; and the right anterior oblique (RAO) projection is used to
separate the ostia of the right-sided SCA and CCA. In most cases, the di-
agnostic catheter can be carefully advanced to engage the right CCA. If
there is any difficulty in engaging the ostium of the right CCA, a soft
wire such as a Wholey or a stiff-angled Glidewire can be used to advance
the catheter to the proximal portion of the CCA. The left CCA is selec-
tively engaged directly off the aortic arch. In general, all catheter ad-
vancements should be performed over a wire.
The standard views to assess for carotid disease are ipsilateral
oblique views between 30° and 45° and the left lateral view to
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Troubleshooting
1. Air and clot embolization: Embolization of either air or clots in the cerebral vas-
culature can lead to catastrophic consequences. Thus, a meticulous technique
with regular checks for air or clots and frequent flushing of catheters with he-
paranized saline is essential. Catheter exchanges should be kept to the mini-
mum during cerebrovascular angiography. When exchanges are performed, ex-
treme care should be taken to wipe the wire of any clots and to flush catheter
and access sheath.
2. Ostial stenosis of the vertebral artery: When the vertebral artery ostium is dis-
eased, direct engagement with a diagnostic catheter is not recommended as
this may cause embolization of the ostial plaque and posterior territory infarct.
Thus, in situations of verterbral ostial disease, a nonselective angiogram should
be obtained instead as described above.
initially define the carotid bifurcation. The angle of mandible serves

as a useful landmark for carotid bifurcation. Since the proximal ICA
lies posterior and medial to the ECA, lateral and posteroanterior (PA)
views may also be necessary to define the anatomy (Figure 6-2).
Selective engagement of the vertebrals can often be achieved using a
JR4 catheter or a Headhunter catheter using the same technique as with
the carotids. However, nonselective angiography of the vertebrals is rou-
tinely performed with the tip of the diagnostic catheter close to but not
directly engaged with the ostia. An ipsilateral arm blood pressure cuff is
inflated to maximize visualization during nonselective angiograms.
A single ipsilateral oblique view is adequate in most cases.
The anterior and middle cerebral circulation is best visualized in a shal-
low PA view at 15° to 30° (Figure 6-3). Positioning the petrous bone at the
base of the orbit in this projection serves as a useful landmark. The intracra-
nial posterior circulation is best seen in a steep PA view at 40° (Figure 6-3).
Lateral views are also frequently used for all three intracranial circulations.
Upper Extremity
Anatomy: The right SCA arises from the bifurcation of the innomi-
nate, whereas the left SCA arises as the third and final branch off the
aortic arch (Figures 6-1 and 6-4). In 0.5% percent of cases, the right
SCA arises as the last branch of the descending thoracic aorta. In its
proximal segment, the SCA first gives off the vertebral artery followed
by the internal mammary artery (IMA), the latter of which supplies the
anterior chest wall (Figure 6-4). In 1% to 5% of individuals, the left
vertebral artery arises directly from aortic arch. The thyrocervical and
costocervical trunks arise from the midsegment of SCA and give
78852_ch06 18/06/10 9:14 AM Page 92
Figure 6-4 Left upper extremity. 1: subclavian; 2: vertebral; 3: internal

mammary; 4: thyrocervical trunk; 5: axillary.
branches to the thyroid gland, cervical muscles, ribs, and the scapular
region (Figure 6-4).
At the lateral margin of the first rib, the SCA becomes the axillary
artery (Figure 6-4). The axillary artery becomes the brachial artery
at the neck of the humeral bone. At the neck of the radius bone, the
brachial artery divides into the radial and ulnar arteries. Occasionally, the
radial artery can originate from the axillary artery (1–3%) or higher in
the course of the brachial artery (15–20%). The ulnar artery forms the
superficial palmar arch and the radial artery forms the deep palmar arch,
although anatomic variations are common (Figure 6-5).
Angiography: Aortic arch angiography is the recommended first step

prior to selective angiography for reasons detailed earlier in this chapter
(Figure 6-1). Selective angiography of the innominate and the left SCA
78852_ch06 09/07/10 12:22 PM Page 93
A B
Figure 6-5 A) Left upper extremity. 1: radial; 2: interosseous; 3: ulnar;
4: superficial palmar arch; 5: deep palmar arch. B) Left upper extremity. 1: radial;
2: interosseous; 3: ulnar; 4: radial loop; 5: accessory radial; 6: brachial.
can usually be accomplished with the standard 5-Fr. JR4 diagnostic

catheter. For more difficult arches, alternative catheters such as Vitek,
Simmons, or Headhunter may be necessary. Angiography of the SCA is
done with the arm adducted in the neutral position using 5 to 10 mL
injections under DSA.
Innominate artery angiography is done in the RAO projection which
separates the bifurcation of the right CCA and ostium of the right-sided
SCA. Orthogonal oblique projections are used to demonstrate the initial
branches of the SCA (Figure 6-4). The right vertebral and right IMA are
visualized in the RAO view, while the left vertebral and left IMA are best
evaluated in the LAO projection.
Upper extremity angiography is done by advancing the diagnostic
catheter, over a Wholey or angled Glidewire, into the distal SCA for
views of the axillary or brachial anatomy and into the distal brachial
artery for radial or ulnar angiography. Upper extremity angiography is
done in the PA projection, but appropriate limb positioning is important
(Figure 6-5). The axillary artery is imaged with the arm in the neutral
position, while the brachial artery is best visualized with the arm
abducted and the forearm supine (on an arm board). For the forearm
and hand arteries, the forearm should be supine on the arm board with
the palm facing up, the thumb abducted, and the fingers splayed.
Mesenteric and Renal

Anatomy: The first major branch of the abdominal aorta is the celiac
trunk which arises at the level of the T12 vertebrae (Figure 6-6). The
celiac trunk divides into the left gastric, common hepatic, and splenic
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Troubleshooting
1. Access issues: Arterial access can be via the ipsilateral brachial or radial if there
is severe peripheral and aortic disease, type 3 arch, severe subclavian tortuos-
ity, or occlusion of the SCA.
2. Patients with thoracic outlet syndrome causing arterial compression: Angiography
is first performed with the arm in a neutral adducted position under PA projection
and then repeated with the arm abducted at the shoulder, externally rotated and
retroverted, similar to a throwing position. Additional positions may be necessary
depending on the patient’s symptoms.
3. Spasm of the brachial or arm arteries: A cocktail of vasodilators such as nitro-
glycerine (200–400 µg) and verapamil (500–1000 µg) in multiple doses should
be liberally used to prevent or relieve spasm of the upper extremity vessels and
to improve visualization of the distal vessels.
4. Poor visualization of the digital vessels: Wrap the hand with a warm cloth to
promote vasodilation and improve visualization.
5. Image quality is compromised by motion artifact: If despite educating the pa-
tient, motion artifact corrupts the image quality, then the patient’s hand and fin-
gers should be taped to an armboard to maintain stability.
arteries and, in so doing, supplies the stomach, liver, and parts of the
esophagus, spleen, duodenum, and pancreas. The superior mesenteric
artery (SMA) arises inferior to the celiac trunk, at the level of the L1
vertebrae. The SMA courses downward to supply the lower aspect of the
duodenum and the pancreas by branching into the inferior pancreatico-
duodenal, middle colic, right colic, ileocolic, and intestinal arteries. The
middle colic, right colic, and ileocecal branches anastamose with the left
colic artery (given off of the inferior mesenteric artery [IMA]) to form
the marginal artery (artery of Drummond). The IMA arises below the
renal arteries at approximately the L3 level and courses inferiorly from
the anterior aorta giving off the left colic artery and sigmoid branches
before terminating in the superior rectal artery.
The renal arteries generally arise from the lateral aspect of the
descending aorta at the level between the L1 and L2 vertebrae (Figure 6-7).
Although the right kidney sits lower in the abdomen than the left, the
right renal artery typically originates slightly higher than the left. And
while the right renal artery usually may have a slight anterior takeoff, the
origin of both renal arteries from the lateral aspect of the aorta is vari-
able. The main renal artery typically continues for several millimeters
before dividing into segmental branches which subsequently terminate
as interlobular and arcuate branches within the renal cortex and medulla.
The presence of accessory renal arteries is not uncommon. These acces-
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Figure 6-6 Mesenteric. 1: celiac; 2: superior mesenteric; 3: inferior mesen-

teric. *Calcified and thrombosed aortic aneurysm.
sory vessels usually arise below the main renal artery and can be of
smaller or equal caliber compared to the parent vessel. Another variant is
the early bifurcation of the main vessel into segmental vessels.
Angiography: Abdominal angiography is routinely performed, in the

PA projection, using a multihole pigtail or an Omni Flush catheter
placed at the T12 vertebrae. This is typically performed prior to selective
renal or mesenteric angiography. It allows for evaluation of the aortic
calcification and aortic aneurysmal dilation in the region of the renal
arteries along with examination of the renal ostia and presence of
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Figure 6-7 Renal and mesenteric. 1: right renal; 2: left renal; 3: common
hepatic; 4: splenic. *The origin of the celiac trunk is “end on” and thus not seen.
The left gastric branch of the celiac trunk is also not clearly appreciated.
anatomic anomalies. For visualization of the mesenteric vessels, a lat-

eral view abdominal aortogram best demonstrates the origins of the
mesenteric vessels since these arise anteriorly (Figure 6-6).
For selective mesenteric and renal angiography, 4-Fr. to 6-Fr.
catheters are typically used with a femoral access site. A JR4, internal
mammary (IMA), or left coronary bypass (LCB) are most often used to
selectively cannulate the SMA, IMA, and celiac trunk. However, catheters
with a reverse angle such as the SoS catheter can also be used to engage
these vessels. Alternatively, if a brachial or radial access is used, the mesen-
teric arteries can also be cannulated with a multipurpose or JR4 catheter.
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Troubleshooting
1. Difficulty visualizing renal ostia: Renal artery ostial disease may be missed by
standard angiography. Thus, if clinical suspicion of RAS is high, extreme
oblique projections with added cranial or caudal angulation may be needed to
better lay out the renal ostia. Intravascular ultrasound (IVUS) can also be used
for better visualization of the renal arteries and to determine the presence of
renal artery ostial disease. Damping of the catheter upon engagement may in-
dicate a significant ostial lesion.
2. Patients with severe renal insufficiency and suboptimal or equivocal noninva-
sive studies: Carbon dioxide imaging can be used instead of iso-osmolar con-
trast imaging. Gadolinium has been associated with nephrogenic systemic fi-
brosis in patients with advanced renal failure and thus is also not used.
The renal arteries can be engaged with a JR4, internal mammary (IMA),
or an SoS catheter. In cases of severe aortoiliac tortuosity, alternative
catheters such as the C2 Cobra catheter may be necessary.
Selective angiography of the celiac trunk is usually performed in a PA
projection or slight RAO or LAO angulation. The SMA and IMA have a
downward course toward the pelvis. Selective SMA and IMA angiogra-
phy is best performed in a lateral or steep LAO projection. A 15° to 30°
LAO oblique view enables good visualization of the renal ostia and prox-
imal segment; and slight cranial or caudal angulation is sometimes neces-
sary for optimal visualization. It is important not only to visualize the
renal ostia but also to determine the amount of associated aortic calcifica-
tion in relation to the ostia. A major pattern to recognize is the classic
“beads on a string” appearance of fibromuscular dysplasia that oc-
curs most commonly in young women and accounts for 10% of cases
with renal artery stenosis (RAS). Finally, when performing renal an-
giography, the field of view should be large enough to visualize the con-
trast in the renal cortex (Figure 6-7). Such nephrographic imaging is im-
portant to gain insight into renal size and regional function. This is
especially important in individuals with suboptimal or equivocal noninva-
sive studies.
Lower Extremity
Anatomy: The descending aorta divides into the bilateral common iliac
arteries at the level of L3–L4 (Figure 6-8). The common iliac artery (CIA)
further divides into the external iliac and internal iliac arteries at the pelvic
inlet anterior to the sacroiliac joint. The internal iliac artery (IIA) and its
branches supply the pelvic organs and gluteal region. The external iliac
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Figure 6-8 Aortoiliac system. 1: aortic bifurcation; 2: right common iliac;

3: left common iliac; 4: right internal iliac; 5: left internal iliac; 6: right external
iliac; 7: left external iliac.
artery (EIA) runs along the medial border of the psoas muscle and passes
under the iliac ligament to become the CFA.
The CFA lies midway between the anterior superior iliac spine and
the symphysis pubis (Figure 6-9). It transitions to the superficial femoral
artery (SFA) at the inferior margin of the femoral head. The SFA runs
medially and anteriorly, passing through the femoral triangle proximally
and the adductor canal in the mid-thigh. The SFA rarely gives off
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Figure 6-9 Right femoral system. 1: common femoral; 2: profunda femoris;

3: medial circumflex; 4: lateral circumflex; 5: perforating branches; 6: superficial
femoral in the femoral triangle; 7: superficial femoral in the adductor canal; 8: su-
perficial femoral about to pierce the adductor hiatus.
branches until it enters the popliteal fossa where it gives off an important
late branch, the descending genicular, which contributes to the collateral
circulation at the level of the knee (Figure 6-10).
In its proximal course, the CFA gives off the profunda femoris
artery (PFA) from its lateral side about 4 cm below the inguinal
ligament. The circumflex branches from the proximal part of the PFA
78852_ch06 18/06/10 9:14 AM Page 100
and forms the collateral network of the upper leg and hip along with
the branches from the IIA (Figure 6-9). Similarly, perforating branches
arising from the distal part of the PFA form the collateral network of the
knee and lower leg with the branches of the popliteal and tibial vessels.
At the distal, posterior aspect of the femur, the SFA passes through
the adductor hiatus to become the popliteal artery (Figure 6-10). The
Figure 6-10 Right femoro-popliteal system. 1: superficial femoral pierc-

ing the adductor hiatus; 2: descending genicular branch; 3: popliteal.
78852_ch06 18/06/10 9:14 AM Page 101
popliteal artery then trifurcates into the anterior tibial artery (AT), per-
oneal artery, and posterior tibial artery (PT) (Figure 6-11). The AT
leaves the main popliteal body by piercing through the interosseous
membrane anteriorly. The popliteal then continues as a short posterior
segment called the tibioperoneal (TP) trunk. As it exits out of the
Figure 6-11 Right popliteal and infrapopliteal system. 1: popliteal;

2: anterior tibial; 3: tibioperoneal trunk; 4: peroneal artery; 5: posterior tibial
artery. *Also seen is the descending genicular branch arising proximally from the
distal superficial femoral artery.
78852_ch06 25/06/10 4:10 PM Page 102
popliteal fossa, the TP trunk gives rise to the peroneal artery laterally,
which runs between the interosseous membrane and the fibula and ter-
minates above the level of the ankle joint. The TP trunk then continues
on medially as the PT.
The arterial supply of the foot is via continuations of the AT and PT
(Figure 6-12). The AT becomes the dorsalis pedis artery as it crosses
midway between the malleoli and lies over the planar surface of the foot.
The PT courses posterior to the medial malleolus and terminates on the
Figure 6-12 Right ankle and foot circulation. 1: anterior tibial; 2: dorsalis
pedis; 3: peroneal; 4: posterior tibial.
78852_ch06 18/06/10 9:14 AM Page 103
plantar surface of the foot as medial and lateral plantar branches. These
foot arteries form important collaterals among themselves when their
proximal parent vessels are occluded.
Angiography: Prior to angiography some general rules should be fol-

lowed: (1) access is typically obtained in the CFA contralateral to the limb
with worse symptoms or noninvasively tested parameters; (2) a low-
osmolar, nonionic contrast is ideal to minimize contrast-related limb dis-
comfort; (3) sequential static overlapping DSA at multiple levels provides
the most comprehensive angiographic evaluation of each limb. A signif-
icant limitation of peripheral angiography is the quantity of contrast used
and excessive radiation exposure.
Angiography of the aortic bifurcation and iliac arteries may be per-
formed with power contrast injection using a 4-Fr. to 5-Fr. pigtail catheter,
Omni Flush catheter, or Straight Flush catheter. Typically, a power
Troubleshooting
1. Artery is cannulated with good blood return but guidewire cannot be advanced
beyond a certain point: Given the possibility of severe peripheral arterial dis-
ease (PAD) including total occlusions, the needle should be exchanged for a
small (4-Fr.) micropuncture sheath and then contrast should gently be injected
to assess for occlusion, tortuosity, or dissection. Never advance a wire that
does not have a freely mobile tip.
2. Image quality is compromised by motion artifact: Consider taping the patient’s
feet to maintain stability. The patient should always be instructed not to move
or breathe during DSA acquisition.
3. Too much scatter or brightness compromising image quality: In contrast to coro-
nary angiography, angiographic images of the periphery are extremely sensitive
to ambient light. Thus, placement of a central wedge filter between the legs
and two lateral wedge filters placed lateral to each leg can greatly enhance
image quality by ensuring focused penetration of the x-rays in the area of inter-
est.
4. Poor opacification of infrapopliteal vasculature: This can occur if the site of in-
jection is too proximal (e.g., EIA). Positioning the diagnostic catheter into the
ipsilateral distal SFA or sometimes even in the ipsilateral popliteal artery can
prevent this problem.
5. Overlap of arterial bed in the foot: The dorsal and plantar arterial arches can
have significant overlap making the identification of lesions difficult. This issue
can be overcome in most cases by external rotation and dorsiflexion of the foot
which separates the dorsal and plantar arterial supply.
78852_ch06 18/06/10 9:14 AM Page 104
injection of 15 mL per second for a total of 30 mL is sufficient to ade-

quately visualize the aortic bifurcation and pelvic arteries. Angiographic
views are taken in the standard PA projection; but in the case of tortuous
vessels or eccentric lesions, angulated views (RAO or LAO) may be
needed (Figure 6-8). For the CIA, an oblique view is obtained with 30° to
45° contralateral angulation. Alternatively for the EIA, ipsilateral oblique
angulation between 30° and 45° is preferred.
Angiography of the lower extremity and its distal runoff is best done
via a selective approach. As mentioned above, access is obtained con-
tralateral to the limb of interest. In one technique, a side-hole flush
catheter such as an Omni Flush, Universal Flush, or Grollman catheter is
advanced into the abdominal aorta through the access sheath over a soft
0.035 wire such as a Wholey or Tiger wire. The flush catheter is then
retracted slowly until the catheter tip gently hooks the contralateral CIA
while the body of the catheter hugs the aortic bifurcation. The flush
catheter is then advanced over the wire to the contralateral EIA or CFA
where it is used for selective injection. One limitation of this technique is
that the flush catheter may not be able to be easily advanced through
tortuous or calcified anatomy. Another common technique involves
using an IMA catheter to hook the contralateral CIA by retracting it
slowly over the 0.035 wire and withdrawing the wire into the catheter at
the level of the iliac bifurcation. The wire can then be advanced down
the contralateral iliac distally; and the catheter can be exchanged for
a straight flush or multipurpose catheter which can then be advanced
over the wire to the level of the CFA for selective injection and run-off
angiography. If the ipsilateral lower extremity needs to be imaged, con-
trast injection directly through the arterial sheath in the CFA usually
allows for adequate visualization of the distal vasculature.
Lower extremity arterial segments are then imaged sequentially
using the following general scheme: (1) origin of CFA to distal SFA
(above knee); (2) distal SFA to distal to posterior tibial and peroneal bi-
furcation (knee); (3) distal popliteal to distal AT/PT (below knee); and
(4) distal AT/PT to terminal branches forming the plantar arterial arch
(foot). Ipsilateral PA views are standard for SFA and popliteal arteries;
however, the AT, TP trunk, and PT should be examined in an ipsilateral
15° to 30° view. The foot should be examined in the contralateral
oblique view at 15° to 20°. The CFA bifurcation, including the ostia of
the SFA and PFA, can be optimally viewed at an ipsilateral oblique angu-
lation of 20° to 30° (Figure 6-9). Similarly, a true lateral allows bet-
ter assessment of the distal popliteal, whereas an ipsilateral oblique
angulation of about 30° optimizes visualization of the infrapopliteal
trifurcation (Figures 6-10 and 6-11). Typically, a “long column of con-
trast” (e.g., rate of 3 mL per second for 5–10 mL injection) is required
78852_ch06 18/06/10 9:14 AM Page 105
for below-the-knee vessels. As the imaging plane is moved down the

lower extremity, a slight delay (2–4 sec) between injection and DSA
activation is recommended to account for transit time and minimize
radiation exposure.
Complications
1. Access related: Complications related to access such as hematoma,
pseudoaneurysm, arteriovenous fistula, dissection, or retroperitoneal
bleed remain the most common form of complications with all angio-
graphic procedures. The incidence of vascular complications is up
to 1% in coronary series but is higher in patients with peripheral
vascular disease. Vascular complications during peripheral angiogra-
phy are evaluated and managed in the same way as vascular complica-
tions occurring with coronary angiography. These are discussed in
detail in Chapters 8 and 9.
2. Angiography related: Complications resulting from wire and catheter
manipulation are rare with diagnostic angiography; but when they do
occur, they require prompt recognition and management with phar-
macologic and mechanical therapies. These include vessel dissection,
perforation, or vessel closure due to plaque shift. Some of the clinical
syndromes arising from these complications are discussed below.
• Acute limb ischemia: This can result from thrombus formation on
equipment especially in long cases or when meticulous discard and
flushing is not performed. Percutaneous mechanical thrombec-
tomy should be promptly attempted by a qualified interventional-
ist and can be supplemented with adjunctive thrombolytic or gly-
coprotein IIb/IIIa therapy.
• Cerebreovascular accident: These usually manifest within a few hours
after the procedure and can be in the form of a transient ischemic
attack or a stroke. If the patient has signs and/or symptoms of a neu-
rologic event during or following the procedure, do not move the pa-
tient from the catheterization table. Cerebral angiography should be
performed immediately with comparison to the initial baseline an-
giograms. This scenario highlights the importance of baseline cere-
bral angiographic imaging. If the repeat cerebral angiogram is nor-
mal, then the prognosis is usually excellent. However, if a large artery
(2–2.5 mm) occlusion occurs due to distal embolization, recanaliza-
tion should be attempted by a qualified interventionalist using
directed thrombolytics or mechanical extraction.
• Intracranial hemorrhage (ICH): This feared complication is exceed-
ingly rare with just diagnostic angiography. However, if ICH does
occur, it demands emergent assessment by a neurovascular surgeon.
78852_ch06 18/06/10 9:14 AM Page 106
3. Miscellaneous: Other general complications such as a radiation injury,

acute renal insufficiency, and sedation-related complications are eval-
uated and managed as with coronary angiography.
Suggested Reading
Criqui MH. Peripheral arterial disease and subsequent cardiovascular mortality:
a strong and consistent association. Circulation. 1990;82:2246–2247.
Bhatt DL, Steg PG, Ohman EM, et al; REACH Registry Investigators.
International prevalence, recognition, and treatment of cardiovascular risk fac-
tors in outpatients with atherothrombosis. JAMA. 2006;295:180–189.
Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease
detection, awareness, and treatment in primary care. JAMA.
2001;286:1317–1324.
Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the man-
agement of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg.
2007;33(suppl 1):S1–S75.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the
management of patients with peripheral arterial disease (lower extremity,
renal, mesenteric, and abdominal aortic): executive summary a collaborative
report from the American Association for Vascular Surgery/Society for
Vascular Surgery, Society for Cardiovascular Angiography and Interventions,
Society for Vascular Medicine and Biology, Society of Interventional
Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing
Committee to Develop Guidelines for the Management of Patients With
Peripheral Arterial Disease) endorsed by the American Association of
Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and
Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society
Consensus; and Vascular Disease Foundation. J Am Coll Cardiol. 2006;
47:1239–1312.
Uflacker R, ed. Atlas of Vascular Anatomy: An Angiographic Approach. 2nd ed.
Philadelphia: Lippincott Williams & Wilkins; 2006.
Valji K, ed. Vascular and Interventional Radiology. 2nd ed. Philadelphia: Saunders
Elsevier; 2006.
Cassserly IP, Sachar R, Yadav JS, eds. Manual of Peripheral Vascular Intervention.
1st ed. Philadelphia: Lippincott Williams & Wilkins; 2005.
Khoury M, Batra S, Berg R, et al. Influence of arterial access sites and interven-
tional procedures on vascular complications after cardiac catheterizations. Am
J Surg. 1992;164:205–209.
78852_ch07 25/06/10 4:11 PM Page 107
CHAPTER 7
Hemodynamics
in the Cath Lab
Brian W. Hardaway, Wilson H. Tang,
and Frederick A. Heupler, Jr.
Hemodynamic data are an important part of every diagnostic catheteriza-

tion, particularly in patients with cardiomyopathies, valvular disorders,
and pericardial disease. The measurement of hemodynamics utilizes pres-
sure, oximetry, and temperature differences to derive functional informa-
tion about the heart. To fully understand hemodynamics, one must first
learn how to make proper measurements, calculate derived values, and
interpret the results in relation to specific disease conditions.
Methodologies of Hemodynamic Measurements

Pressure Measurements: The most accurate method for measuring
pressure in the heart is to utilize a system with the pressure transducer
(usually a strain gauge type) located at the exact location of interest.
However, while catheters with a pressure transducer at the tip are
available, they are too expensive to be used routinely and are generally
only used for research purposes. Thus, the most common method of
measuring pressure in the cardiac catheterization lab utilizes a system
incorporating a fluid-filled catheter connected through a manifold to a
pressure transducer. This system, however, has several characteristics
that influence its fidelity and its accuracy. Because the pressure wave-
form is transmitted through fluid until it reaches the transducer
outside the body, there is both a time delay and a dampening of the
pressure signal that usually filters out the high frequency components.
Underdamping of the system can be a problem especially if air bubbles
are present in the system (Figure 7-1). Other common sources of error
are listed in Table 7-1.
107
78852_ch07 25/06/10 4:11 PM Page 108
Figure 7-1 A) Normal pressure waveform. B) Pressure underdamping caused

by an air bubble in the tubing. This produces high frequency oscillations that
result in the peak pressures appearing higher.
Oximetry Measurements: Oximetry measurements are most com-

monly performed to measure cardiac output utilizing the Fick method
(described later in this chapter) and to rule out a left-to-right shunt
(described later in this chapter). Oximetry measures the oxygen satura-
tion of blood. The oxygen content of blood can then be calculated.
Oxygen content ~Hgb(g>dL) 1.36(mLO2>g Hgb) Sat
where Hgb is hemoglobin in grams per deciliter; 1.36 is the oxygen

carrying capacity of blood in milliliters of oxygen per gram of hemo-
globin; and Sat is the oxygen saturation of the blood. The dissolved
78852_ch07 25/06/10 4:11 PM Page 109
Chapter 7 • Hemodynamics in the Cath Lab 109
Table 7-1 Common Sources of Error in Hemodynamic Measurements

Source of Error Correct Technique Common Example of Error
Transducer At level of mid-right atrium, ↓ Pressure recorded if

position halfway up the body between positioned too high
spine and sternum
Catheter bore Maximize catheter bore size
Catheter length Minimize length of tubing
Kink in tubing Replace tubing or catheter
Fluid viscosity Catheter should be filled with Contrast in tubing
normal saline, avoid contrast
Air in system Flush catheters and manifold to Air bubble at connection
avoid presence of air bubbles points or at transducer
Tip positioning Reposition catheter “Catheter whip”
Stable Average measurements over
arrhythmias several beats to obtain an average
Troubleshooting
Inserting PA Catheter
1. Obtain vascular accesses, typically with an 8-Fr. sheath, allowing passage of the
7-Fr. PA (Swan-Ganz) catheter. Typically, if the pulmonary artery (PA) catheter is
guided solely by pressure tracings to advance it to wedge position, the right in-
ternal jugular vein and the left subclavian vein provide the most direct anatomic
routes to the pulmonary artery that matches the natural curve of the catheter.
2. Inflate the balloon at the tip of the catheter under water to ensure no air leak.
3. Make sure that all lumens of the PA catheter are flushed.
4. Zero the pressure transducer at the level of the mid-right atrium.
5. Connect the PA catheter’s distal port to the pressure transducer. Make sure that
there are no bubbles in the tubing or the catheter.
6. Advance the catheter 20 cm through the sheath prior to balloon inflation to en-
sure the catheter tip clears the sheath. Do not advance if any resistance is met.
7. Beware of arrhythmias especially after the catheter crosses the tricuspid valve,
primarily premature ventricular contractions (PVCs), and non-sustained ventricu-
lar tachycardia (NSVT). In the setting of underlying LBBB, the catheter may in-
duce complete heart block. In the setting of myocardial infarction, the catheter
may induce ventricular fibrillation.
8. Monitor pressures as the catheter is being advanced through the right atrium
(RA), right ventricle (RV), and PA to wedge position. Be careful not to overwedge.
9. Do not pull back the catheter with the balloon inflated. Damage to valves, either
pulmonary or tricuspid may result.
78852_ch07 25/06/10 4:11 PM Page 110
oxygen in blood is generally negligible in these calculations and is usu-

ally ignored.
Temperature Measurements: A thermistor is mounted at the tip of

the pulmonary artery catheter to measure the temperature of the fluid
as it passes through the pulmonary artery. Temperature is most com-
monly used to calculate cardiac output using the thermodilution tech-
nique, which is a variant of indicator dilution. Cold saline is injected
through an opening in the catheter 25 to 30 cm proximal to the tip.
The temperature is measured as a function of time, and temperature
change can be used to calculate cardiac output (see “Cardiac Output”
section).
Hemodynamic Measurements in Clinical Scenarios: See Figures 7-2

through 7-6.
Figure 7-2 Normal hemodynamic pressure measurements in various cardiac

chambers. RA, mean right atrial pressure; RV, right ventricular pressure; PA, pul-
monary artery pressure; PCW, pulmonary capillary wedge pressure; LA, mean left
atrial pressure; LV, left ventricular pressure.
78852_ch07 25/06/10 4:11 PM Page 111
Figure 7-3 Normal RA pressures. Right atrial pressure is the same as central
venous pressure and is equal to right ventricular diastolic pressure. “a” wave, right
atrial systole; “x” descent, right atrial relaxation; “v” wave, right atrial filling during
ventricular systole; “y”-descent, right atrial emptying. Usually, the “a” wave is
higher than the “v” wave in normal patients. Giant “a” waves are seen in right-sided
heart failure with a stiff right ventricle. Cannon “a” waves are seen in complete
heart block when the right atrium contracts against a closed tricuspid valve. (Note:
The distance between horizontal lines is 4 mm Hg, and the time between vertical
lines is 1 second.) (From Topol EJ, Califf RM, et al. Textbook of Cardiovascular
Medicine, 3rd Edition. Philadelphia: Lippincott Williams & Wilkins, 2006.)
Figure 7-4 Normal RV pressures. Right ventricular systolic pressures are ele-
vated with right-sided heart failure, pulmonary valve stenosis, and pulmonary hyper-
tension. Right ventricular diastolic pressures are elevated with cardiac tamponade
and increased right ventricular stiffness. (Note that the distance between horizontal
lines is 4 mm Hg and the time between vertical lines is 1 second.) (From Topol EJ,
Califf RM, et al. Textbook of Cardiovascular Medicine, 3rd Edition. Philadelphia:
Lippincott Williams & Wilkins, 2006.)
78852_ch07 25/06/10 4:11 PM Page 112
Figure 7-5 PA pressures. Pulmonary artery pressures are elevated with left-
sided heart failure, lung disease, and pulmonary vascular disease. In pulmonary vas-
cular disease, the pulmonary artery diastolic pressure can be significantly higher than
the pulmonary capillary wedge pressure. This finding is most commonly found in pri-
mary pulmonary hypertension, chronic pulmonary embolism, and Eisenmenger syn-
drome with intracardiac shunts. (Note: The distance between horizontal lines is 4 mm
Hg, and the time between vertical lines is 1 second.) (From Willard JE, Lange RA,
Hillis LD. Cardiac catheterization. In: Kloner RA, ed. The guide to cardiology, 3rd. Ed.
New York: Le Jacq Communications, 1995:145–164.)
Figure 7-6 Pulmonary capillary wedge pressures. “a” wave, left atrial systole;
“v” wave, left atrial filling during ventricular systole. (Note: The distance between
horizontal lines is 4 mm Hg, and the time between vertical lines is 1 second.) (Adapted
from Willard JE, Lange RA, Hillis LD. Cardiac catheterization. In: Kloner RA, ed. The
guide to cardiology, 3rd. Ed. New York: Le Jacq Communications, 1995:145–164.)
78852_ch07 25/06/10 4:11 PM Page 113
PRESSURE GRADIENTS ACROSS STENOSES: Measuring pressure gradi-

ents across stenotic valves is an important process in determining the
need for surgical intervention particularly when the hemodynamics as
measured by noninvasive means are in question. The valve orifice area
can often be estimated by a formula that was developed by Dr. Richard
Gorlin if the mean pressure gradient, cardiac output, and the systolic
ejection time are known; particularly if the patient is not in a low cardiac
output state:
Valve orifice area (VOA) in cm2

cardiac output(L>min)
44.3 (K) heart rate (SEP or DFP) 2¢P(mm Hg)
where SEP is the systolic ejection period in aortic stenosis (length of time
blood is ejected from LV every beat); DFP is the diastolic filling period in
mitral stenosis (length of time blood filling LV every beat); P is the
mean pressure gradient; constant (K 0.85) is added in mitral stenosis.
The Hakki formula is a simplified derivation of the Gorlin
equation:
cardiac output(L>min)
Valve orifice area (VOA) in cm2
3 pressure gradient(mm Hg)
The Angel correction mandates that the above result be divided by 1.35
for a heart rate 75 beats per minute in the setting of mitral stenosis, or
90 beats per minute in the setting of aortic stenosis.
Caution is advised when using the Hakki formula if coexisting aortic
regurgitation or mitral regurgitation is present as this will cause underes-
timation of the aortic valve area and mitral valve area respectively.
Aortic Stenosis: The normal orifice area of the aortic valve is 3 to 4 cm2.
The aortic valve can become significantly narrowed prior to the onset of
symptoms or even hemodynamic significance.
Aortic Valve Orifice Areas

Normal aortic orifice area 3–4 cm2
Mild stenosis 1.5 cm2
Moderate stenosis 1.0–1.5 cm2
Severe stenosis 1.0 cm2
The most accurate method for measuring aortic valve gradients

is by obtaining simultaneous pressure measurements from the left
78852_ch07 25/06/10 4:11 PM Page 114
Figure 7-7 Simultaneous pressure tracings of left ventricle and ascending

aorta, demonstrating the significant gradient across the aortic valve. (From
Willard JE, Lange RA, Hillis LD. Cardiac catheterization. In: Kloner RA, ed. The
guide to cardiology, 3rd. Ed. New York: Le Jacq Communications, 1995:145–164.)
ventricle and the ascending aorta (Figure 7-7). This method allows
the calculation of the mean gradient by direct measurement from both
recordings. The easiest way to accomplish this is to use a dual-lumen
pigtail catheter, which permits simultaneous measurement of pressures in
the LV and ascending aorta.
Alternatively, a long arterial sheath can be placed in the descending
thoracic aorta, and pressure measured from the sideport. The femoral
artery pressure is also often substituted for this measurement. The peak
femoral artery pressure is usually higher than the peak aortic root pres-
sure due to reflected pressure waves seen in the periphery, thus using the
femoral artery results in underestimation of the pressure gradient. This
can be somewhat compensated by measuring the pressure difference
between the catheter at the ascending aorta and the sidearm of the
femoral artery sheath, and subtracting the difference.
A more commonly utilized method involves pullback of the catheter
from the left ventricle into the ascending aorta. This technique yields a
“peak-to-peak” gradient between the maximum aortic pressure and the
78852_ch07 25/06/10 4:11 PM Page 115
Figure 7-8 Pressure tracing of the pullback across the aortic valve.
maximum left ventricular pressure (Figure 7-8). Each of these peaks oc-
curs at different points in time, however, and this measurement is only
an estimate of the mean gradient. In addition, in patients with severe
aortic stenosis, the catheter itself may take up a significant fraction of
the orifice area, resulting in worsened stenosis and increased gradients.
The Gorlin and Hakki formulas can be used to estimate the valve ori-
fice area, but may be inaccurate in severe aortic stenosis with low-output
states. The accuracy of the formula is flow-dependent and will result in
small orifice areas, despite low gradients, if the flow across the aortic
valve is low. This is frequently observed in patients with severe systolic
LV dysfunction.
If maneuvers to increase cardiac output (i.e., exercise, dobutamine,
nitroprusside) are performed on this subset of patients and a significant
increase in the estimated valve orifice area is observed (usually resulting
in a valve area 1 cm2) this is termed “pseudostenosis.” Failure of the
estimated valve orifice area to significantly increase with these measures
implies either true severe aortic stenosis (increase in aortic valve pressure
gradients with maneuvers) or poor left ventricular contractile reserve (no
significant increase in aortic valve pressures with maneuvers).
Mitral Stenosis: The normal mitral valve orifice area is 4 to 6 cm2.

Significant narrowing can occur prior to hemodynamic compromise.
When the valve area falls to ~2.0 cm2, the left atrial pressures will start in-
creasing to maintain cardiac output. Valve areas less than 1.0 cm2 fre-
quently require some intervention.
78852_ch07 25/06/10 4:11 PM Page 116
Troubleshooting
Calculating Valve Area in Aortic Stenosis
68-year-old male:
CO 4800 mL/min
HR 80 beats per minute
SEP 0.35
Mean AV gradient 80 mm Hg
Gorlin formula:
CO>(HR)(SEP)
Valve orifice area (VOA)
44.3 (k) 1¢P
4800>(80) (0.35)
VOA 0.4 cm2
44.3( 180)
Hakki formula:
CO(L>min)
VOA
1¢P
4.8
VOA 0.5 cm2
( 280)
Mitral Valve Orifice Areas

Normal mitral orifice area 4–6 cm2
Mild stenosis 1.6 cm2
Moderate stenosis 1.1–1.5 cm2
Severe stenosis 1.0 cm2
The “Gold Standard” for determination of mitral valve gradients

remains simultaneous direct LA pressure (via interatrial septostomy) and
LV pressure measurements. Frequently, however, direct LA pressure
measurement is substituted by PCWP measurement (Figure 7-9).
Caution is advised when interpreting simultaneous PCWP/LV pressure
tracings for the determination of the mitral valve gradient as there is a
temporal delay between early left atrial emptying and the corresponding
y-descent seen on PCWP tracings which leads to overestimation of the
mean mitral gradient. Some heart catheterization laboratories have com-
puterized algorithms to compensate for this overestimation.
The Gorlin equation is also used in this instance, except that the dias-
tolic filling period (Figure 7-10) is substituted in lieu of the systolic ejection
78852_ch07 25/06/10 4:11 PM Page 117
Figure 7-9 Simultaneous pressure tracings of PCWP and the LV demonstrat-

ing the gradient across the mitral valve and the slow y-descent of the PCW
pressure tracing. (From Willard JE, Lange RA, Hillis LD. Cardiac catheteriza-
tion. In: Kloner RA, ed. The guide to cardiology, 3rd ed. New York: Le Jacq
Communications, 1995: 145–164.)
Figure 7-10 Diastolic filling period used to calculate the mitral valve area.
78852_ch07 25/06/10 4:11 PM Page 118
Troubleshooting
Calculating Valve Area in Mitral Stenosis
37-year-old male:
CO 5000 mL/min
HR 76 beats per minute
DFP 0.4
Mean MV gradient 20 mm Hg
Gorlin:
CO>(HR)(DFP)
Valve orifice area (VOA)
44.3 (k) 1¢P
where k 0.85 (for the mitral valve)
5000>(76) (0.4)
VOA 1.0 cm2
44.3(0.85) ( 120)
Hakki:
CO(L>min)
VOA
1¢P
5.0
VOA 1.1 cm2
( 120)
period used in AS, and that an empiric constant of 0.85 is added to the
equation. Concomitant mitral regurgitation with mitral stenosis will affect
this calculation, and usually will underestimate the true orifice area.
Hypertrophic Obstructive Cardiomyopathy (HOCM): In HOCM, the

obstruction lies below the aortic valve and may be dynamic, with little or
no resting gradient. The pullback to measure the peak-to-peak pressure
should start at the ventricular apex and proceed through the left ventric-
ular outflow tract and through the valve. In typical HOCM, there will be
a gradient from the ventricular apex to the LVOT, but no gradient across
the valve (Figure 7-11). In Yamaguchi’s variant (apical LVH), no gradi-
ent will be noted, although the classic spade-like appearance may be ob-
served with left ventriculography.
If a significant resting gradient is not appreciated, then provocative
maneuvers can be performed to unmask an intraventricular gradient. The
most common maneuvers include Valsalva, nitroglycerin administration,
amyl nitrite inhalation, or PVC induction. In patients suspected of
HOCM, the immediate post-PVC beat is characterized by an increase in
78852_ch07 25/06/10 4:11 PM Page 119
Figure 7-11 Pullback from LV apex to LV outflow tract demonstrating an

intraventricular gradient consistent with HOCM.
contractility which leads to an increase in the dynamic LVOT obstruction

resulting in a decrease in stroke volume and hence a decrease in pulse
pressure as compared to the beat immediately preceding the PVC. This is
known as the Brockenbrough–Braunwald–Morrow sign (Figure 7-12).
Alternatively, in the case of a fixed obstruction (i.e., Aortic Stenosis) the
post-PVC beat is characterized by an increase in contractility resulting in
an increase in stroke volume and hence an increase in pulse pressure as
compared to the pre-PVC beat.
Intracardiac Pressure Waveforms

Mitral and Tricuspid Regurgitation: The hemodynamic hallmarks of
mitral regurgitation are increased left atrial pressure and reduced cardiac
output. A prominent v wave is suggestive of, but not specific to, mitral
regurgitation (Figure 7-13).
Cardiac Tamponade: A pericardial effusion that results in hemody-

namic compromise causes tamponade. With regard to hemodynamic
measurements, there is eventual diastolic equalization of pressures in all
cardiac chambers (CVP RVEDP PCWP LVEDP), usually associ-
ated with pulsus paradoxus (exaggerated inspiratory fall in arterial
pressures of greater than 10 mm Hg), a fall in cardiac output, and hy-
potension. Pulsus paradoxus, however, is neither sensitive nor specific for
78852_ch07 25/06/10 4:11 PM Page 120
Figure 7-12 Brockenbrough–Braunwald–Morrow sign. The gradient

across the aortic valve is increased in the postextrasystolic beat, with a reduction
in aortic or systemic pressure. This accentuation of the gradient is either small or
absent in a fixed obstruction/valvular aortic stenosis.
tamponade, and may be found in constrictive pericarditis, pulmonary

embolism, and COPD. On the pressure tracings, there may be a promi-
nent x-descent with a blunted y-descent in addition to the diastolic
equalization of pressures (Figure 7-14).
Constrictive versus Restrictive Physiology: The diagnosis of constric-

tive pericarditis may be difficult. Differentiating constrictive pericarditis
from restrictive cardiomyopathy is even harder. From a hemodynamic
standpoint constrictive pericarditis is characterized by equalization of
78852_ch07 09/07/10 12:28 PM Page 121
Figure 7-13 Severe mitral regurgitation. The V wave in the PCW tracing
is very prominent in this case, and the y-descent is sharp. (From Topol EJ, ed.
Textbook of Cardiovascular Medicine. Philadelphia, PA: Lippincott Williams &
Wilkins; 2002.)
Figure 7-14 Cardiac tamponade, with a large pericardial effusion.

Note the diastolic equalization of pressures in the RV and RA positions.
78852_ch07 25/06/10 4:11 PM Page 122
Figure 7-15 Constrictive pericarditis. A classic “W” or “M” pattern is

seen in the right atrial tracing.
diastolic pressures and ventricular interdependence. The classic hemody-

namic criteria for constrictive pericarditis are (1) less than 5 mm Hg
difference between the LVEDP and RVEDP, (2) PA pressure less than
60 mm Hg, and (3) RVEDP/RVSP ratio greater than 30%. Other find-
ings observed on pressure tracings of constrictive pericarditis include a
“dip and plateau” pattern in the ventricular pressure tracings, an “M or
W” pattern in the atrial tracing, and an elevation of the mean right atrial
pressure during inspiration, none of these features is either sensitive or
specific for the diagnosis of constriction (Figure 7-15).
During inspiration there is an increase in right-sided flow and pres-
sure. The constraining effect of the pericardium on right ventricular
expansion in diastole causes interventricular septal bowing toward the
left ventricle. This septal bowing effectively leads to a decrease in left ven-
tricular preload and subsequently cardiac output. The reverse happens
with expiration where LV flow and pressure increases and interventricu-
lar septal bowing toward the right ventricle occurs causing a decrease in
right-sided pressures. This concept of ventricular interdependence in
constrictive pericarditis can be demonstrated by obtaining simultaneous
RV and LV pressure tracings. Discordance of the LV and RV systolic
pressures will be observed during the respiratory cycle (Figure 7-16).
Respiratory discordance between the LV and RV systolic pressure is
more sensitive than classic hemodynamic criteria for differentiating
constrictive pericarditis from restrictive myocardial disease in the
majority of patients, but it still remains less than 80% sensitive.
More recently, the respiratory changes in the areas under the curves
of the RV and LV pressure tracings have been shown to be more
reliable than the systolic pressure changes. The “Systolic Area
Index” is the ratio of the RV area (mm Hg ⴛ seconds) to the LV
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Figure 7-16 Constrictive pericarditis. Ventricular interdependence and

respiratory variation are seen in this example.
area (mm Hg ⴛ seconds) in inspiration versus expiration. A systolic

area index greater than 1.1 has a sensitivity and positive predictive
value greater than 95% for differentiating constrictive pericarditis
from restrictive myocardial disease.
Shunt Calculation: Shunts can be localized and quantified using oxime-

try, indocyanine green dye, and angiography. The most common
method used clinically is oximetry. In the location of the shunt, blood
usually flows from the left-sided (higher pressure) chamber to the right-
sided (lower pressure) chamber (left-to-right shunt), with abnormally
high oxygen saturation in that chamber and all chambers distal. The level
where this “step-up” in oxygen saturation is detected identifies where
the shunt exists. A “step-up” is considered significant if it is 7%
from the vena cava to the right atrium and 5% from the right
atrium to the right ventricle or 5% from the right ventricle to the
pulmonary artery.
The quantification of shunting is determined by calculating the
shunt fraction, which in left-to-right shunts is the Qp/Qs (the ratio of
pulmonary to systemic blood flow). Oxygen saturations should be drawn
in the superior vena cava, inferior vena cava, right atrium (three sites),
right ventricle (three sites), pulmonary artery, and aorta.
Qp O2 sat(systemic arterial) O2 sat(systemic mixed venous)

Qs O2 sat(pulmonary venous) O2 sat(pulmonary arterial)
Adding 3 ⴛ SVC saturation to the IVC saturation, and dividing

the sum by 4 calculates the mixed venous saturation.
78852_ch07 25/06/10 4:11 PM Page 124
Troubleshooting
Shunt Calculation
61-year-old male with an ASD and the following O2 saturations:
Femoral artery 98% (systemic arterial and pulmonary venous)
SVC 69%
IVC 73%
PA 80%
(3) (0.69) (0.73)
MVO2 0.70(systemic mixed venous)
4
Qp O2 Sat(systemic arterial) O2 Sat(systemic mixed venous)

Qs O2 Sat(pulmonary venous) O2 Sat(pulmonary arterial)
Qp 0.98 0.70
1.55
Qs 0.98 0.80
Remember:
Qp/Qs: 1.5 small
1.5–2.0 medium
2.0 large
Minimal Qp/Qs Reliably Detected

1.5–1.9 at level of atrium
1.3–1.5 at level of ventricle
1.3 at level of great vessels
Shunts are small if the Qp/Qs 1.5, moderate if the Qp/Qs is

between 1.5 and 2.0, and large if the Qp/Qs is 2.
Right-to-Left Shunts: Right-to-left shunts cannot be localized or quan-

tified using a standard right heart catheterization. Sampling must be
done at the pulmonary vein level as well as the chamber of interest (e.g.,
left atrium) to determine if a “step-down” in saturation is found. This
technique usually necessitates a trans-septal puncture.
Cardiac Performance
Cardiac Output: The primary purpose of the heart is to deliver oxy-
genated blood to the peripheral tissues. Cardiac output is measured clin-
ically in two ways, the thermodilution and the Fick methods. Cardiac out-
put can also be indirectly estimated with left ventriculography. Cardiac
78852_ch07 25/06/10 4:11 PM Page 125
output is affected by several different factors including age, body size, and
metabolic demands. To normalize resting cardiac output among different
body sizes, the cardiac index is used:
CO(L>min)
Cardiac index(L>min>m2 )
BSA(m2 )
where
1[height(cm) weight(kg)]
BSA (body surface area)
3600
Thermodilution Method: The thermodilution technique is based on in-

dicator dilution methods. This method utilizes a bolus injection of a
known amount of a substance, and followed by measurement of the con-
centration of this substance downstream as a function of time. The con-
centration–time curve can then be used to determine the cardiac output.
While this technique has been used with several different indicators, for
example, indocyanine green, the most common indicator used today is
room temperature saline, with the temperature difference between
saline and blood measured in lieu of concentration. The temperature is
measured with a thermistor usually at the level of the injectate bag and at
the tip of the catheter. While this usually provides a reasonably accurate
result, if the temperature of the saline is increased between the injectate
bag and the injection port, the measurement can be falsely elevated. Most
commonly this occurs because the saline is heated by the operator’s hand
while in the injection syringe. In low-output states, the saline gets
warmed by the blood and heart prior to reaching the thermistor, which
may result in inaccurate calculations. Valvular abnormalities, such as tri-
cuspid or pulmonic regurgitation, or intracardiac shunting will also affect
the thermodilution cardiac output.
Fick Method: Adolph Fick, in 1870, developed a principle that demon-

strated that the total uptake or release of any substance by an organ
is the product of blood flow to the organ and the arteriovenous
Troubleshooting
Common Pitfalls in Measuring Cardiac Output
1. Warming the saline in the syringe with your hand prior to injection in the ther-
modilution method.
2. Not measuring cardiac outputs at the same time that pressure measurements
are done.
78852_ch07 25/06/10 4:11 PM Page 126
concentration difference of the substance. In common clinical practice,

the organ to which this is applied is the lungs, and the substance is oxy-
gen. This method calculates pulmonary blood flow, which in the absence
of intracardiac shunts, equals systemic blood flow. Thus, systemic blood
flow equals oxygen consumption divided by the pulmonary arteriovenous
oxygen difference. The arteriovenous oxygen difference is calculated by
subtracting the oxygen content of mixed venous blood, usually pul-
monary arterial blood in most clinical settings, from pulmonary venous
blood, which is estimated by systemic arterial blood. The oxygen content
equals oxygen saturation (%) multiplied by 1.36 mL O2/g hemoglobin
(oxygen carrying capacity of hemoglobin) multiplied by hemoglobin
(g/100 mL blood). The term for dissolved oxygen in the blood is usually
negligible and therefore dropped.
Fick CO(L/min)
oxygen consumption(mL>min)
(arterial venous O2 sat) 1.36 Hgb(mg>dL) 10
The uptake of oxygen by the lungs can be measured directly using a
metabolic cart. Given the unwieldiness, time, and expense, oxygen con-
sumption is often estimated by a formula or nomogram. This simplifica-
tion can, however, introduce inaccuracies to the calculation, especially
in patients with significantly higher or lower metabolic demands than
usual (see Troubleshooting: Calculation of Cardiac Output and Cardiac
Index).
Factors Affecting Oxygen Consumption

Age
Gender
Hyper or hypothyroidism
Hyper or hypothermia
Exercise
Sepsis
Angiographic Techniques: This method uses the left ventriculogram

to estimate stroke volume based on geometric assumptions about the
shape of the ventricle. The stroke volume is multiplied by the heart rate,
which gives an estimate of cardiac output. This method usually is the
least accurate, especially in ventricles that do not hold up to geometric
assumptions (Table 7-2).
78852_ch07 25/06/10 4:11 PM Page 127
Troubleshooting
Calculation of Cardiac Output and Cardiac Index
A 56-year-old man:
Height 180 cm
Weight 70 kg
Oxygen consumption 250 mL/min
Arterial O2 Saturation 98%
Venous O2 Saturation 70%
Hemoglobin 14 g/dL
oxygen consumption(mL>min)
CO
(arterial venous O2 sat) 1.36 Hgb 10
250
CO 4.69 L>min
(0.98 0.70) (1.36) (14)(10)
BSA 1(height (cm) weight (kg)>3600)
BSA 1(180 70>3600) 1.87 m2
CI(L>min>m2 ) CO(L>min)>BSA (m2 )
CI 4.69>1.87 2.51 L>min>m2
Table 7-2 Methods for Determining Cardiac Output, and

Conditions in Which They Are Most (or Least) Reliable
Method Most reliable Least reliable
Fick Low cardiac output High cardiac output

Thermodilution High cardiac output Low cardiac output
Pulmonic regurgitation
Tricuspid regurgitation
Intracardiac shunting
Angiographic Normal-shaped ventricle Extensive segmental wall
motion abnormalities
Dilated ventricle
Aortic regurgitation
Mitral regurgitation
78852_ch07 25/06/10 4:11 PM Page 128
Left Ventricular Filling Pressures: The left ventricular filling pressures

are often estimated by the PCWP. Differentiating the PA pressure from
PCWP can sometimes be difficult, especially in the setting of severe
mitral regurgitation, but three criteria can be used. The mean PCWP
should be about 10 mm Hg less than the mean PA pressure. Blood
withdrawn from the catheter in the wedged position should have an
arterial saturation. Finally, if fluoroscopy is available, the tip is “wedged”
when it is lodged and not moving in the distal PA.
The LVEDP provides the best hemodynamic correlation with the
volume status of the heart and can help guide diuretic and vasodilator
therapy. The LVEDP in normal patients is 3 to 12 mm Hg. This parame-
ter may increase with pressure or volume overload and with decreased left
ventricular compliance.
Potential Etiologies of Left Ventricular End Diastolic

Pressure Elevation
Aortic insufficiency
Mitral regurgitation
Intracardiac shunts
High-output CHF
Hypertension
Hypertrophic cardiomyopathy
Aortic stenosis
Cardiomyopathy—ischemic or nonischemic
Restrictive CM
Infiltrative CM
Vascular Resistance: Resistance is defined as the ratio of the pressure

gradient across a vascular bed divided by the flow through that bed.
Clinically, the two commonly calculated resistances are the systemic
vascular resistance and the pulmonary vascular resistance.
Systemic vascular resistance (SVR) Wood units (mm Hg/L/min)

mean aortic pressure mean RA pressure
Qs or CO
Pulmonary vascular resistance (PVR) Wood units (mm Hg/L/min)
mean PA pressure mean LA pressure
Qp or CO
Units: 80 dynes-sec-cm 1 Wood unit (or mm Hg/L/min)
5
78852_ch07 25/06/10 4:11 PM Page 129
In most patients, changes in vascular resistance reflect changes in

arteriolar tone or changes in the viscosity of blood (often secondary to
anemia). In patients who are hypotensive or in shock, SVR calculations
help to differentiate between certain etiologies, and may help guide
therapy. For example, a hypotensive patient with a low SVR may have
sepsis, while a patient in cardiogenic shock often has hypotension with
an elevated SVR.
Acknowledgment
The authors acknowledge the contribution of David Lee to the previous edition
of this chapter.
Suggested Reading
Baim DS, ed. Grossman’s Cardiac Catheterization, Angiography, and Intervention.
7th ed. Philadelphia, PA: Williams & Wilkins; 2005.
Bonow RO, Carabello B, Kanu C, et al. ACC/AHA 2006 guidelines for the
management of patients with valvular heart disease: a report of the American
College of Cardiology/American Heart Association Task Force on Practice
Guidelines J Am Coll Cardiol. 2006;48:e1–e148.
Brandfonbrener M, Landowne M, Shock NW. Changes in cardiac output with
age. Circulation. 1955;12:556.
Fick A. Uber die Messung des Blutguantums in den Herzventrikeln. Sitz der
Physik-Med ges Wurtzberg. 1870;16.
Gorlin R, Gorlin SG. Hydraulic formula for calculation of the area of the stenotic
mitral valve, other cardiac valves, and central circulatory shunts. Am Heart J.
1951;41:1.
Hakki AH, Iskandrian AS, Bemis CE, et al. A simplified valve formula for the cal-
culation of stenotic cardiac valve areas. Circulation. 1981;63:1050.
Heupler FA. Hemodynamics. Intensive Review of Cardiology Review Course;
2000.
Hurrell DG, Nishimura RA, Higano ST, et al. Value of respiratory changes in left
and right ventricular pressures for the diagnosis of constrictive pericarditis.
Circulation. 1996;93:2007.
Talreja DR, Nishimura RA, Oh JK, et al. Constrictive pericarditis in the modern
era: novel criteria for diagnosis in the cardiac catheterization laboratory.
JACC. 2008;51:315–319.
Kendrick AH, West J, Papouchado M, et al. Direct Fick cardiac output: are
assumed values of oxygen consumption acceptable? Eur Heart J. 1988;9:337.
Selzer A, Sudrann RB. Reliability of the determination of cardiac output in man
by means of the Fick principle. Circ Res. 1958;6:485.
Topol EJ, ed. Textbook of Cardiovascular Medicine. 2nd ed. Philadelphia, PA:
Williams & Wilkins; 2002.
78852_ch07 25/06/10 4:11 PM Page 130
APPENDIX A
Normal Hemodynamic
Values
Flows
Cardiac index (L/min/m2) 2.6–4.2
Stroke volume index (mL/m2) 35–55
Pressures (mm Hg)

Aorta/systemic artery
Peak systolic/end diastolic 100–140/60–90
Mean 70–105
Left ventricle
Left atrium (pulmonary capillary wedge)
Mean 1–10
“a” wave 3–15
“v” wave 3–15
Pulmonary artery
Mean 10–16
Right ventricle
Right atrium
Mean 0–8
“a” wave 2–10
“v” wave 2–10
Resistances
Systemic vascular resistance
Wood units 10–20
Dynes-sec-cm–5 770–1500
Pulmonary vascular resistance
Wood units 0.25–1.50
Dynes-sec-cm–5 20–120
Oxygen consumption (mL/min/m2) 110–150
AVO2 difference (mL/dL) 3.0–4.5
130
78852_ch07 25/06/10 4:11 PM Page 131
APPENDIX B
AHA/ACC Guidelines for

the Management of Patients
with Valvular Heart Disease
Recommendations for Cardiac Catheterization in Aortic Stenosis

Indication Class
1. Coronary angiography before AVR in patients I
at risk for CAD.
2. Assessment of severity of AS in symptomatic I
patients when AVR is planned or when
noninvasive tests are inconclusive or there
is a discrepancy with clinical findings
regarding severity of AS or need for surgery.
3. Coronary angiography is recommended before I
AVR in patients with AS for whom a pulmonary
autograft (Ross procedure) is contemplated and
if the origin of the coronary arteries was not
identified by noninvasive technique.
4. Assessment of severity of AS before AVR when III
noninvasive tests are adequate and concordant
with clinical findings and coronary angiography
is not needed.
5. Assessment of LV function and severity of AS in III
asymptomatic patients when noninvasive tests
are adequate.
131
78852_ch07 25/06/10 4:11 PM Page 132
Recommendations for Cardiac Catheterization in Chronic Aortic

Regurgitation
Indication Class
1. Coronary angiography before AVR in patients I
at risk for CAD.
2. Assessing severity of regurgitation, LV function, I
or aortic root size when noninvasive tests are
inconclusive or discordant with clinical findings
in patients with AR.
3. Assessment of LV function and severity of III
regurgitation before AVR when noninvasive
tests are adequate and concordant with clinical
findings and coronary angiography is not
needed.
4. Assessment of LV function and severity of III
regurgitation in asymptomatic patients when
noninvasive tests are adequate.
Recommendations for Cardiac Catheterization in Mitral Stenosis

Indication Class
1. Assess the severity of MS when noninvasive I
tests are inconclusive or when there is a discrep-
ancy between noninvasive tests and clinical find-
ings regarding the severity of MS.
2. Catheterization for hemodynamic evaluation I
including left ventriculography (to evaluate
severity of MR) for patients with MS is indicated
when there is a discrepancy between the
Doppler-derived mean gradient and valve area.
3. Assess hemodynamic response of pulmonary IIa
artery and left atrial pressures to exercise when
clinical symptoms and resting hemodynamics
are discordant.
4. Assess the cause of severe pulmonary arterial IIa
hypertension when out of proportion to severity
of MS as determined by noninvasive testing.
5. Assess mitral valve hemodynamics when 2D and III
Doppler echocardiography data are concordant
with clinical findings.
78852_ch07 25/06/10 4:11 PM Page 133
Appendix B • AHA/ACC Guidelines for the Management of Patients 133
Indications for Cardiac Catheterization in Mitral Regurgitation

Indication Class
1. Left ventriculography and hemodynamic meas- I
urements are indicated when noninvasive tests
are inconclusive regarding severity of MR, LV
function, or the need for surgery.
2. Left ventriculography and hemodynamic meas- I
urements are indicated when there is a discrep-
ancy between clinical and noninvasive findings
regarding severity of MR.
3. Hemodynamic measurements are indicated I
when pulmonary artery pressure is out of pro-
portion to the severity of MR as assessed by
noninvasive testing.
4. Coronary angiography is indicated before MV I
repair or MV replacement in patients at risk for
CAD.
5. Left ventriculography and hemodynamic meas- III
urements are not indicated in patients with MR
in whom valve surgery is not contemplated.
Adapted from Bonow RO et. al. Circulation 2008;118:e523-e661
78852_ch07 25/06/10 4:11 PM Page 134
78852_ch08 18/06/10 9:17 AM Page 135
CHAPTER 8
Approach to the
High-Risk Patient
Daniel J. Cantillon
Adverse events during diagnostic right and left heart catheterization

are more likely to occur in high-risk patients (Table 8-1). Procedural
indications should be reviewed carefully to justify the increased risk.
An adverse outcome can be avoided by identifying a high-risk
patient, implementing preventive measures, and recognizing compli-
cations early.
General preventive measures include correction of any electrolyte
abnormalities prior to the procedure; awareness of any pre-existing
atrioventricular (AV) nodal block, bundle branch block; or prolonga-
tion of the QT on the baseline surface electrocardiogram (EKG) to
identify patients at risk for procedural arrhythmias. For patients with
renal insufficiency, the amount of contrast dye should be minimized
and bi-plane imaging considered when available.
Table 8-1 High-Risk Patients

Left main coronary artery disease
Severe ventricular dysfunction
Severe aortic valvular stenosis
Aortic dissection, aneurysm, or atheroma
Cardiogenic shock
Acute coronary syndrome
Hypertrophic obstructive cardiomyopathy
Coagulopathy or increased bleeding risk
Severe pulmonary hypertension
Acute/chronic kidney disease
Peripheral vascular disease
135
78852_ch08 18/06/10 9:17 AM Page 136
Common Problems in High-Risk Patients

Hypotension: Periprocedureal hypotension may be caused by contrast
allergy or contrast-induced vasodilation, vagal response, ischemia, dys-
rhythmia, hypovolemia, oversedation. It is important to follow a simple
algorithm to identify and treat the cause. First, ascertain that hypotension
is real and not caused by artifact (i.e., catheter damping or whip). At the
same time, identify any changes in rhythm or ST segments. Next concen-
trate on complications related to the last task performed (Table 8-2). For
example, hypotension or dampening of the pressure waveform during
attempts to engage the diagnostic catheter into the left main (LM) or
right coronary artery should immediately raise concern for severe ostial
disease, iatrogenic vasospasm, or coronary dissection. This is especially
true when engaging coronary arteries with anomalous origin or in patients
Table 8-2 Troubleshooting Acute Hypotension in the Lab

Procedural Event
Precipitating Acute
Hypotension Onset Suspected Cause Treatment
Coronary catheter Severe ostial disease Catheter withdrawal

engagement Vasospasm Nitroglycerin 50–200 μg IC
Iatrogenic dissection PCI or bypass surgery
RCA contrast injection Vagal stimulation Avoid over-injection of dye
Myocardial ischemia Coronary revascularization
Vascular access Vagal stimulation Self-limited
(immediate) Atropine 0.5–1 mg IV
Vascular access Bleeding Volume resuscitation
(delayed) Transfusion
Vascular surgery evaluation
Crossing the aortic Aortic dissection Emergent surgical correction
valve Coronary dissection PCI or bypass surgery
PA catheter or wire RV perforation Volume resuscitation
manipulation in the RV Cardiac tamponade Pericardiocentesis with drain
PA catheter balloon Arterial rupture Volume resuscitation
inflation Emergent surgical correction
Transvenous pacing wire RV perforation Pericardiocentesis with drain
Immediately post-shock Electromechanical Fluoroscopy to verify
for tachyarrhythmia dissociation cardiac loss of cardiac motion
ACLS protocol for PEA arrest
78852_ch08 18/06/10 9:17 AM Page 137
Chapter 8 • Approach to the High-Risk Patient 137
with heavily calcified and diseased aortas in which a greater degree of

catheter manipulation or torque was required.
Hypotension during vascular access is typically vagal-mediated,
self-limited and it occurs within minutes of vascular manipulation.
Hypotension 30 minutes to 12 hours after vascular access should raise
suspicion for retroperitoneal bleeding. Patients commonly complain of
unilateral flank or back pain. Hypotension immediately following contrast
dye injection of the right coronary artery can also be vagal mediated.
Having a patient cough may help clear contrast from the coronary circu-
lation and restore normal heart rate. Typically, the right coronary artery
is more likely to spasm when engaged compared to the LM trunk. Both
effects are heightened by the presence of flow-limiting coronary lesions,
and mitigated by precise catheter control and a smooth engagement
technique without allowing the tip of the catheter to become deeply
seated.
Hypotension during diagnostic right heart catheterization may be
attributable to multiple causes. Forceful advancement of the pulmonary
artery (PA) catheter within the right ventricle with the balloon deflated or
with the tip deflected away from the outflow tract can result in free wall
perforation and tamponade. Similarly, the use of a 0.25-in guidewire when
attempting to direct the PA catheter beyond the outflow tract in a dilated
and/or dysfunctional ventricle can also easily perforate the right ventricu-
lar free wall. An abrupt increase in ventricular ectopy with hypotension
while manipulating the catheter or wire in the right ventricle should
immediately alert the operator to this possibility. Aggressive volume ex-
pansion is usually the only measure needed to support patients with
iatrogenic right ventricular perforation. Pericardiocentesis with a drain
may be necessary in selected cases.
Bradycardia: Transient bradycardia caused by ionic contrast agents

or hypervagotonia usually resolves without treatment. If bradycardia
does not resolve spontaneously, treatment with atropine 0.5 to 1 mg
IV or more rarely a continuous infusion of dopamine may be re-
quired. A temporary transvenous pacemaker (TVP) may be required in
selected cases. A typical presentation requiring temporary pacing sup-
port involves a patient with a pre-existing left bundle branch block who
develops complete or high-grade AV block while manipulating a catheter
in the right ventricle during a right heart catheterization. Prophylactic
TVP placement should be considered in these patients. A prophylactic
TVP is not indicated for first-degree AV block or Mobitz I second-
degree heart block.
General indications for TVP also include symptomatic or hemody-
namically significant bradycardia attributable to sinus node dysfunction,
78852_ch08 18/06/10 9:17 AM Page 138
high-grade atrioventricular block, and enhanced vagal tone (Table 8-3).

Blunt-tipped passive placement (i.e., “contact”) pacing wires are most
commonly selected as they are easy to use, readily available, and generally
atraumatic. It is important to remember to select the pacemaker wire
with the preformed curvature appropriate for the vascular access site.
Passive temporary wires designed for jugular and subclavian access have a
smooth terminal curvature (similar to a PA catheter) to allow the wire to be
advanced into the right ventricular outflow tract (RVOT) and pulmonary
artery and then gently withdrawn into the right ventricle (RV) where coun-
terclock torque will nestle the tip up along the RV floor at or near the apex.
Advancing the wire up into the RVOT and the PA outside of the cardiac
silhouette is important to ensure the wire has not inadvertently passed into
Table 8-3 ACC/AHA Indications for Transvenous Pacemakers

in the Setting of Myocardial Infarction
Class I
1. Symptomatic bradycardia
2. Bilateral bundle branch block
3. New or age indeterminate bifascicular block with PR segment prolongation
4. Mobitz type II second-degree AV block
Class IIa
1. New or age indeterminate right bundle branch block (RBBB) with left anterior
fascicular block (LAFB) or left posterior fascicular block (LPFB)
2. RBBB with prolonged AV conduction
3. New or age indeterminate left bundle branch block (LBBB)
4. Incessant ventricular tachycardia for overdrive pacing
5. Recurrent sinus pauses greater than 3 seconds not responsive to atropine
Class IIb
1. Bifascicular block of indeterminate age
2. New or age indeterminate isolated RBBB
Class III
1. Prolonged AV conduction
2. Mobitz type I second-degree AV block with normal hemodynamics
3. Accelerated idioventricular rhythm
4. BBB or fascicular block known to exist before myocardial infarction
Adapted from Antman EM, et.al. ACC/AHA Guidelines for the management of patients with
ST-Elevation myocardial infarction—Executive summary. Circulation 2004;110:588–636.
78852_ch08 18/06/10 9:17 AM Page 139
the coronary sinus (CS). These wires are not designed for CS pacing.
Passive blunt-tipped pacing wires designed for femoral access typically have
a J-tipped curvature. Under fluoroscopy, the wire is advanced up into the
inferior vena cava (IVC) across the tricuspid valve where the curved tip is
directed posteriorly and inferiorly along the RV floor at or near the apex. In
patients with right ventricular enlargement, straight or curved balloon-
tipped temporary wires are also available.
Active fixation temporary wires are also available and are typically ad-
vanced into the appropriate chamber under the guidance of a 6 or 7 Fr. size
stiff outer sheath. The outer sheath is directed to the desired location under
fluoroscopy approximately 0.5 to 1 cm away from the wall. The wire is then
advanced beyond the sheath to the wall and torqued clockwise to screw it
into place. Gently retracting the outer sheath and testing capture thresholds
verifies appropriate fixation. Active fixation wires are particularly helpful for
atrial pacing, when getting a stable position with good capture is often dif-
ficult with the blunt-tipped passive wires. The outer sheath must be care-
fully advanced and never allowed to tent the myocardium.
Regardless of wire selection, pacing output should be initiated under
fluoroscopy. Sudden diaphragmatic movements tracking pacemaker
spikes indicate diaphragmatic pacing requiring lead repositioning. The
capture threshold, defined as the lowest current necessary for capture,
should be established. Output is generally started at 5 mA and slowly
decreased until capture is lost. Once the capture threshold is obtained
(ideally less than 1 mA), the output is set to two to three times the capture
threshold as a safety margin. Sensing thresholds are then tested by setting
the pacing rate 10 to 20 beats below the intrinsic rate with the pace-
maker in its most sensitive setting (lowest mV recognition available).
The sensitivity is then gradually increased until asynchronous pacing
occurs. This is the point at which the device can no longer detect the native
QRS complex because the threshold has been set higher than the ampli-
tude of the native complex. The pacemaker is then programmed to sense
at 50% of the sensing threshold as a safety margin.
The most common complications of TVP insertion include vascular
or myocardial rupture or damage, cardiac tamponade, induction of cardiac
arrhythmias, pneumothorax, and bleeding complications at the access site.
Tachycardia: Registry data suggests that ventricular tachycardia or

fibrillation complicates 0.4% of all diagnostic catheterizations. If a tach-
yarrhyhmia causes hemodynamic compromise, ACLS (advanced cardiac
life support) protocols should be initiated promptly. “Cough CPR (car-
diopulmonary resucitation)” may help the patient maintain conscious-
ness during a ventricular arrhythmia by accelerating venous return and
augmenting cardiac output. However, early defibrillation and initiation
78852_ch08 18/06/10 9:17 AM Page 140
of antiarrhythmic medications, such as amiodarone 150 to 300 mg and/or

lidocaine 1 mg/kg or empirically 100 mg, are recommended whenever a
patient develops malignant ventricular tachycardia. Continuous infusions
of these medications after the loading dose are generally indicated to pre-
vent recurrent arrhythmias.
Atrial fibrillation (AF) with ventricular response can pose a problem
during the procedure. Hemodynamic instability merits cardioversion
under ACLS protocol. However, the risk of embolic stroke favors rate
control when possible when the duration of AF is greater than 48 hours
or uncertain. Traditional AV nodal agents such as β-blocker and calcium
channel blockers are the first-line drugs. However, digoxin, while an
older drug, is often effective and a largely forgotten therapy in the cath
lab. In appropriately selected patients, a loading dose of 0.5 mg IV may
slow the ventricular response within 30 minutes and provide a durable
response for the duration of the procedure. A full loading dose of
digoxin is generally 1 g over 24 hours. Caution is advised in patients with
potassium levels outside the range of normal or in patients with renal
dysfunction.
Airway Compromise/Respiratory Failure: Most diagnostic heart catheter-

izations are performed under conscious sedation rather than general anes-
thesia. Hence, any airway compromise or respiratory failure during
the procedure requires prompt attention as progressive hypoxemia,
hypercapnea, and acidemia may lower the threshold for ventricular
arrhythmias and increase the risk of cardiac arrest.
A focused preprocedural physical examination of the patient verifies
adequate respiratory/pulmonary status to tolerate laying flat for the du-
ration of the procedure and candidacy for conscious sedation. Patients
with acutely decompensated heart failure are often better served having
an elective diagnostic catheterization after adequate diuresis and medical
optimization. Additionally, it is good practice to assess the patient’s neck
habitus and visualize the uvula, as well as asking about any difficulty with
endotracheal intubation in the past to identify patients in whom obtaining
an emergent airway might become a problem. A Mallampati airway
score is used routinely in some cath labs to identify potentially difficult
tracheal intubations. A Mallampati classification is an estimate of the
tongue size relative to the oral cavity.
When respiratory failure does occur in the lab, it is important to rap-
idly discriminate procedural iatrogenic causes (such as oversedation with
opiates and benzodiazepines), and patient factors (intrinsic pulmonary
disease, acutely decompensated failure, etc.). The latter may prompt
endotracheal intubation, while the former can be rapidly reversed by
administering naloxone 0.4 mg, an opiate receptor antagonist.
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Specific High-Risk Patient Scenarios

Acute Coronary Syndrome (ACS): In all patients with ACS, especially
those with ST segment elevation myocardial infarction, the goal is to
quickly and accurately assess all major epicardial vessels in at least two or-
thogonal views while rapidly identifying the culprit lesion(s) so that either
percutaneous or surgical revascularization may proceed. These patients
are at high risk of life-threatening arrhythmias, cardiogenic shock, and
death. Use of anticoagulants and anti-platelet medications places these
patients at higher risk of bleeding and vascular complications.
There are important strategic considerations for the diagnostic proce-
dure in high-risk ACS patients. In the setting of acute STEMI (ST-
segment elevation myocardial infarction), some operators elect to begin
coronary angiography by imaging the opposite vessel of the ECG-
predicted acute infarct artery using a diagnostic catheter, and then proceed
with angiography of the infarct vessel using a guide catheter to allow a
rapid transition to percutaneous intervention. The major advantage is ob-
viating the time spent exchanging a diagnostic catheter for a guide catheter
to re-engage the infarct vessel. This strategy is particularly useful when
patients with triple vessel disease or pre-existing critical stenosis in one
major epicardial vessel develop coronary plaque rupture and acute STEMI
in the opposite artery. By starting in the noninfarct artery, one can identify
a lesion that might alter the patient’s management. For example, critical
LM or proximal LAD disease in a patient with an acute RCA infarct might
prompt a decision to refer for emergent coronary artery bypass grafting or
at least the prophylactic placement of an intra-aortic balloon pump before
beginning percutaneous intervention on the infarct-related RCA.
Left Main Trunk Coronary Artery Disease: According to the Society

for Cardiac Angiography and Interventions, patients with LM disease
have a twofold greater risk of complications from cardiac catheterization.
Angiography of a patient with severe LM stenosis (Figure 8-1) may pro-
duce profound hypotension, thereby potentiating myocardial ischemia.
LM disease should be suspected in patients with a markedly positive
stress test (LV, left ventricle, dilation on stress and/or lung uptake
of sestamibi), ischemic ECG changes in a large, anterior distribu-
tion, or in patients presenting with ACS with associated heart fail-
ure. Often, the first clue suggesting LM stenosis is dampening of the
catheter upon engagement of the LM ostium (Figure 8-2). If this oc-
curs, the catheter should be promptly removed and carefully re-engaged
approaching the LM from a slightly different angle. If dampening recurs
and is not rectified with careful catheter manipulation, then the catheter
should be removed and a subselective injection performed. Injection
78852_ch08 18/06/10 9:17 AM Page 142
Figure 8-1 Angiogram demonstrating a severe distal LM trunk stenosis (arrow).
Figure 8-2 Pressure dampening and ventricularization upon catheter engage-

ment of the left main (LM) trunk. Waveform alterations seen upon catheter en-
gagement of a severe LM trunk stenosis. Clues to LM stenosis include a pressure
gradient (dampening) and ventricularization of the pressure waveform.
78852_ch08 18/06/10 9:17 AM Page 143
into the left CS will often be enough to unmask severe disease.

Subsequent injections should be made with nonionic contrast and lim-
ited to revealing targets for bypass grafts. In most cases the entire study
of the left system can be limited to two subselective injections, consisting
of a straight PA cranial (left anterior descending artery view) and an
RAO caudal angulated view (left circumflex artery view).
Aortic Dissection or Aneurysm: The rationale for coronary angiogra-

phy prior to surgical correction of aortic dissection is to identify severe
coronary lesions that should be grafted at the time of open heart surgery.
However, there are data suggesting that coronary angiography in
patients with type A aortic dissection does not improve in-hospital
mortality. Cardiac CT (computed tomography) angiography is emerg-
ing as a noninvasive substitute for invasive angiography in patients with
aortic disease and a low to intermediate probability for coronary artery
disease. Nonetheless, conventional coronary angiography remains the
mainstay of preoperative evaluation of patients with aortic pathology.
Catheter selection and techniques utilized should be made with
knowledge of the specific aortic anatomy and pathology. For patients
with ascending aortic aneurysms, the use of longer tipped catheters such
as the JL5 or JL6 may be necessary to reach the LM trunk ostium. Use
of the multipurpose catheter may be necessary to reach the right coro-
nary ostium due to effacement of the aortic root. Additionally, choosing
the appropriate vascular access site can help avoid engaging the false aortic
lumen in the case of aortic dissection or avoiding diseased segments in
the case of aneurysmal disease. For example, obtaining right radial or
brachial access should be considered in patients with aortic dissection
sparing the ascending aorta but involving the arch beyond the innomi-
nate artery or the proximal descending aorta. When traversing dissected
aorta is unavoidable, using soft-tipped exchange-length wires and longer
sheath minimizes the risk of aortic trauma and keeps catheters inside the
true lumen. When in doubt, gentle nonselective contrast injections in
orthogonal views with cine angiography can help identify the coronary
ostia, as well as the catheter tip location with respect to the false lumen.
This can help the operator select catheters most appropriate to safely
engage the ostium. The true lumen usually has brisk pulsatile flow,
whereas flow within the false lumen appears static and often fails to clear
rapidly. Only nonselective views of the coronary arteries may be obtain-
able in some cases.
Aortic Stenosis: The goals of cardiac catheterization in patient with

aortic stenosis (AS) are to confirm the diagnosis of outflow
obstruction, localize the obstruction (subvalvular, valvular, or
78852_ch08 18/06/10 9:17 AM Page 144
supravalvular), estimate the severity of the stenosis, estimate the left

ventricular function, and evaluate the coronary circulation. Patients
with AS are more likely to have aortic root dilation, especially in the
setting of a bicuspid aortic valve, which may require alternate catheter
selection for coronary angiography. Complications of cardiac catheteri-
zation in patients with AS include dysrhythmias, myocardial perforation,
cardiac tamponade, stroke, myocardial infarction, and death. The aortic
valve does not need to be crossed if valve surgery is planned on the
basis of the noninvasive assessment.
Transient hypotension and/or bradycardia may be life threatening in
patients with critical AS. In cases of profound and protracted hypoten-
sion, intra-aortic balloon pump (IABP) counterpulsation may serve as a
“bridge” to definitive therapy. If hypotension occurs while trying to
cross the valve, perforation of the CS with resultant tamponade should
be suspected. In such cases, rapid surgical intervention is necessary.
Ventricular arrhythmias are life threatening in patients with severe AS
because intravenous medications tend not to circulate well in the setting
of severe outflow obstruction. If asystolic or pulseless electrical activ-
ity (PEA) arrest occurs in a patient with critical AS, ACLS protocol
should be initiated, and intracardiac epinephrine (5 mg) should be
given early in the resuscitative effort.
Cardiogenic Shock: Patients presenting to the catheterization lab in

cardiogenic shock are at very high risk for morbidity and mortality dur-
ing catheterization. Cardiogenic shock occurs in 5% to 15% of patients
with an acute myocardial infarction. In the GUSTO I trial, patients pre-
senting in cardiogenic shock accounted for 58% of the mortality in the
entire trial. The overriding goal of cardiac catheterization in patients
with cardiogenic shock is to rapidly identify the coronary lesion(s)
responsible. Most operators will place an IABP prior to angiography in
order to minimize the risk of further hemodynamic collapse. Patients
with cardiogenic shock may benefit from routine placement of a pul-
monary artery (Swan-Ganz) catheter for guided therapy following the
procedure in the ICU (intensive care unit).
Indications and contraindications of IABP placement are listed in
Table 8-4. When first introduced in 1962, IABPs were surgically placed.
Beginning in 1980, however, the percutaneous approach via the femoral
artery replaced the surgical approach as the primary means of insertion.
Balloon size is selected based on the patient’s height. Most patients
receive a 40-cc balloon. Patients shorter than 64 in or taller than 72
in require smaller (34 cc) or larger (50 cc) balloons, respectively.
The IABP can be inserted either through a sheath (8 or 9.5 Fr.) or via a
sheathless technique.
78852_ch08 18/06/10 9:17 AM Page 145
Table 8-4 Indications and Contraindications to IABP Placement

Indications Contraindications
Cardiogenic shock Moderate aortic insufficiency (⬎2⫹)

Severe mitral regurgitation Abdominal aortic aneurysm
Decompensated aortic stenosis Aortic dissection
Ventricular septal defect Bilateral lower extremity PVD
Refractory ischemia Significant arteriovenous shunts
High-risk PCI Severe coagulopathy
Bridge to definitive therapy Sepsis
No planned definitive therapy
After vascular access has been obtained, the IABP is inserted into the
descending thoracic aorta over a guidewire. Fluoroscopic guidance is
essential to achieve optimal placement in the aorta. The proximal
radiopaque tip should be located just below the subclavian artery or
at the level of the carina (Figure 8-3), and the distal end should be above
the renal arteries (usually at the level of L1–L2) and completely out of
the sheath. The central lumen is aspirated and flushed with heparinized
saline and connected to a pressure transducer. The balloon is then con-
nected to the pump and filled to half volume. Adequate filling and loca-
tion should be confirmed by fluoroscopy. Once location is confirmed,
the IABP is filled completely and then secured with sutures. Patients are
routinely placed on systemic anticoagulation to prevent potential throm-
boembolic complications resulting from an indwelling intravascular
device. However, manufacturers of IABPs indicate that systemic antico-
agulation is optional.
Optimal adjustment of the timing and triggers results in maximum
hemodynamic effects (Figure 8-4). Timing of inflation should correlate
with the onset of diastole. To properly adjust timing of inflation, the
IABP should be placed on an inflation ratio of 1:2 to observe aug-
mented and unaugmented beats. The central pressure waveform is used
to guide proper timing. Ideally, the balloon should inflate with the clo-
sure of the aortic valve, identified by the dicrotic notch of the central
pressure waveform tracing. Deflation should occur with aortic valve
opening, which can be timed with the onset of the R wave by ECG trac-
ing. When timed appropriately, the central aortic waveform should have
an augmentation pressure greater than the systolic pressure, and a post-
deflation pressure 10 to 15 mm Hg below the unagumented diastolic
blood pressure.
78852_ch08 18/06/10 9:17 AM Page 146
B
Figure 8-3 Optimal positioning of the intra-aortic balloon pump.
A) Diagram demonstrating the optimal positioning of the IABP approximately
2 cm distal to the left subclavian artery. B) The radio-opaque tip of the IABP is
located approximately 2 cm cranial to the left mainstem bronchus at the level of
the carina (double arrowheads).
After IABP insertion, patients should have daily checks of hemoglo-

bin, hematocrit, platelet count, white blood cell count, renal function,
and a chest x-ray for placement. Meticulous attention to peripheral
pulses and access site is of paramount importance in detecting early vas-
cular complications.
78852_ch08 18/06/10 9:17 AM Page 147
Figure 8-4 Timing of IABP inflation and deflation. A) Correct timing:

With correct timing of IABP inflation and deflation an augmentation of diastolic
and systolic blood pressures is seen. Inflation occurs at the onset of diastole
(arrow) and deflation should occur prior to the onset of systole (arrowhead),
resulting in decreased aortic end diastolic and systolic pressures. B) Premature
inflation: Inflation of IABP prior to dicrotic notch (arrow). This may result in
premature aortic valve closure, increased LV wall stress, aortic regurgitation, and
increased myocardial oxygen demand. C) Delayed inflation: Inflation of IABP
following the dicrotic notch (arrow) may result in inadequate accentuation of
coronary perfusion. D) Premature deflation: Observed as a precipitous drop in the
pressure waveform following diastolic augmentation (arrow). Other observations
include a suboptimal diastolic augmentation and an assisted systole that is equal
or greater than the unassisted systole (arrowhead). This may result in suboptimal
afterload reduction and increased myocardial oxygen demand. E) Delayed defla-
tion: Observed as an assisted end diastolic pressure equal to or greater than the
unassisted end diastolic pressure, a prolonged rate of rise of the assisted systole
(arrowhead), and a widened diastolic augmentation (double arrow). A lack of
afterload reduction and an increase in myocardial oxygen demand occur.
78852_ch08 18/06/10 9:17 AM Page 148
Table 8-5 Common Complications Associated with IABP

Counterpulsation
Vascular Nonvascular
(6–25%a) (4–15%a)
Hematoma formation Sepsis

Arterial dissection Thrombocytopenia
Vascular laceration Hemolysis
Limb ischemia Groin infection
Thromboembolic complications Peripheral neuropathy
Renal ischemia
Spinal cord ischemia
a
Incidence.
Complications can be divided into vascular and nonvascular compli-

cations (Table 8-5). Vascular complications occur in 6% to 25% of cases.
Specific complications include limb ischemia, arterial dissection, vascular
laceration (requiring surgical repair), and major hemorrhage.
Pulmonary Hypertension: Indications for cardiac catheterization in

patients with pulmonary hypertension include determination of cause,
assessment of severity, reversibility, quantification of intracardiac shunts,
and pulmonary angiography. During any right heart catheterization, the
sudden onset of shortness of breath or hypoxemia and hypotension may
indicate pneumothorax during jugular or subclavian access, pulmonary
embolus, or cardiac perforation. In general, inflation of the balloon into
a pulmonary capillary wedge position is safe, well tolerated and provides
valuable diagnostic information. However, patients with severe pulmonary
arterial hypertension are at increased risk of PA rupture. Hypotension in a
patient with spontaneous cough (especially hemoptysis) after prolonged
inflation of the balloon in the pulmonary capillary wedge position
should raise the concern for PA rupture, especially in a patient with un-
derlying severe pulmonary arterial hypertension. Aggressive volume
expansion and surgical evaluation are warranted.
Increased Bleeding Risk: Patients with thrombocytopenia or coagu-

lopathy are at increased risk for bleeding complications from diagnostic
catheterization (i.e., hematoma or retroperitoneal bleed). The precise
threshold at which point a cardiac catheterization becomes contraindi-
cated is somewhat controversial and depends on the indication for the
78852_ch08 18/06/10 9:17 AM Page 149
study. Many centers use a platelet count of less than 50,000 or an inter-
national normalized ratio (INR) of greater than 2.0. However, it is in-
appropriate to delay taking a patient to the lab coming through the
emergency department with an acute ST elevation myocardial infarction
by waiting on an INR or platelet level to return. For patients with INR
⬎2.0, there are data to suggest that manual sheath removal and pressure
hemostasis are preferred to reduce bleeding complications, or suturing
the sheath in place for removal after coagulopathy reversal. For patients
with increased bleeding risk, vascular access trauma can be minimized by
using commercially available micropuncture kits with smaller needles,
wires, and sheaths that can be upsized to more traditional sheath sizes to
accommodate diagnostic catheters. Additionally, venous puncture of the
internal jugular vein for right heart catheterization can be performed
under direct ultrasound guidance when bleeding risk is a concern.
When a retroperitoneal bleed is suspected, a noncontrast CT scan of
the abdomen and pelvis with extension of axial imaging to mid-thigh is the
best modality to establish the diagnosis. Vascular surgical consultation may
be necessary; however, the majority of these events are managed conserv-
atively with volume resuscitation, hemodynamic monitoring in an ICU
with serial measurements of hemoglobin or hematocrit. Prompt reversal of
coagulatopathy with transfusion of frozen plasma and/or platelets is often
necessary, especially in patients with life-threatening bleeds.
Acknowledgments
The author acknowledges the contribution to this chapter of Michael R. Tamberella,
MD, and A. Michael Lincoff, MD, from the previous version of this book.
Suggested Reading
Bertrand ME. Identification of intervention patients at increased risk. Am Heart J.
1995;130:647–650.
Boehrer JD, Lange RA, Willard JE, et al. Markedly increased periprocedure mortal-
ity of cardiac catheterization in patients with severe narrowing of the left main
coronary artery. Am J Cardiol. 1992;70:1388–1390.
Penn MS, Smedira N, Lytle B, et al. Does coronary angiography before emergency
aortic surgey affect in-hospital mortality? J Am Coll Cardiol. 2000;35:889–894.
78852_ch08 18/06/10 9:17 AM Page 150
78852_ch09 24/06/10 3:11 PM Page 151
CHAPTER 9
Hemostatic Devices
James E. Harvey and A. Michael Lincoff
Obtaining hemostasis in patients after cardiovascular catheterization is a

critical component of the procedure. When the novel technique for per-
cutaneous endovascular access was introduced by Seldinger over 50 years
ago, his reported method for achieving hemostasis included “20 to
30 minutes of hand-held pressure after catheter removal followed by
overnight bed rest.” Since then, manual pressure or mechanical com-
pression has remained the gold standard for achieving postprocedural
hemostasis following femoral artery puncture. However, with the increase
in coronary and peripheral vascular procedures over the past two decades
has come a demand for more efficient and cost-effective methods of achi-
eving hemostasis. This has led to the development of many types of vas-
cular closure devices (VCDs) designed to increase patient comfort while
maintaining safety and ease-of-use. These devices offer the advantages of
early sheath removal, early ambulation, and early hospital discharge, as
well as allow for uninterrupted anticoagulation when needed. In addition
to manual compression or mechanical compression devices (including
mechanical clamp devices and hemostatic pads), the currently available
VCDs fall into three major categories: collagen-based biosealant, percu-
taneous suture based, and staples and clips, with minimal variation in cost
between the devices ($175 to $190 at our institution).
Devices
Manual Compression: Despite many available VCDs on the market,
manual pressure remains a fundamental component of arteriotomy man-
agement because of its low cost, good safety profile (complication rate of
0.23% following diagnostic catheterization in large series and ⬎50 years
experience), short learning curve, and ability to be employed despite
femoral artery dissection, significant peripheral vascular disease, or a
“low stick.” Limitations of this technique include the length of time
needed before ambulation, prolonged hospitalization time, need for
151
78852_ch09 24/06/10 3:11 PM Page 152
trained personnel, patient discomfort, staff fatigue, and slowing of the

catheterization laboratory workflow. For patients following percuta-
neous coronary intervention (PCI) or in those who have been on antico-
agulation with heparin, manual compression can be safely performed
once the activated clotting time (ACT) is less than 180 seconds or the
activated partial thromboplastin time (aPTT) is less than 50 seconds.
When removing the sheath, gentle pressure is applied over the skin
puncture site being careful not to crush the sheath and “strip” clot into
the femoral artery. Manual pressure is then held directly above the arte-
riotomy at a point approximately 1.5 cm cephalad to the skin puncture
site. Pressure should be held for approximately 3 minutes per
French size for arterial punctures and 2 minutes per French size for
venous punctures and can be gradually reduced over that time (i.e.,
after a 6-Fr. arterial sheath removal, hold full pressure for 5 minutes,
then 75% pressure for 5 minutes, then 50% pressure for 5 minutes, then
25% pressure for 3 to 5 minutes). The pedal pulses should be checked
every few minutes during femoral artery compression. If the pedal pulses
are absent during femoral artery compression, the pressure should be
intermittently reduced to allow perfusion to the distal lower extremity.
Keep in mind that this is only an estimate and that patients with a mildly
elevated ACT or those receiving antiplatelet therapy (i.e., aspirin, clopi-
dogrel, prasugrel, etc.) may need an additional 10 to 15 minutes of man-
ual pressure to achieve hemostasis. Low-risk patients should remain
supine for 2 to 3 hours (0.5 hours per French size) after hemostasis,
especially when a small diameter catheter is used (ⱕ5 Fr.); high-risk
patients should remain supine for 4 to 6 hours after hemostasis. One
study involving low-risk patients (5-Fr. sheath, diagnostic catheterization
only, no anticoagulation) who received 10 to 15 minutes of manual
compression followed by 1 hour of bed rest and 1 hour of observation
reported a minor complication rate of 3.3% and a major complication
rate of 0.1%. The major complication of manual compression is pseudoa-
neurysm that results from poor hemostasis (pressure).
Hemostatic Pads: Hemostatic pads (D-Stat Dry, SyvekPatch, Chito-Seal)

are small pieces of gauze or other material that are impregnated with a
procoagulant mixture that causes local vasoconstriction and potentiates
clot formation. Used in conjunction with manual compression, the patch
is applied topically over the puncture site after sheath removal and remotely
activates the coagulation cascade from the skin surface. Coagulation cas-
cade activation is potentiated down the sheath tract to the arterial wall.
The benefits of patches include decreased time to hemostasis, reduced
time to ambulation, no insertion of foreign material into the body, and
78852_ch09 24/06/10 3:11 PM Page 153
Chapter 9 • Hemostatic Devices 153
immediate repeat arterial puncture if necessary. Other advantages include

shortened hospitalization and a low incidence of major vascular compli-
cations (0.1%).
D-Stat Dry hemostatic bandage (Vascular Solutions, Inc., Minnea-
polis, MN) is a nonwoven gauze patch that is coated with thrombin that
potentiates the coagulation cascade by directly converting fibrinogen to
fibrin. It is used as an adjunct to manual compression and is indicated
to reduce the time to hemostasis in patients undergoing diagnostic
endovascular procedures utilizing 4- to 6-Fr. sheaths. A recent study of
367 patients looked at the use of D-Stat Dry versus manual compression
alone and found that use of D-Stat Dry resulted in a significant reduc-
tion in time to hemostasis (7.8 vs. 13.0 min; p ⫽ 0.001) with no signif-
icant difference in major or minor complications. The D-Stat Dry patch
is directly applied over the skin puncture site and manually compressed
for a minimum of 6 minutes (for low-risk normotensive patients not an-
ticoagulated) to 10 minutes (anticoagulated, hypertensive, large sheath
size) or until hemostasis is achieved. ACT should be less than 180 sec-
onds or in accordance with the local institutional guidelines. Not antico-
agulated patients should not ambulate for 1.5 (4 Fr.) to 2.5 (6 Fr.)
hours; anticoagulated patients should not ambulate for 2 to 4 hours.
D-Stat Dry is contraindicated in patients with known sensitivity to bovine-
derived materials.
SyvekPatch (Marine Polymer Technologies, Inc., Danvers, MA) is
made of poly-N-acetyl glucosamine (p-G1cNAc), which causes local
vasoconstriction and potentiates clot formation. This small patch should
be applied directly over the arterial puncture site and manually com-
pressed for 10 minutes following sheath extraction. ACT should be less
than 300 seconds. Patients are required to lie supine for 2 hours after
the patch has been held in place. An uncontrolled study of 200 patients
who underwent diagnostic coronary angiography with a 6-Fr. catheter
evaluated the use of the SyvekPatch as an adjunct to manual pressure
followed by 1 hour of bed rest reported no major and only 2% minor
adverse events, all of which were successfully managed with additional 1
to 2 hours of bed rest.
Mechanical Compression: Mechanical compression involves the use of

a C-arm clamp, sandbags, or a pneumatic compression device
(FemStop). The C-arm clamp is a device with a flat base and a horizon-
tal arm that extends over the base and angles down at a 90° angle to
apply pressure to the femoral artery. The tip of the device consists of a
metal or plastic disk, which is placed directly over the arterial puncture
site for approximately 20 to 30 minutes. The FemStop applies direct
78852_ch09 24/06/10 3:11 PM Page 154
Figure 9-1 Graphic depiction of the FemStop device for vascular hemostasis.
This type of mechanical compression device places a transparent plastic bubble
over the arterial puncture site and secures it with a plastic arch and belt wrapped
around the patient. (Courtesy of RADI Medical Systems, Inc., Reading, MA.)
pneumatic pressure over the femoral artery to tamponade bleeding.

A transparent plastic bubble is placed over the arterial puncture site and
secured with a plastic arch and belt wrapped around the patient
(Figure 9-1).
A recent study that compared manual to mechanical compression
demonstrated that time to hemostasis was approximately 33% shorter with
manual compression. Studies done in the 1970s and 1980s noted that
there were no significant differences in rates of vascular complications
between manual and mechanical compression techniques. Although
mechanical compression devices provide a hands-free approach, they
do not eliminate the need for staff supervision during the period of
compression.
Collagen-based Biosealant Devices: Collagen-based biosealant VCDs

utilize bovine collagen-based products to facilitate clot formation. These
VCDs augment hemostasis via two mechanisms: (1) the device deploys a
collagen mass that expands after deployment and mechanically seals the
arterial wall and sheath tract and (2) it provides additional collagen to
the arterial wall defect promoting platelet adherence, activation, and
aggregation.
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Figure 9-2 The Angio-Seal closure device. A) Carrier sheath inserted

over a guidewire into vascular lumen. Blood flow through vessel locator verifies
correct intravascular positioning. B) Device inserted into artery with anchor
exposed. Note arrow-to-arrow design of this device ensures correct insertion.
C) Collagen plug and anchor “sandwich” the arteriotomy site with the use of the
tamper tube.
Collagen-based VCDs are generally used in patients who are un-

likely to require immediate repeat arterial access. Due to the expansive
collagen product, it may be difficult to reaccess the artery close to the
previous puncture site and it is usually recommended to wait 90 days
until repeat puncture at the same site is attempted. Collagen-based devices
should only be used when arterial access was obtained with a single anterior
puncture of the common femoral artery. Several different models of colla-
gen-based VCDs are commercially available; the three most common are
Angio-Seal, DuettPro, and VasoSeal.
Angio-Seal (St. Jude Medical, St. Paul, Minn) is a popular collagen-
based VCD that involves placing a collagen plug directly over an
intravascular anchoring system. First, a carrier sheath is exchanged for the
femoral artery sheath (Figure 9-2). Once inserted, the intravascular an-
chor protrudes from the end of the carrier into the femoral artery. The
sheath and carrier are then removed, which pulls the intravascular anchor
against the inside of the arterial wall. Tension is applied to the connecting
suture, advancing the collagen plug down onto the outside of the arterial
wall defect. The patient is required to remain in the supine position
for 2 hours after the Angio-Seal has been deployed. Repeat arterial
puncture should not be performed for a period of 90 days. With re-
gards to safety and efficacy, a randomized trial comparing the Angio-Seal
to manual pressure showed that time to hemostasis following angiogra-
phy was significantly shorter in the Angio-Seal group (2.5 minutes) com-
pared with manual pressure (15.3 minutes). This study also demonstrated
78852_ch09 24/06/10 3:11 PM Page 156
Figure 9-3 The Duett closure device. Balloon-positioning catheter within the
femoral artery and attached syringe of procoagulant mixture. Balloon tamponade
of arteriotomy while procoagulant is injected into tissue surrounding puncture
site (inset).
significantly fewer complications, such as bleeding and/or hematoma

formation, for Angio-Seal patients receiving heparin. In general, the
Angio-Seal device affords rapid deployment, earlier hospital discharge, and
improved patient comfort following cardiac catheterization. It has also
been used successfully used in radial, carotid, and subclavian arterial punc-
ture sites, venous puncture sites, and even right ventricular perforation. It
has the lowest reported vascular complication rates of all closure devices.
The DuettPro sealing device (Vascular Solutions, Minneapolis, MN)
is a collagen-based VCD that utilizes a 7-mm balloon attached to a 3-Fr.
catheter to inject a procoagulant mixture of collagen and thrombin
(Figure 9-3). The device is advanced through the existing femoral sheath
78852_ch09 24/06/10 3:11 PM Page 157
into the arterial lumen, the mounted balloon is inflated in the artery,
and then the entire device is gently retracted until the balloon abuts the
arteriotomy puncture site. The mixture of collagen and thrombin is
injected to the tissue surrounding the arterial puncture site. Thrombin
in the presence of collagen converts fibrinogen to fibrin and accelerates
the coagulation cascade. The sheath is removed, the balloon is deflated,
and manual pressure is applied for 2 minutes. Patients are required to
remain in the supine position for approximately 2 hours to promote
adequate hemostasis and reduce the risk of complications. Unlike the
Angio-Seal device, there is no contraindication to immediate repunc-
ture with the Duett device. One serious potential complication of the
Duett device is the inadvertent injection of the procoagulant
collagen–thrombin mixture into the artery. A large study comparing the
Duett device to manual pressure showed that the times to hemostasis
and ambulation were significantly lower with the Duett device, but the
incidence of major vascular complications was higher.
The VasoSeal hemostatic devices (VasoSeal Elite and VasoSeal ES;
Datascope, Montvale, NJ) are collagen-based VCDs that utilize a puri-
fied collagen plug to accentuate hemostasis. To deploy these devices, a
dilator and a sheath are collectively advanced over a guidewire to the sur-
face of the femoral artery (Figure 9-4). The dilator is removed and the
collagen plug is advanced through the sheath into the vascular access
track. Following placement of the device, patients are kept supine
for 2 hours. This device is similar to the Angio-Seal device in that
it delivers a collagen plug into the skin tract; however, there is no
intraluminal component remaining after the device is deployed. In pa-
tients undergoing coronary angiography, the Vasoseal device had mean
times to hemostasis and ambulation of 18 minutes and 110 minutes,
Figure 9-4 The VasoSeal closure device. A) Dilator advanced over

guidewire to previously demarcated depth at surface of femoral artery. B) Collagen
injected over arteriotomy site while simultaneously withdrawing delivery appa-
ratus resulting in vascular hemostasis.
78852_ch09 24/06/10 3:11 PM Page 158
respectively; however, an increase in vascular complications following

PCI has been noted.
A prospective randomized controlled trial directly compared the
safety and efficacy of Angio-Seal, Duett, and VasoSeal ES and found the
devices to have similar rates of successful deployment and complication.
Of note, in the diagnostic arm of this study, the Angio-Seal device did re-
quire a longer time to achieve hemostasis; however, it also resulted in
earlier ambulation (p ⫽ 0.0001). A second randomized trial published in
the same year directly compared Angio-Seal and VasoSeal in patients un-
dergoing diagnostic coronary angiography and angioplasty. No statisti-
cally significant difference was found in time to hemostasis, time to am-
bulation, device failure, or postprocedural complications. It is important
to realize that all of these models of VCDs have been modified by the
manufacturer since these studies were published and no randomized
controlled trials directly comparing the currently marketed devices exist.
Percutaneous Suture Devices: Percutaneous suture VCDs deploy a

pair of needles at the arteriotomy site and enable a knot to be thrown
and tied at the level of the artery wall. Arterial closure is usually instant
and immediate repuncture is possible. These devices are advantageous
for patients with large arterial punctures, procedures needing unin-
terrupted anticoagulation, or whenever repeat arterial access is an-
ticipated. A common limitation of percutaneous suture VCDs is that
most are complex and require significant operator training before
he/she is competent in its use. Common commercially available percu-
taneous suture VCDs include the Perclose devices (Proglide and Prostar
XL), SuperStitch, and X-Press.
Perclose Proglide (Abbott Vascular, Abbott Labs, IL) is a popular
and well-established single suture VCD that is indicated to close arteri-
otomy sites following percutaneous diagnostic and interventional pro-
cedures using a 5-Fr. to 8-Fr. system. Perclose also makes a Prostar XL
device designed for larger sheath sizes (6.5 to 10 Fr.) that utilizes a four-
needle, bisuture system that ties and secures two sutures at the arteri-
otomy site. However, for larger catheter–based procedures (⬎8 Fr.),
many practitioners simply place two Proglide devices at a perpendicular
angle to each other prior to dilating the arteriotomy to a sheath size
greater than that indicated for the single suture device (“preclose” tech-
nique). Using this technique, the sutures are in place prior to removal of
the larger catheter and the arteriotomy can be closed with two sutures
following completion of the procedure.
To deploy, the Perclose devices are inserted over a 0.038-in. wire
(or smaller) after sheath removal and advanced until blood returns from
78852_ch09 24/06/10 3:11 PM Page 159
Figure 9-5 The Perclose closure device. A) Perclose system within

femoral artery. B) Deployment of suture. C) Hemostasis achieved with tamping
of knot down to arteriotomy.
a marker lumen (Figure 9-5). The lever on the device handle is raised
thereby deploying the footplate in the vessel lumen. The device is with-
drawn until the footplate is against the intraluminal wall, and then the
plunger is depressed, delivering two needles through the artery wall to
the footplate. The needles attach to the suture and the plunger is with-
drawn, thereby pulling the suture out through the center of the device.
The footplate is retracted and the device is partially pulled out allowing
a knot pusher to be inserted onto the exposed suture and advance the
pre-tied knot to the level of the arteriotomy. The device is removed and
the suture/knot are tightened; hemostatis is usually instant. Following
the placement of the percutaneous suture, patients are required to
remain in the supine position for 1 to 2 hours.
SuperStitch (Sutura, Inc., Fountain Valley, CA) is a relatively new
percutaneous suture device that utilizes a nonabsorbable monofilament
polypropylene suture to close the arteriotomy site (Figure 9-6). The device
has a specially designed tip that allows it to be used in antegrade proce-
dures and to be advanced into the lumen without wire guidance. It is
indicated for use after percutaneous endovascular procedures using a 6- to
8-Fr. catheter system. Unlike the other percutaneous suture–mediated
devices, SuperStitch has a three-button handle specially designed for ease-
Figure 9-6 A) SuperStitch device. B) Tip of device. C) Kwiknot. (Images pro-

vided courtesy of Sutura Inc.)
78852_ch09 24/06/10 3:11 PM Page 160
Figure 9-7 Deployment of SuperStitch Device. A) The device is advanced

through an existing sheath. The first button is depressed. B) This opens out the
"arms". C) The device is retracted against the vessel wall. D) Button number 2 is
depressed, which deploys the needles. E) Button number 3 closes the "arms". The
needles retract and draw the sutures out of the vessel. F) The knot can be tied
manually or by using the Kwiknot device. The Kwiknot ties and cuts the suture
close to the vessel wall. (Images provided courtesy of Sutura Inc.)
of-use; the manufacturer states that deploying the device is “as simple as
1-2-3.” Device deployment is described in Figure 9-7. In an uncon-
trolled, prospective study of 150 patients who underwent femoral artery
closure with the SuperStitch device immediately following diagnostic or
interventional cardiac catheterization, successful deployment (hemostasis
achieved within 2 minutes) was achieved in 92% of patients; 4% of pa-
tients developed a hematoma ⬎10 cm and only 0.7% had a major compli-
cation. One case report describes the successful percutaneous closure of a
patent foramen ovale using this device. No randomized controlled trials
have yet been reported on this device.
X-Press (Datascope Corporation, Fairfield, NJ) is another percuta-
neous suture device that is fully nonmechanical consisting of a 6-Fr.
over-the-wire catheter, a guidewire, a suture pack with a single strand of
suture, two needles, and a knot pusher. Unlike Perclose or SuperStitch,
the X-press device has no intraluminal moving parts, thereby limiting the
risk of vessel dissection, ruptured plaque, or vessel occlusion. The RACE
randomized controlled trial compared femoral artery closure with the
X-Press device versus manual compression in patients who underwent
diagnostic catheterization or PCI and demonstrated a significant reduc-
tion in time to ambulation in the X-Press arm. In the whole cohort of
78852_ch09 24/06/10 3:11 PM Page 161
patients, rates of major complications were no different between the two

treatment groups; however, in the PCI patients, the rate of major
complications was lower in the X-Press group (0% in the X-press arm,
3.4% with manual compression, p ⫽ 0.037). Currently, this device can
only be used for vascular sheaths up to 6 Fr. in size.
A trial comparing four different methods of arterial closure showed
that the Perclose had a 2.3% incidence of major complications, inferior
only to the Angio-Seal. Another large randomized trial found that the
times to hemostasis, ambulation, and discharge were significantly lower
in patients who received suture-mediated closure compared to manual
pressure. The mean time to ambulation was 2 hours with suture-
mediated closure and 6.5 hours with manual compression. However, a
significantly higher incidence of vascular complications was noted in the
suture-mediated closure group. Anticoagulated patients derived particular
benefit from suture-mediated closure in regards to hemostasis, time to
ambulation, and discharge.
Staple and Clip Devices: Staple and clip VCDs deliver a metallic
extraluminal component that “cinches” the edges of the arteriotomy.
The staples and clips are made of biologically inert metals (nitinol, tita-
nium) thereby causing less of an inflammatory response than is often
caused by the collagen-based biosealant devices.
The StarClose (Abbott Vascular, Abbott Labs, IL) VCD deploys a
nitinol clip to the extraluminal side of the arterial wall that provides cir-
cumferential traction toward the arterial wall defect thereby closing the
arteriotomy. A study comparing StarClose to Angio-Seal and manual
compression found no significant difference in complication rate; however,
patients in the StarClose arm were more likely to require additional com-
pression after successful device deployment.
The EVS Vascular Closure System (angioLink Corporation, Taunton,
MA) is a VCD that augments hemostasis by deploying an extraluminal
titanium staple at the arteriotomy. It is composed of an introducer assem-
bly with vessel dilator, a titanium staple, and a trigger-activated trigger
deployment system (Figure 9-8). Advantages of this device include: (1) it
can be used in large arteriotomies (⬎10 Fr.) and (2) it can safely be used
to close noncommon femoral arteriotomies (superficial and deep
femoral arteries). The device is utilized by removing the arterial sheath
and advancing the dilator and introducer assembly into the lumen until
there is blood return through a central lumen. The stabilization feet tem-
porarily deployed in the lumen and retracted until gentle resistance is felt
(the “feet” are against the vessel wall). The dilator is removed and the sta-
ple device is advanced through the introducer until gentle resistance is met
78852_ch09 24/06/10 3:11 PM Page 162
Figure 9-8 EVS Vascular Closure System. (From Caputo RP, Ebner A,
Grant W, et al. Percutaneous femoral arteriotomy repair—initial experience with
a novel staple closure device. J Invasive Cardiol. 2002;14:652–656.)
and then the staple is deployed. The stabilization feet are retracted and the
introducer is removed. An uncontrolled prospective study of 89 consecu-
tive arteriotomies closed by the EVS VCD reported 92% successful arterial
closure and no complications.
Novel Devices: The Catalyst Closure Device System (Cardiva Medical

Corporation, Sunnyvale, CA) is a new VCD that consists of an expand-
able nitinol mesh disk mounted on the end of an 18-gauge wire. The
Catalyst II wire is inserted into the artery through the existing catheter-
ization sheath (5 to 7 Fr.) and the nitinol disk is expanded in the vessel
lumen. The nitinol disk is gently pulled against the artery wall as the
sheath is removed and an external clip is applied to the wire, thereby
maintaining site-specific hands-free compression of the arteriotomy and
achieving hemostasis. The device is left in this position for an appropriate
“dwell time” (15 minutes for a diagnostic case, 120 minutes after PCI)
during which time the natural recoil of the vascular wall smooth muscle
occurs, causing the arteriotomy size to decrease significantly. After the
dwell time, the intraluminal disk is retracted, the wire is removed from
the groin, and “fingertip” manual pressure is applied to the puncture site
for 5 to 7 minutes. While no studies are yet available for the Catalyst II
78852_ch09 24/06/10 3:11 PM Page 163
device, a prospective study of its precursor (the Boomerang Catalyst

Device) reported a 99% rate of successful hemostasis with no major
complications. Benefits of this device include no residual indwelling
material and potentially minimal arterial wall and soft tissue scarring; a
limitation is the need for some manual pressure.
The Femoral Introducer Sheath and Hemostasis (FISH) device
(MIR Corporation, Bloomington, IN) is a novel product that combines
access and closure on the same device. This unique device incorporates
an extracellular matrix closure patch that is premounted onto a 5, 6, or
8 Fr. access sheath. A recent prospective randomized controlled trial of
297 patients demonstrated a significant reduction in time to hemostasis,
time to ambulation, and time to discharge with the FISH device when
compared to manual compression. There were higher rates of major or
minor complications associated with use of the FISH device; however,
these were not statistically significant. Ongoing research is needed to de-
termine the safety and efficacy of this device compared with other meth-
ods of vascular closure.
Complications
Arterial puncture and cannulation is associated with significant vascular
complications including hemorrhage, pseudoaneurysm, arteriovenous
fistula, thrombosis, embolism, and infection; the occurrence of these is
associated with increased morbidity and mortality (Table 9-1). The risk of
vascular complications requiring surgery ranges from 0.5% to 1% following
diagnostic catheterization, from 0.5% to 3% following balloon angio-
plasty, and up to 14% following coronary stenting. The clinical and
procedure-related risk factors associated with vascular complications are
listed in Table 9-2. In general, a higher rate of vascular occlusion (local
thrombosis or distal embolization) occurs with the collagen-based
Table 9-1 Vascular Complications

Potential Complications
Pseudoaneurysm
Arteriovenous fistula
Hemorrhage
Thrombosis
Embolism
Infection
78852_ch09 24/06/10 3:11 PM Page 164
Table 9-2 Risk Factors Associated with Increased Incidence

of Vascular Complications
Risk Factors
Clinical Factors
Advanced age
Female gender
Smaller body surface area
Congestive heart failure
Peripheral vascular disease
Procedural Factors
Anticoagulation
Cardiac intervention (PTCA, atherectomy, valvuloplasty)
Use of larger sized sheaths
biosealant devices than with the percutaneous suture devices. Infection

occurs more often with VCDs that deploy foreign material that is left at
the arteriotomy site and severe perivascular infection and endarteritis have
been described following the deployment of VCDs. As a result, many op-
erators will resterilize the puncture site prior to utilization of a VCD.
Arterial Access Site and Sheath Size

6-Fr. catheter systems via the femoral artery remain the most widely used
system for coronary angiography. However, smaller sheath size and
radial artery access are increasingly being employed in an effort to reduce
hospitalization time and complication rate. A substudy of the SYNERGY
trial found a lower rate of hemorrhagic complications associated with
radial artery access when compared to femoral artery access.
Additionally, in the femoral artery arm, sheath size was directly propor-
tional to rate of non-CABG TIMI-major bleeding (1.5% for 4 or 5 Fr.,
1.6% for 6 Fr., 3.3% for 7 Fr., and 3.8% of 8 Fr., p ⬍0.0001). Another
trial comparing femoral artery access and closure with Angio-Seal or
Starclose versus radial artery access found that radial artery access is associ-
ated with a lower rate of major complications and improved patient
comfort; however, transradial access was also associated with longer proce-
dural times and increased radiation exposure. Other studies report that
the difference in procedural time and radiation exposure is overcome as
operator experience with the transradial approach increases. A study
comparing coronary angiography with 4-Fr. femoral artery access, 6-Fr.
78852_ch09 24/06/10 3:11 PM Page 165
femoral artery access with Angio-Seal closure, and radial artery access
found similar times to ambulation and hospital discharge between the
groups; however, use of a 4-Fr. system came at the cost of inferior angio-
graphic image quality. Angiographic quality with a 4-Fr. system can be
significantly improved when a contrast power injector is used.
Cost
Hospital length of stay and the need for trained personnel are major fac-
tors that contribute to the total cost of percutaneous cardiac procedures.
One goal for VCDs is that their use will result in a shorter time to patient
discharge and a decreased need for trained personnel and that these will
directly translate into lower hospital costs. One study looking at the
safety and cost associated with the use of Perclose versus manual com-
pression in patients post PCI found no difference in complication rate,
but did note a significant reduction in time to discharge and cost for
patients in the Perclose arm. A similar study with the Duett device found
a nonstatistically significant trend toward lower cost with the device ver-
sus manual compression. A cost-minimization analysis of use of the
Angio-Seal device in patients post PCI predicted the use of Angio-Seal
to be more cost-effective than manual pressure; however, a prospective
study comparing the actual cost of Angio-Seal versus mechanical com-
pression with the FemStop device found arterial closure with Angio-Seal
to be more expensive. This was largely due to the difference in cost of
the devices. A pilot study looking at the use of the Angio-Seal in patients
who had undergone PCI found that same-day discharge was feasible and
safe in select patients treated for stable angina. While this trial did not
directly look at hospital cost, the authors noted that the dramatic reduc-
tion in time to hospital discharge would significantly reduce the cost of
the procedure. Another study of patients undergoing diagnostic
catheterization reported that use of a 6-Fr. system and Angio-Seal device
closure was more costly than using a 4-Fr. system and manual pressure.
Overall, these studies indicate that use of smaller catheters is likely
more cost-effective and safe for diagnostic procedures. However, for
patients undergoing PCI, the significant reduction in time to hospital
discharge increasingly made possible by the use of VCDs will probably
result in an ultimate reduction in cost as well.
Conclusions
Manual pressure has long been the gold standard for achieving hemosta-
sis in patients after percutaneous cardiovascular procedures. However,
many VCDs are now commercially available and they offer the advantages
78852_ch09 24/06/10 3:11 PM Page 166
of early sheath removal, early ambulation, and early hospital discharge, as

well as allow for uninterrupted anticoagulation when needed. As physi-
cians have become more experienced with the newer generations of
VCDs, the associated procedural complication rates associated with their
use have been shown to be comparable or even lower than those associ-
ated with manual pressure. Smaller catheter sizes and radial artery access
are being increasingly used for diagnostic coronary procedures and their
use is associated with lower rates of complication and decreased costs
when compared to VCDs. However, in interventional procedures, the
significant reduction in time to hospital discharge and ability to not in-
terrupt anticoagulation associated with VCDs make their use safe and
likely more cost-effective.
Suggested Reading
Seldinger SI. Catheter replacement of the needle in percutaneous arteriography:
a new technique. Acta Radiol. 1953;39:368–376.
Doyle BJ, Konz BA, Lennon RJ, et al. Ambulation 1 hour after diagnostic cardiac
catheterization: a prospective study of 1009 procedures. Mayo Clin Proc.
2006;81:1537–1540.
Hallak OK, Cubeddu RJ, Griffith RA, et al. The use of the D-STAT dry bandage
for the control of vascular access site bleeding: a multicenter experience in
376 patients. Cardiovasc Intervent Radiol. 2007;30:593–600.
D-Stat Dry Hemostatic Bandage Topical Hemostat. Minneapolis, MN: Vascular
Solutions, Inc.; 2009.
Palmer BL, Gantt DS, Lawrence ME, et al. Effectiveness and safety of manual
hemostasis facilitated by the SyvekPatch with one hour of bedrest after
coronary angiography using six-French catheters. Am J Cardiol. 2004;93:
96–97.
Abbott WM, Austen WG. The effectiveness and mechanism of collagen-induced
topical hemostasis. Surgery. 1975;78:723–729.
Blanc R, Mounayer C, Piotin M, et al. Hemostatic closure device after carotid
puncture for stent and coil placement in an intracranial aneurysm: technical
note. AJNR Am J Neuroradiol. 2002;23:978–981.
Massiere B, von Ristow A, Cury JM, et al. Closure of carotid artery puncture site
with a percutaneous device. Ann Vasc Surg. 2009;23:256 e5–e7.
Micha JP, Goldstein BH, Lindsay SF, et al. Subclavian artery puncture repair with
Angio-Seal deployment. Gynecol Oncol. 2007;104:761–763.
Petrov I, Dimitrov C. Closing of a right ventricle perforation with a vascular closure
device. Catheter Cardiovasc Interv. 2009;74:247–250.
Mooney MR, Ellis SG, Gershony G, et al. Immediate sealing of arterial puncture
sites after cardiac catheterization and coronary interventions: initial U.S. feasi-
bility trial using the Duett vascular closure device. Catheter Cardiovasc Interv.
2000;50:96–102.
Michalis LK, Rees MR, Patsouras D, et al. A prospective randomized trial comparing
the safety and efficacy of three commercially available closure devices (Angioseal,
Vasoseal and Duett). Cardiovasc Intervent Radiol. 2002;25:423–429.
78852_ch09 24/06/10 3:11 PM Page 167
Shammas NW, Rajendran VR, Alldredge SG, et al. Randomized comparison of

Vasoseal and Angioseal closure devices in patients undergoing coronary angiog-
raphy and angioplasty. Catheter Cardiovasc Interv. 2002;55:421–425.
Bhatt DL, Raymond RE, Feldman T, et al. Successful “pre-closure” of 7 Fr and
8 Fr femoral arteriotomies with a 6 Fr suture-based device (the Multicenter
Interventional Closer Registry). Am J Cardiol. 2002;89:777–779.
Hon LQ, Ganeshan A, Thomas SM, et al. Vascular closure devices: a comparative
overview. Curr Probl Diagn Radiol. 2009;38:33–43.
Clinical Investigators Review Sutura Next Generation SuperStitch Vessel Closure
Device. Business Wire.
Eggebrecht H, Naber C, Woertgen U, et al. Percutaneous suture-mediated clo-
sure of femoral access sites deployed through the procedure sheath: initial
clinical experience with a novel vascular closure device. Catheter Cardiovasc
Interv. 2003;58:313–321.
Ruiz CE, Kipshidze N, Chiam PT, et al. Feasibility of patent foramen ovale closure
with no-device left behind: first-in-man percutaneous suture closure. Catheter
Cardiovasc Interv. 2008;71:921–926.
Sanborn TA, Ogilby JD, Ritter JM, et al. Reduced vascular complications after
percutaneous coronary interventions with a nonmechanical suture device:
results from the randomized RACE study. Catheter Cardiovasc Interv. 2004;
61:327–332.
Ratnam LA, Raja J, Munneke GJ, et al. Prospective nonrandomized trial of
manual compression and Angio-Seal and Starclose arterial closure devices in
common femoral punctures. Cardiovasc Intervent Radiol. 2007;30:182–188.
Caputo RP, Ebner A, Grant W, et al. Percutaneous femoral arteriotomy repair—
initial experience with a novel staple closure device. J Invasive Cardiol.
2002;14:652–656.
Cardiva Catalyst II Instructions for Use. Sunnyvale, CA: Cardiva Medical, Inc.;
2010.
Doyle BJ, Godfrey MJ, Lennon RJ, et al. Initial experience with the Cardiva
Boomerang vascular closure device in diagnostic catheterization. Catheter
Cardiovasc Interv. 2007;69:203–208.
Bavry AA, Raymond RE, Bhatt DL, et al. Efficacy of a novel procedure sheath
and closure device during diagnostic catheterization: the multicenter random-
ized clinical trial of the FISH device. J Invasive Cardiol. 2008;20:152–156.
Bashore TM, Bates ER, Berger PB, et al. American College of Cardiology/
Society for Cardiac Angiography and Interventions Clinical Expert Consensus
Document on Cardiac Catheterization Laboratory Standards. A report of the
American College of Cardiology Task Force on Clinical Expert Consensus
Documents. J Am Coll Cardiol. 2001;37:2170–214.
Hoffer EK, Bloch RD. Percutaneous arterial closure devices. J Vasc Interv Radiol.
2003;14:865–885.
Lasic Z, Nikolsky E, Kesanakurthy S, et al. Vascular closure devices: a review of
their use after invasive procedures. Am J Cardiovasc Drugs. 2005;5:185–200.
Cantor WJ, Mahaffey KW, Huang Z, et al. Bleeding complications in patients
with acute coronary syndrome undergoing early invasive management can be
reduced with radial access, smaller sheath sizes, and timely sheath removal.
Catheter Cardiovasc Interv. 2007;69:73–83.
78852_ch09 24/06/10 3:11 PM Page 168
Sciahbasi A, Fischetti D, Picciolo A, et al. Transradial access compared with femoral

puncture closure devices in percutaneous coronary procedures. Int J Cardiol.
2009;137:199–205.
Elgharib NZ, Shah UH, Coppola JT. Transradial cardiac catheterization and percu-
taneous coronary intervention: a review. Coron Artery Dis. 2009;20:487–493.
Reddy BK, Brewster PS, Walsh T, et al. Randomized comparison of rapid ambu-
lation using radial, 4 French femoral access, or femoral access with AngioSeal
closure. Catheter Cardiovasc Interv. 2004;62:143–149.
Rickli H, Unterweger M, Sutsch G, et al. Comparison of costs and safety of a
suture-mediated closure device with conventional manual compression after
coronary artery interventions. Catheter Cardiovasc Interv. 2002;57:297–302.
Zhang Z, Mahoney EM, Gershony G, et al. Impact of the Duett sealing device on
quality of life and hospitalization costs for coronary diagnostic and interven-
tional procedures: results from the Study of Economic and Quality of Life
substudy of the SEAL trial. Am Heart J. 2001;142:982–988.
Resnic FS, Arora N, Matheny M, et al. A cost-minimization analysis of the angio-
seal vascular closure device following percutaneous coronary intervention.
Am J Cardiol. 2007;99:766–770.
Juergens CP, Leung DY, Crozier JA, et al. Patient tolerance and resource uti-
lization associated with an arterial closure versus an external compression
device after percutaneous coronary intervention. Catheter Cardiovasc Interv.
2004;63:166–170.
Yee KM, Lazzam C, Richards J, et al. Same-day discharge after coronary stenting:
a feasibility study using a hemostatic femoral puncture closure device. J Interv
Cardiol. 2004;17:315–320.
78852_ch10 18/06/10 12:23 PM Page 169
CHAPTER 10
Post-Cath Complications
Arun Kalyanasundaram
and Mehdi H. Shishehbor
Although a relatively safe procedure, cardiac catheterization carries a low

but significant risk of both major and minor complications. The com-
bined complication of contrast media reaction, cardiogenic shock, cere-
brovascular accident, congestive heart failure, cardiac tamponade, and
renal failure following a diagnostic catheterization is ⬍2%, and the risk of
mortality is 0.1% (0.6 in a 1,000).
A brief history should be elicited to detect any symptoms suggestive
of potential complications (Table 10-1).
The post-catheterization examination accordingly needs to focus
on likely complications and should be directed by the history. The vital
signs should be reviewed and blood pressure and pulse checked in
supine and erect position if possible. The presence of tachycardia after
cardiac catheterization should always prompt a search for the underly-
ing cause. It may be a manifestation of intravascular depletion second-
ary to diuresis or bleeding or a sign of decompensated heart failure. It
may also be a marker of pericardial irritation. Fever immediately after
catheterization is not normal and may be a pyrogen reaction to fluids
or medications. Any fever should prompt a search for an infective
focus.
A brief neurologic examination should routinely be performed, and
special attention should be paid to the patient’s speech and gait.
Importantly, patients may not note neurologic deficits until they ambu-
late; these may include focal paresis or paralysis, visual symptoms, sensory
deficits, and ataxia.
The jugular venous pressure should be assessed as an index of intravas-
cular status, while cardiac auscultation should focus on the presence of any
pericardial rub. All patients who have had subclavian or jugular cannulation
need to be examined for signs of pneumothorax, as it may not manifest
during the procedure.
169
78852_ch10 18/06/10 12:23 PM Page 170
Table 10-1 Symptoms Suggestive of Cardiac Catheterization

Complications
Symptom Differential Diagnoses
Chest pain Coronary ischemia

Aortic dissection
Coronary perforation
Cardiac perforation
Dyspnea Coronary ischemia
Congestive heart failure
Pneumothorax
Groin pain Localized bleeding
Leg pain/numbness Femoral nerve compression
Femoral artery dissection
Femoral artery thrombosis
Local nerve block from anesthetic
Flank pain Retroperitoneal bleed
Nausea/hiccups Hemopericardium
Local Complications
The most important part of the examination that is unique to the post-
cath check is the assessment of the catheterization site. The site of catheter-
ization should be checked for evidence of bleeding, pseudoaneurysm,
arteriovenous fistula (a new onset bruit), or vascular compromise (absent
distal pulses). Factors associated with high risk of local bleeding include
advanced age, female gender, low body mass index (BMI), and use of an-
ticoagulants or platelet glycoprotein IIb/IIIa inhibitors. Fluoroscopy
prior to obtaining access routinely has been shown to reduce the com-
plication rate significantly. Bleeding has been recognized increasingly as
an important predictor of increased mortality. Due to their associated
morbidity and mortality, we will discuss post-catheterization bleeding,
pseudoaneurysm, and infection in greater detail.
Hematoma: Bleeding after cardiac catheterization may be external or

may manifest as a hematoma. Clinically, hematomas present as pain or
local discomfort, focal discoloration or bruising, hemodynamic compro-
mise, and rarely as femoral nerve compression and quadriceps weakness.
Meticulous detail to puncture technique by using external and inter-
nal landmarks and avoidance of multiple or posterior wall puncture will
reduce the incidence of local bleeding. When using fluoroscopy, attention
78852_ch10 18/06/10 12:23 PM Page 171
Chapter 10 • Post-Cath Complications 171
should be given to the presence of calcium. In general, the femoral punc-

ture should be above or below any calcification if possible. Other measures
to reduce the frequency and severity of groin bleeding include careful
monitoring of anticoagulation and careful attention to hemostasis during
sheath removal. Adequate hemostasis must be achieved with manual pres-
sure or a closure device before leaving the patient’s bedside (Figure 10-1).
Retroperitoneal Hematoma: Retroperitoneal hematoma is usually asso-

ciated with arterial puncture above the inguinal ligament. Hence, rou-
tine angiography of the common femoral artery might be reasonable
even in diagnostic procedures to determine the risk of this complication.
Since all the bleeding may be internal, the patient often presents with
unexplained hypotension and tachycardia (occasionally bradycardia)
without any external signs. Flank pain and bruising may be seen in some
patients. An unexplained falling hematocrit may be the only finding in
others. Dysuria might also be a presenting symptom as the hematoma
presses on the bladder.
The best modality for detection of a retroperitoneal hematoma is
a computed tomography (CT) scan. Ultrasound may be used if CT is not
available. Since the therapy of retroperitoneal hematoma is based on its
clinical implications, and directed toward correcting those, some physi-
cians do not routinely obtain radiologic imaging studies. Unstable pa-
tients should not be sent for a CT scan. A conservative strategy of reserv-
ing these tests for patients where a definitive diagnosis is required to guide
therapy, such as determining the need for withholding anticoagulant or an-
tiplatelet therapy in stable patients might be reasonable.
Pseudoaneurysm: Pseudoaneurysm is defined as arterial wall disrup-

tion with resultant extraluminal flow into a chamber contained by adja-
cent tissue. Arterial tissue does not contribute to the wall of the
pseudoaneurysm. The incidence of pseudoaneurysm has varied between
Troubleshooting
Management of retroperitoneal hematoma: The mainstay of therapy for
a hematoma or retroperitoneal hematoma consists of volume resuscitation and blood
transfusion if appropriate. Further anticoagulants and platelet antagonists should be
withheld. The decision to reverse anticoagulation and transfuse platelets in patients
receiving platelet glycoprotein IIb/IIIa inhibitors or platelet adenosine diphosphate
(ADP) antagonists (ticlopidine or clopidogrel) should be individualized for each patient.
Patients could be taken back to the cardiac catheterization suite, and the vascular sys-
tem imaged via contralateral access. Endovascular intervention is a definite option,
especially if identified early in the course of the development of the hematoma.
78852_ch10 18/06/10 12:23 PM Page 172
Figure 10-1 A) Dissection of the common femoral artery extending from the dis-
tal external iliac into and involving the entire common femoral artery with extensive
compromise of the true lumen with an 80% stenosis from compression by the false
lumen, which is full of thrombus. B) On the right anterior oblique angiogram, the foot-
plate and collagen plug from the Angio-Seal device are visualized.
172
78852_ch10 18/06/10 12:23 PM Page 173
0.3% and 0.5% of cardiac catheterizations in large series. In a recent

study of patients treated with platelet glycoprotein IIb/IIIa inhibitors,
pseudoaneurysms were noted in 0.5% of patients treated with manual
pressure, 0.8% of patients treated with Angio-Seal, and 0.4% of patients
treated with Perclose.
A pseudoaneurysm may present with pain, new bruit, and pulsatile
mass, expanding hematoma, or leg weakness. The best diagnostic im-
aging modality for a pseudoaneurysm is a color flow duplex ultra-
sonography. The pseudoaneurysm is occasionally multichambered.
The mean transverse diameter of pseudoaneurysms in a recently pub-
lished series was 2.46 cm by 2.14 cm. The majority of the pseudoa-
neurysms in this study arose from the common femoral artery with the
average pseudoaneurysm tract length of 1.4 cm, and the average depth
of the pseudoaneurysm neck arising from the native artery of 30.2 mm
(Figure 10-2).
A pseudoaneurysm may rupture or lead to thromboembolism, neu-
rovascular compression, or pressure necrosis. The risk factors for
pseudoaneurysm have included multiple arterial punctures, superficial
femoral artery puncture, large sheath size, arterial hypertension, and
antiplatelet or antithrombotic therapy. Of note, pseudoaneurysms that
Figure 10-2 Femoral artery pseudoaneurysm.

78852_ch10 18/06/10 12:23 PM Page 174
Troubleshooting
Management of femoral artery pseudoaneurysm: Ultrasound-guided
thrombin injection (UGTI) is the preferred method of treatment in most cases with a
success rate ⬎90%. Ultrasound-guided compression was the most commonly used
therapy prior to the advent of UGTI, but it was associated with a failure rate 5% to
15%. Surgical repair has been associated with a high risk of complications predom-
inantly due to the associated comorbidities in this group of patients. There have
been small case series of successful use of endovascular-covered stents to treat
pseudoaneurysms.
are less than 2 cm are of no major consequence and should only be

monitored.
Infections: Groin infection is a rare complication of cardiac catheteriza-

tion. This is rarely seen with manual compression (reported incidence,
0–0.05%), but its incidence is higher in patients receiving closure devices
(0–0.3%). The most commonly implicated organism is Staphylococcus aureus.
Patients often present with groin pain, groin erythema, purulent discharge,
fever, and leucocytosis. Since cardiac catheterization is inherently a sterile
procedure, infection is usually secondary to breakdown in sterile tech-
nique. Careful attention must be paid to the condition of skin at the access
site prior to insertion of the sheath, and an alternate site should be selected
if there are concerns about dermal integrity. While some physicians admin-
ister periprocedural antibiotics to patients receiving closure devices, there is
no randomized controlled data to support such a practice. The lack of
proven benefit must be weighed against the risk of drug allergy, superin-
fection, drug resistance, and cost.
The therapy for groin infection includes appropriate antibiotics and
surgical debridement if indicated. Early consultation with a vascular
surgeon is advisable.
Contrast-induced Nephropathy (CIN): CIN is a complication defined

as new onset or exacerbation of renal dysfunction after contrast admin-
istration. The risk is directly related to baseline renal function. CIN is
defined as either a relative increase in serum creatinine of ⱖ25% above
the baseline value, or an absolute increase ⬎0.5 mg/dL of creatinine,
and it typically develops about 24 to 48 hours post contrast exposure.
Risk factors for development of CIN include baseline renal insuffi-
ciency, diabetes mellitus, left ventricular ejection fraction (LVEF) ⬍40%,
uncontrolled hypertension, anemia, dehydration, advanced age (⬎75
years), use of diuretics, other nephrotoxic medications, and volume of
78852_ch10 18/06/10 12:23 PM Page 175
contrast used. Adequate hydration pre- and post-catheterization is

the best strategy to reduce the incidence of CIN. Initial studies
suggested that hydration with sodium bicarbonate before contrast ex-
posure was more effective than hydration with sodium chloride for
prophylaxis of contrast-induced renal failure, although a systematic re-
view concluded that the effectiveness remains uncertain. N-acetylcysteine
likely reduces the incidence of contrast nephropathy, although this has
not been consistently demonstrated. Given the virtual lack of side ef-
fects and possible benefit, utilization is recommended in patients with
impaired glomerular filtration rate (GFR). Most episodes of CIN
resolve over time with careful hydration and monitoring. In addition
to CIN, atheroembolic-associated renal insufficiency should also be
considered. In general, urine eosinophils are checked. However, the
management of this condition is similar to CIN and requires hydration
and time.
Physical Limitations Post-Catheterization

All patients are advised to restrict activities for a short duration of time
to permit adequate healing of the access site. Table 10-2 outlines com-
monly prescribed minimum restrictions for patients after cardiac
catheterization at a major medical center. Some patients may be advised
Table 10-2 Activity Restriction Following Cardiac Catheterization

Approach Activity Restriction
Brachial Dressing to be removed after 1 day

Keep site clean and dry
No strenuous activity until sutures removed (cutdown)
or 48 hours (Seldinger technique)
Not to lift >10 lb
No bowling or tennis
No activity that involves excessive pushing or pulling with
involved arm
Femoral Can resume normal activity after 24 hours
No swimming or bath (can shower) for a week if closure device used
For the first 24 hours
No driving
No lifting of objects >10 lb
No climbing, cycling, or any other strenuous activity
78852_ch10 18/06/10 12:23 PM Page 176
to restrict their activities further on the basis of the findings of their car-
diac catheterization.
Indications for Routine Labs

No labs need to be checked routinely after diagnostic cardiac catheter-
ization. In patients suspected of bleeding, the hematocrit should be
checked as necessary. Renal function is checked after 48 hours in
patients with known renal insufficiency who are suspected to be at risk
for CIN. In our program we routinely assess cardiac enzymes post
procedure, however, this is not mandatory unless indicated clinically.
Suggested Reading
Aguirre FV, Topol EJ, Ferguson JJ, et al. Bleeding complications with the
chimeric antibody to platelet glycoprotein IIb/IIIa integrin in patients under-
going percutaneous coronary intervention. EPIC Investigators. Circulation.
1995;91:2882–2890.
Amini M, Salarifar M, Amirbaigloo A, et al. N-acetylcysteine does not prevent
contrast-induced nephropathy after cardiac catheterization in patients with
diabetes mellitus and chronic kidney disease: a randomized clinical trial. Trials.
2009;10:45.
Applegate RJ, Little WC, Craven T, et al. Vascular closure devices in patients
treated with anticoagulation and IIb/IIIa receptor inhibitors during percuta-
neous revascularization. J Am Coll Cardiol. 2002;40:78–83.
Cherr GS, Travis JA, Ligush J Jr, et al. Infection is an unusual but serious compli-
cation of a femoral artery catheterization site closure device. Ann Vasc Surg.
2001;15:567–570.
Cooper CL, Miller A. Infectious complications related to the use of the
Angio-seal hemostatic puncture closure device. Catheter Cardiovasc Interv.
1999;48:301–303.
Davidson CJ, Hlatky M, Morris KG, et al. Cardiovascular and renal toxicity of a
nonionic radiographic contrast agent after cardiac catheterization. A prospec-
tive trial. Ann Intern Med. 1989;110(2):119–124.
Doyle BJ, Rihal CS, Gastineau DA, et al. Bleeding, blood transfusion, and in-
creased mortality after percutaneous coronary intervention: implications for
contemporary practice. J Am Coll Cardiol. 2009;53(22):2019–2127.
Fitts J, Ver Lee P, Hofmaster P, et al. Fluoroscopy-guided femoral artery puncture
reduces the risk of PCI-related vascular complications. J Interv Cardiol.
2008;21(3):273–278.
La Perna L, Olin JW, Goines D, et al. Ultrasound-guided thrombin injection for
the treatment of postcatheterization pseudoaneurysms. Circulation. 2000;102:
2391–2395.
Lumsden AB, Miller JM, Kosinski AS, et al. A prospective evaluation of surgically
treated groin complications following percutaneous cardiac procedures. Am
Surg. 1994;60:132–137.
78852_ch10 18/06/10 12:23 PM Page 177
Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced

nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA.
2004;291(19):2328–2334.
Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics—2007
update: a report from the American Heart Association Statistics Committee
and Stroke Statistics Subcommittee. Circulation. 2007;115(5):e69–e171.
Rudnick MR, Goldfarb S, Wexler L, et al. Nephrotoxicity of ionic and nonionic
contrast media in 1196 patients: a randomized trial. The Iohexol Cooperative
Study. Kidney Int. 1995;47(1):254–261.
Sohail MR, Khan AH, Holmes DR Jr, et al. Infectious complications of percuta-
neous vascular closure devices. Mayo Clin Proc. 2005;80(8):1011–1015.
Thalhammer C, Kirchherr AS, Uhlich F, et al. Postcatheterization pseudoa-
neurysms and arteriovenous fistulas: repair with percutaneous implantation of
endovascular covered stents. Radiology. 2000;214:127–131.
Trivedi H, Daram S, Szabo A, et al. High-dose N-acetylcysteine for the preven-
tion of contrast-induced nephropathy. Am J Med. 2009;122(9):874 e9–874
e15.
Waigand J, Uhlich F, Gross CM, et al. Percutaneous treatment of pseudoa-
neurysms and arteriovenous fistulas after invasive vascular procedures.
Catheter Cardiovasc Interv. 1999;47:157–164.
Zoungas S, Ninomiya T, Huxley R, et al. Systematic review: sodium bicarbonate
treatment regimens for the prevention of contrast-induced nephropathy. Ann
Intern Med. 2009;151(9):631–638.
78852_ch10 18/06/10 12:23 PM Page 178
78852_ch11 18/06/10 9:19 AM Page 179
CHAPTER 11
Study Questions
1. Absolute contraindications to cardiac catheterization include:

a. Acute renal failure
b. Decompensated congestive heart failure
c. Severe hypokalemia
d. Patient’s refusal to undergo cardiac catheterization
e. All of the above
2. Medications that should be withheld prior to cardiac catheterization include:

a. Aspirin
b. Metformin
c. Unfractionated heparin
d. Clopidogrel
e. None of the above
3. True or false. Renal atheroembolic disease accounts for the majority of acute
renal failure cases following cardiac catheterization procedures.
4. True or false. Contrast reactions are allergic reactions mediated by immunoglob-

ulin E (IgE).
5. The main source of radiation exposure to the operator is from:

a. Escape of x-rays through the shielding of the x-ray tube
b. Forgetting to wear lead during the cardiac catheterization
c. Scatter from the patient
d. All of the above contribute equally to operator radiation exposure
6. Techniques used to minimize radiation exposure include which of the following:

a. Personal lead shielding
b. Taking a step back from the irradiated area before engaging in fluoroscopy
c. Keeping beam-on time to an absolute minimum
d. All of the above
7. Coronary artery “dominance” is determined by:

a. Size of the coronary artery; right-dominant in approximately 85% of cases
b. Artery that gives rise to the posterior descending artery; left-dominant in
approximately 15% of cases
179
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c. Artery that gives rise to the posterior descending artery; codominant in

d. Artery that gives rise to the atrioventricular (AV) node artery; right-dominant
in approximately 85% of cases
e. Artery that gives rise to the posterior descending artery; right-dominant in
8. A “ventricularized” waveform results from:

a. A deep-seated catheter, restricting coronary inflow
b. A catheter within the left ventricular cavity
c. Significant left main coronary artery stenosis
d. Both a and b
e. Both a and c
9. To minimize the risk of coronary dissection when using the Amplatz catheters,
the operator should:
a. Rotate the catheter counterclockwise to disengage it from the coronary
ostium prior to removing the catheter
b. Withdraw the catheter straight back to disengage the coronary ostium
c. Rotate the catheter clockwise to disengage it from the coronary ostium
prior to removing the catheter
d. Not use this catheter
10. The most common coronary anomaly is:

a. Origin of the left main trunk from the right sinus of Valsalva
b. Origin of the right coronary artery from the left sinus of Valsalva
c. Origin of the left circumflex coronary artery from the right sinus of Valsalva
d. Left anterior descending and left circumflex arteries arising from separate
ostia
e. Both a and c
f. Both b and c
g. Both c and d
11. Since the Gorlin equation for calculation of aortic valve area is somewhat com-
plicated, the simplified Hakki formula is frequently used preferentially. In which
circumstance(s) might the formula be inaccurate?
a. Low transvalvular gradient
b. Severe aortic stenosis (valve area ⬍0.8 cm2)
c. High cardiac output
d. Sinus tachycardia (⬎100 bpm)
e. a and d
12. Which of the following is considered the gold standard (most accurate) for
cardiac output measurement?
a. Pulmonary artery thermodilution
b. Fick technique
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Chapter 11 • Study Questions 181
c. Quantitative ventriculography
d. All of the above are equally accurate
13. What is normal mixed venous oxygen saturation (Svo2)?

a. 35%
b. 50%
c. 60%
d. 75%
14. Relative contraindications for ventriculography include:

a. Elevated left ventricular end diastolic pressure
b. Severe fibrocalcific aortic stenosis
c. Severe left main stenosis
d. Reduced creatinine clearance
e. All of the above
15. When inserting a Swan-Ganz (pulmonary artery) catheter, the balloon should
be inflated in the:
a. Femoral vein
b. Right atrium
c. Right ventricle
d. Pulmonary artery
16. Which radiographic projection for aortography is preferred to identify type A

aortic dissection?
a. Left anterior oblique projection
b. Right anterior oblique projection
c. Steep antero-posterior (AP) cranial projection
d. Shallow AP caudal projection
17. Aneurysmal left ventricular wall motion bulges outward in systole. This move-
ment is termed:
a. Akinesis
b. Dyskinesis
c. Hypokinesis
d. Asyneresis
18. Aorto-coronary bypass grafts anastomosed to the left coronary system may be
cannulated with any of the following except:
a. Amplatz left 2 (AL2)
b. Multipurpose A (MPA)
c. Judkins left 4 (JL4)
d. Left coronary bypass (LCB)
e. Judkins right 4 (JR4)
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19. The best diagnostic catheter for an aorto-coronary bypass graft to the right
coronary artery (RCA) with a steep inferior angulation at the ostium is:
a. Multipurpose B (MPB)
b. JR4
c. Short-tip Judkins right
d. Right coronary bypass (RCB)
e. Hockey stick
20. From the distal to proximal (closest to aortic valve) ascending aorta, the order
of coronary bypass grafts is:
a. Left anterior descending (LAD), diagonal, left circumflex (LCX)
b. Left circumflex, diagonal, LAD
c. Diagnosed, the circumflex, LAD
d. LAD, left circumflex, diagonal
21. The best view to assess the left internal mammary artery (LIMA) to LAD
anastomosis is:
a. Straight postero-anterior (PA) cranial
b. Left anterior oblique (LAO) 50°, caudal 30°
c. Straight PA caudal
d. 90° lateral
22. What is the best view when performing ascending aortography to identify
potential grafts to LAD or LCX?
a. Straight PA cranial
b. Straight PA caudal
c. Right anterior oblique (RAO) 35° to 40°
d. LAO 35° to 40°
23. When having difficulty cannulating upward takeoff bypass grafts with JR or
Coronary Bypass Graft (LCB or RCB) catheters, the next best catheter to use is:
a. Multipurpose B1
b. Multipurpose A1
c. Amplatz right 2 (AR2)
d. Amplatz left 2 (AL2)
24. The best technique to prevent postcatheterization groin complication is:

a. Use of fluoroscopy and bony landmarks
b. Use of ultrasound and micropuncture needle
c. Use of minimal local sedation
d. Radial approach
25. The best way to minimize contrast-induced nephropathy (CIN) is:

a. N-acetylcysteine 600 mg by mouth twice daily for 4 doses
b. Sodium bicarbonate infusion
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c. Low-osmolar nonionic contrast

d. Using the least amount of contrast as possible
e. All of the above
26. The best closure device for a calcified and diseased common femoral artery is:
a. Manual compression
b. FemStop
c. Perclose
d. Angio-Seal
27. The only vascular closure device that allows re-entry with a 0.035 wire after
sheath has been removed is:
a. Angio-Seal
b. Perclose
c. Starclose
d. Mynx
28. The best method to treat common femoral artery pseudoaneurysm is:
a. Covered stent
b. Surgical correction
c. Ultrasound-guided compression
d. Ultrasound-guided thrombin injection
29. What is the best management approach for a common femoral and external
iliac artery dissection when placing a femoral sheath?
a. Surgical consultation
b. Obtaining access in the opposite groin and evaluating the dissection from
the contralateral side
c. Placing a self-expanding stent via the ipsilateral groin
d. Performing balloon angioplasty followed by covered stent placement
30. Complications from closure devices include:

a. Retroperitoneal bleed
b. Pseudoaneurysm formation
c. Intermittent claudication
d. All of the above
31. True or false. Closure devices are absolutely contraindicated when using a
4-Fr. or 5-Fr. sheath.
Case 1 (Questions 32 and 33)

A 69-year-old diabetic man with a history of bypass surgery 10 years ago and se-
vere peripheral vascular disease presents to the emergency department complain-
ing 4 hours of substernal chest pain, nausea, vomiting, and shortness of breath.
78852_ch11 18/06/10 9:19 AM Page 184
On exam, he is diaphoretic, his blood pressure is 90/68 mm Hg, and his pulse
oximetry is 91%. Lung exam reveals bibasilar rales and his EKG shows diffuse ST
segment depression. Bedside troponin is positive. He is taken emergently to the
cath lab. Arterial access is difficult. The patient’s condition continues to deterio-
rate. His blood pressure is 80/62 mm Hg, heart rate is 115 beats per minute
(sinus tachycardia), and his respiratory rate is 30 breaths per minute. He is se-
dated and intubated. His blood pressure after endotracheal intubation is 65/48
mm Hg, heart rate is 95 beats per minute, and pulse oximetry is 70%. FIO2 on the
ventilator is 100%.
32. Hypotension in this patient is best explained by which of the following?

a. Cardiogenic shock
b. Acute retroperitoneal bleed
c. Endotracheal intubation
d. Vagal reaction
e. a and c
33. Sudden hypoxemia in this patient is best explained by:

a. Pulmonary edema
b. Anaphylactic reaction to lidocaine
c. Barotrauma (i.e., pneumothorax)
d. Right-to-left intrapulmonary shunt
34. The best view for selective renal arteriography is:

a. Straight AP projection
b. Shallow left anterior oblique projection
c. Shallow right anterior oblique projection
d. Steep left anterior oblique projection
Case 2 (Questions 35 and 36)

A 72-year-old man with history of peripheral vascular disease and diabetes presents
with a 1-week history of progressively worsening exertional chest pressure. The
past 12 hours he has experienced two 15-minute episodes of resting chest dis-
comfort associated to diaphoresis. He is evaluated in the emergency depart-
ment after his second episode. In the emergency department, he is pain free and
his EKG shows new deep T wave inversions in the anterior precordial leads. Four
months prior to presentation, he underwent percutaneous revascularization with
stenting of left external iliac artery and femoropopliteal bypass on the right. On
exam, an Allen test on the right is positive (i.e., insufficient ulnar collateral flow).
He has a normal femoral pulse on the right and 1⫹ femoral pulse on the left. He
is taken to the cath lab urgently for cardiac catheterization and possible coronary
revascularization.
35. True or false. It is safe to access the femoropoliteal bypass graft on the right.
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36. The left femoral approach is selected. If difficulty is encountered obtaining

access, the following techniques should be used except:
a. Doppler needle guidance
b. Micropuncture needle kit
c. Continue repeated attempts using routine access needle
d. Fluoroscopic guidance
37. The best view to visualize the iliac arteries includes:

a. Contralateral angulation
b. Ipsilateral angulation
c. Straight PA
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Answers
1. d. The only absolute contraindication to cardiac catheterization is a patient’s re-
fusal to undergo the procedure. Acute renal failure, decompensated congestive
heart failure, and severe hypokalemia are all relative contraindications. The risks
and potential benefits for cardiac catheterization should be assessed prior to
pursuing the procedure in these circumstances. Additional scenarios that pose
an increased risk of cardiac catheterization include active bleeding, acute stroke,
malignant hypertension, untreated active infection, digitalis toxicity, aortic valve
endocarditis, severe anemia or coagulopathy, and reduced life expectancy.
2. b. Metformin should be held the day prior to the procedure and restarted
2 days after the procedure if renal function remains unchanged. Metformin is
eliminated primarily via the kidneys and therefore accumulates among patients
with renal insufficiency (glomerular filtration rate ⬍70 mL/min, or serum
creatinine ⬎1.6 mg/dL). Contrast media can impair renal function and lead to
further retention of metformin, which is known to precipitate the onset of
lactic acidosis. The incidence of lactic acidosis associated with metformin,
regardless of exposure to contrast media, is 0.03 cases per 1,000 patients per
year, and 50% result in death. There is no conclusive evidence to indicate that
contrast media precipitates the development of metformin-induced lactic acidosis
among patients with normal serum creatinine (⬍1.5 mg/dL). This complication
is almost exclusively observed among non–insulin dependent diabetic patients
with abnormal renal function before injection of contrast media.
In patients who are candidates for percutaneous coronary intervention
after diagnostic angiography, aspirin 325 mg should be administered on the
day of the procedure. The use of clopidogrel (600 mg loading dose) prior to
catheterization may be indicated in patients who are likely to undergo percu-
taneous coronary intervention. This must be weighed against the possibility
that they will require coronary artery bypass graft surgery, which often must be
postponed for several days after administration of clopidogrel. Warfarin should
be stopped several days before the procedure. Ideally, the international normal-
ized ratio should be less than 1.5 to 1.8 prior to catheterization, depending on
operator comfort and acuity of the indication. Heparin (3,000 to 5,000 units
IV) should be considered for patients undergoing cardiac catheterization via an
arm approach. It is also reasonable to pursue cardiac catheterization in patients
on unfractionated heparin; however, great care must be taken to achieve an
anterior artery wall arteriotomy in order to minimize the risk of bleeding.
3. False. Renal dysfunction can result from administration of contrast agents,

which is reported to occur in approximately 5% patients, or from renal athero-
embolic disease, which is significantly less common. Renal atheroembolic disease
complicates approximately 0.15% of cardiac catheterizations and should be
suspected when acute renal failure occurs in conjunction with other clinical
signs of embolization such as discolored toes, livedo reticularis, systemic or
urinary eosinophilia, and abdominal pain.
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4. False. A great deal of controversy exists regarding the exact mechanism of con-
trast reactions, but it is thought that the majority of reactions are not mediated
by immunoglobin E, and thus are not truly allergic. Multiple investigators have
demonstrated conclusively, however, that immediate reactions involve the gran-
ular release of histamine by mast cells and basophils, producing an anaphylac-
toid response. Regardless of the mechanism, the risk of a reaction to contrast is
increased twofold in patients with a strong history of allergy or atopy such as
asthma. A common misconception is that a prior reaction to seafood confers a
greatly elevated risk of an adverse reaction with contrast exposure. In reality, pa-
tients with allergies to seafood have a similar risk of contrast reactions as those
who have a strong history of other allergic reactions. Patients with a previous
adverse reaction to contrast have about a sixfold increased risk of an adverse re-
action upon repeat exposure to contrast when compared with individuals with-
out a prior adverse reaction. This elevated risk justifies pharmacologic prophy-
laxis with steroids and histamine blockade prior to planned repeat contrast
exposure for patients with a history of moderate or severe reactions, although it
should be noted that data is very limited on the efficacy of these preventive
pharmacologic measures when modern-day nonionic low osmolar contrast
media (LOCM) or iso-osmolar contrast media (IOCM) is used. Physicians
should also note that serious life-threatening reactions have been reported de-
spite the use of steroid and antihistamine prophylaxis.
5. c. The main source of radiation exposure for the operator is scatter from
the patient. A secondary, less significant, source is escape of x-rays through the
shielding of the x-ray tube. Protection for the operator consists of shielding,
proper positioning from the radiation source, and adjusting the fluoroscopic
controls in an attempt to minimize radiation exposure while maintaining a high-
quality image.
6. d. Personal shielding involves lead aprons, thyroid collars, and lead glasses.
Lead aprons should have shielding properties equivalent to 0.5 mm of lead,
which shields the covered areas of the operator from roughly 90% of scatter
radiation. Lead glasses protect the operator from possible radiation-induced
cataracts and should have side shields to decrease radiation from the lateral
direction. Thyroid shields prevent large cumulative doses of radiation that
could lead to thyroid cancer. These items should be checked annually with
fluoroscopy to inspect for possible cracks, holes, and other signs of deterioration.
The catheterization table will commonly have two lead shields: one which is a
table side drape that protects the lower body of the operator, and one which
is an adjustable lead acrylic shield that is suspended from the ceiling to aid in
the protection of the operator’s head and upper torso.
The inverse square law addresses the important concept that radiation
dose drops rapidly by the inverse square of the relative increase of distance
from the radiation source. Operators can decrease their radiation exposure by
taking a step back from the irradiated area before engaging in fluoroscopy.
Moving the image intensifier, which is located above the patient, to as close
78852_ch11 18/06/10 9:19 AM Page 188
to the patient as possible also reduces scatter radiation by reducing geometric

magnification (radiation dose usually increases with the square of the magni-
fication). Placing hands in the direct beam of radiation should only be done
in cases of emergency.
Modifying fluoroscopic controls can also decrease radiation exposure for
both the operator and the patient; however, these modifications may occasion-
ally reduce image quality. One of the “golden rules” for minimizing radiation
exposure is keeping beam-on time to an absolute minimum. Fluoroscopy or
cineangiography should not be engaged if the image on the monitor is not being
used. Most fluoroscopic machines have an option that allows the operator to
select the level of image quality (low, normal, high). Low image quality reduces
radiation dose rate, but often produces a noisy image. These images may be ac-
ceptable in certain situations such as checking position of a guidewire or
catheter. Most fluoroscopic machines have pulsed fluoroscopy which results in
x-rays being produced in short bursts instead of a continuous stream as in con-
ventional fluoroscopy. Reducing the pulse frequency to 15 or 7.5 pulses of
x-rays/second will reduce radiation exposure at the cost of producing a some-
what flickering, choppy image. A similar result is seen when one reduces the
cine frame rate. Applying collimators (blades outside the x-ray tube that block
x-rays) to the area of interest not only reduces scatter radiation to the operator
but also improves image quality.
7. e. The posterior descending artery, which courses in the posterior interven-

tricular groove, determines coronary dominance. In 85% of the cases, the pos-
terior descending artery arises from the right coronary artery, making the
coronary circulation right-dominant. In 7% of the cases, the circulation is
codominant, with the posterior interventricular groove being supplied by
both the right coronary artery and the left circumflex coronary artery. In 8%
of the cases, the posterior descending artery arises from the left circumflex,
making it the dominant artery.
8. e. A dampened pressure waveform (drop in the catheter tip systolic pressure)

or a ventricularized pressure waveform (drop in the catheter tip diastolic
pressure) usually indicates that the catheter tip is either deep-seated, restricting
coronary inflow, or the tip is against the wall. It also indicates the possibility
of significant left main stenosis. This can be a dangerous situation that needs to
be recognized quickly. The catheter tip should be immediately withdrawn from
the ostium. The ostium can be re-engaged cautiously. If a small injection of
dye reveals significant ostial left main stenosis (another clue may be the absence
of dye reflux into the aortic root with the injection), two short cine runs
aimed at visualizing distal targets for bypass surgery should promptly be
performed, and the catheter then immediately pulled back from the ostium.
Care must be taken to avoid multiple engagements of the left main trunk as
this can lead to abrupt vessel closure. In cases where significant left main trunk
stenosis is suspected, the operator can take nonselective angiograms of the left
main trunk by injecting dye with the catheter tip positioned in left sinus.
Catheter damping may also be seen in cases of spasm of the left main trunk.
78852_ch11 18/06/10 9:19 AM Page 189
In such instances, intracoronary nitroglycerin can be injected (200 ␮g) and

follow-up picture can be taken to document relief of spasm.
9. a. To minimize the risk of coronary dissection when using the Amplatz

catheters, the operator should rotate the catheter counterclockwise to disen-
gage it from the coronary ostium prior to removing the catheter. Withdrawing
the Amplatz catheters straight back will cause the catheter to “dive” into the
coronary artery and increase the risk of dissection.
10. g. The various coronary anomalies in order of frequency are as follows: left
anterior descending and left circumflex arteries arising from separate ostia
(0.5%); origin of the left circumflex coronary artery from the right sinus of
Valsalva (0.5%); origin of the right coronary artery from the ascending aorta
above the right sinus of Valsalva (0.2%); origin of the right coronary artery
from the left sinus of Valsalva (0.1%); AV fistula (0.1%); origin of the left main
trunk from the right sinus of Valsalva (0.02%).
11. d. The Hakki formula calculates valve area (in cm2) by dividing the cardiac out-
put (in L/min) by the square root of the peak pressure gradient across the valve
(in mm Hg). This method does not require the assessment of the systolic ejec-
tion time or the transvalvular flow, and the peak systolic gradient instead of the
mean gradient may be entered into the formula. However, in the presence of
tachycardia, the formula is less accurate because the percentage of time/minute
in systole and diastole changes markedly at higher heart rates. In order to
account for this, the result should be divided by 1.35 for heart rates ⬎90 (Angel
adjustment).
12. b. The Fick principle assumes that the rate at which oxygen is consumed is a
function of the rate of blood flow and the rate of oxygen pick up by the red
blood cells. In the cath lab, it is used to determine cardiac output by the dif-
ference in oxygen concentration in blood before it enters and after it leaves
the lungs, and from the rate at which oxygen is consumed. Three variables
need to be identified:
• Vo2 consumption per minute using a spirometer (with the subject rebre-
athing air) and a CO2 absorber
• the oxygen content of blood taken from the pulmonary artery (representing
mixed venous blood)
• the oxygen content of blood from a cannula in a peripheral artery (repre-
senting arterial blood)
From these, cardiac output can be calculated:
CO ⫽ O2 Uptake / ([Arterial O2] – [Venous O2])
While considered to be the most accurate method for cardiac output meas-
urement, Fick measurement is invasive, requires time, and the attainment of
78852_ch11 18/06/10 9:19 AM Page 190
reliable oxygen samples. Quantitative ventriculography is a rather crude esti-

mation of cardiac output and is infrequently used. Pulmonary artery ther-
modilution calculates cardiac output by quantifying a “temperature curve”; a
small amount (typically 10 mL) of cold saline is injected into the pulmonary
artery and the temperature a known distance away (6 to 10 cm) is attained,
using the same catheter. Higher cardiac outputs will change the temperature
rapidly, whereas lower cardiac outputs will change the temperature slowly.
The technique is liable to gross errors unless certain requirements are strictly
adhered to, and in certain clinical circumstances.
13. d. Mixed venous blood in a well patient at rest is about 75% saturated, which
indicates that under normal conditions tissues extract 25% of the oxygen
delivered. In general, any clinical condition which leads to an Svo2 ⬍60%
threatens tissue oxygenation, and an Svo2 ⬍30% should be viewed as a med-
ical emergency. True mixing of venous blood (in the absence of shunt) occurs
in the pulmonary artery; therefore, slow aspiration from the distal lumen of a
pulmonary artery catheter can provide a sample.
14. e. Other relative contraindications include decompensated heart failure, pres-

ence of left ventricular thrombus, acute coronary syndrome, mechanical aortic
prosthesis, or endocarditis of left-sided valves. For all these reasons, ventricu-
lography is more sparingly performed, especially given the myriad other non-
invasive imaging options available.
15. b. The balloon should be inflated either in the terminal end of the inferior
vena cava, or in the right atrium. In the femoral vein, the balloon or vein
might be traumatized due to the relatively narrow diameter. The balloon
should always be inflated before entering the right ventricle in order to reduce
the risk of ventricular ectopy or free wall perforation.
16. a. The LAO projection is ideal for visualizing and “opening” the aortic arch,
thereby delineating the origins of the innominate, left carotid, and left subcla-
vian arteries. It is also useful for identifying the origin and extent of type A
aortic dissection. The RAO view can be particularly useful when searching for
aorto-coronary bypass grafts to the left coronary system.
17. b. Dyskinetic wall motion refers to paradoxical wall motion during systole.
Aneurysmal dyskinesis is frequently appreciated after a transmural myocardial
infarction and is a particular risk for development of mural thrombus. With
time, dyskinetic injury will heal into akinetic scar.
18. c. Left aorto-coronary bypass graft usually originate superior and anterolater-
ally in the ascending aorta. The AL2 catheter is a good choice if the aortic
root is dilated. In many cases, all grafts can be cannulated with a JR4. Both
78852_ch11 18/06/10 9:19 AM Page 191
the MPA and the LCB are useful in certain circumstances. The JL4 does not
generally cannulate left-sided grafts.
19. a. Often, grafts to the RCA arise from the inferior aspect of the aortic root
and descend aggressively down to the distal RCA or PDA. The JR4 is usu-
ally the default initial catheter for attempted cannulation of grafts, but in
this instance it may be a poor choice. The JR4 is unlikely to cannulate in a
coaxial manner, so injection into the ostium may lead to inadequate
(“streaming”) or absent filling. The MPB is often a good selection because
of its modest primary bend, thereby aligning it well with an acute inferiorly
angulated graft.
20. b. Usually, the location of the various grafts in relation to one another follows
a predictable sequence. Grafts to the LCX are typically placed most superior,
followed in succession inferiorly by grafts to the diagonal branches of the
LAD, the LAD itself, and the RCA (see Figure 4-1).
21. d. The best view to assess LIMA to LAD anastomosis is 90° lateral view. In
this view, the LAD lies below the sternum. Straight PA cranial is the best view
for mid and distal LAD. Choice B is the best view to assess LMT, LAD, and left
circumflex bifurcation. Straight PA caudal will best show the LMT, proximal
LAD, and the left circumflex.
22. d. The best view to localize the origin or the presence of bypass grafts to LAD
or left circumflex is the LAO 35° to 40°. The anterior and lateral border of
the ascending aorta should be carefully reviewed frame by frame. The opera-
tor should account for each myocardial territory either by the presence of col-
laterals or by visible graft stump before concluding graft occlusion. For grafts
to RCA, an RAO 35° to 40° view is best. Straight PA cranial or caudal is
almost never used when performing aortography.
23. d. The best catheter for engaging an upward takeoff graft is usually AL2. This
catheter should be formed in the distal ascending aorta and slowly pushed
down to the level of interest. Subsequent clockwise or counterclockwise rota-
tion should engage the grafts. At times once engaged the catheter must slightly
be pulled back for better engagement. In order to disengage, the catheter
should be pushed down and rotated so that it is no longer in the same plane
as the ostium of bypass graft. For downward takeoff, we typically use Multi-
purpose B1.
24. d. Fluoroscopy and bony landmarks are extremely important and should be
used for every case if a groin approach is undertaken. However, based on
most recent large studies, the radial approach is the safest technique to re-
duce groin-associated complications. This approach is safe and has rarely
78852_ch11 18/06/10 9:19 AM Page 192
been associated with hand complications. In general, there is a learning curve

associated with the radial approach. The use of ultrasound and micropunture
needle can significantly decrease groin complications; however, it is associated
with longer procedure time.
25. d. There has been conflicting data regarding the best method to reduce CIN.
In general, the two most accepted methods to reduce CIN are hydration with
normal saline and using as little contrast as possible. However, for patients at
risk of CIN (diabetes, known chronic kidney disease, and history of CIN), a
multimodality approach including N-acetylcysteine, sodium bicarbonate, and
low-osmolar nonionic contrast in addition to biplane angiography to minimize
contrast use is recommended.
26. a. The safest and most reliable method to establish hemostasis is manual com-
pression. The use of vascular closure device in calcified, diseased arteries has
been associated with dissections and high failure rate.
27. b. Perclose allows reaccess through side lumen if necessary. In our institution,
Perclose has been the preferred device for coronary, structural, and peripheral
interventions. However, this device has an associated learning curve. As noted
in Chapter 9, data on closure devices are mixed. Our own analysis has shown
Perclose to be slightly superior at least for patients undergoing coronary
intervention.
28. d. The safest and most effective method to treat common femoral artery
pseudoaneurysm is ultrasound-guided thrombin injection. With this technique,
over 97% of common femoral artery pseudoaneurysms can be safely treated.
Covered stent should rarely be used in the common femoral arteries because
it is a bend region. Surgical correction is associated with morbidity.
Ultrasound-guided compression may be effective for small pseudoaneurysm;
however, it will rarely work for pseudoaneurysm over 2 cm.
29. b. In general, the safest approach when dealing with sheath-related dissection
in the groin area is using the contralateral side to evaluate the extent of the
dissection. In most cases once the sheath is removed, the dissection flap closes
and no other intervention is necessary. In cases where there is hemodynamic
compromise and the common femoral artery is involved, surgical approach is
best tolerated. If surgery is not available, balloon angioplasty alone may be a
reasonable option. In general, one should avoid stenting the common femoral
artery.
30. d. Complications from closure devices occur in 0.5% to 1% of patients under-

going a diagnostic cardiac catheterization. It is important to remain vigilant
for potential complications immediately after deploying a closure device as
well as 1 to 2 weeks after the procedure when patients return for follow-up.
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Intermittent claudication or acute limb ischemia occurs more commonly with

collagen-based biosealant devices, whereas pseudoaneurysm or retroperitoneal
bleeds can be seen with any closure device. Other potential complications
not listed above include arteriovenous fistula and infection. The incidence
of infection is higher with closure devices that leave foreign material at the
arteriotomy site.
31. False. Only hemostatic pads should be considered with a 4-Fr. French sheath
and selected devices with a 5-Fr. sheath (i.e., Perclose Proglide). However,
closure devices are generally not necessary when using smaller French systems
(4 or 5-Fr.) because manual compression is cost-effective and satisfactory
from a patient perspective (i.e., short bedrest time and time to ambulation).
32. e. A knowledge of common causes of hypotension in the cath lab is essential.

As a principle, identifying the task immediately prior to onset of hypotension
often narrows the differential diagnosis (see Table 8.2). The patient in the
clinical vignette is clearly in cardiogenic shock and this is the main cause of
hypotension, but there are important potential contributing factors that need
to be understood to treat this patient appropriately. Hypotension occurred
immediately after two events: arterial access and sedation/intubation. Although
a vagal reaction may occur as access is being obtained, this is usually transient
and relatively benign, unlike this patient’s clinical course. It is important to
think of a retroperitoneal bleed as treatment would entail volume expansion
(i.e., fluids and blood transfusions) as well as inotropic support. A retroperi-
toneal bleed in this patient is unlikely as hypotension does not occur immedi-
ately after obtaining arterial access. Depending on the rate of bleeding, it may
occur late in the case or during recovery. Sedation and intubation causing loss
of adrenergic drive is an important contributor to this patient’s hypotension.
33. d. Profound hypoxemia in this patient occurred following endotracheal intu-

bation. Although it is important to keep anaphylaxis to lidocaine in the differ-
ential diagnosis, there are no other clinical signs of anaphylaxis. Pulmonary
edema may be a contributing factor, but it does not explain a sudden decrease
in blood oxygen saturation. Tension pneumothorax and a right-to-left intra-
pulmonary shunt can be easily evaluated with fluoroscopy. This patient did
not have a pneumothorax. The tip of the endotracheal tube was in the right
main stem bronchus causing profound hypoxemia from a right-to-left intra-
pulmonary shunt.
34. b. The origin of both renal arteries from the lateral aspect of the aorta is variable.
The right renal artery commonly originates slightly anterior and a shallow left
anterior oblique projection may be best to identify the origin of both renal ar-
teries. However, it is important to make adjustments for optimal visualization
of each renal artery (i.e., the view that maximizes the length of the tip of the
catheter). Occasionally, cranial or caudal angulation may be necessary to
optimize visualization of the renal artery ostium.
78852_ch11 18/06/10 9:19 AM Page 194
35. False. Direct cannulation of a femoropopliteal synthetic vascular graft less

than 6 months old should be avoided to decrease the risk of graft complica-
tions (i.e., bleeding or graft thrombosis). This patient’s graft is 4 months old.
36. c. In patients with peripheral vascular disease, use of a micropuncture needle

kit should be considered at the start of the procedure. The threshold for using
a Doppler needle system (SMART needle) should be low in difficult access cases.
In patients with calcified vessels, the common femoral artery can be accessed
under direct fluoroscopic guidance.
37. a. In general, iliac arteries are best visualized using contralateral angulation.
However, visualization of the pelvic arteries is often performed in the straight
AP projection using a power injection. In cases of tortuous vessels or eccentric
lesions, angulated views are necessary. The common iliac arteries are best
visualized using contralateral angulation and the external iliac arteries may be
best visualized using ipsilateral angulation.
78852_Index 18/06/10 5:28 PM Page 195
INDEX
Page numbers followed by f indicate figures; those followed by t indicate tables.
A Airway compromise/respiratory
Abdominal angiography, 95–97 failure, 140
Omni Flush catheter for, 95 AL2 (Amplatz left 2) catheter, 182, 191
posteroanterior view for, 95 ALARA (as low as reasonably achiev-
Abdominal aorta, anatomy of, 66f able) principle, 27, 28t
ACC (American College of AL (left Amplatz) catheter, 32–34,
Cardiology), guidelines for the 33f
management of patients with Allen test, 37, 39, 86
valvular heart disease, 131–133 Allergic reaction(s), 179, 187
Access needle, 30 during cardiac catheterization, 14
Acetylcysteine (Mucomyst), for renal to contrast agents, 2, 14, 25–27,
dysfunction, 15, 16t 26t
ACS (acute coronary syndrome), 141 to latex, 2
ACT (activated clotting time), 152 to medication, 2
Activated clotting time (ACT), 152 to procaine, 37
Activated partial thromboplastin time American College of Cardiology
(aPTT), 152 (ACC), guidelines for the
Activity restriction, post-cath compli- management of patients with
cations, 175, 175t valvular heart disease,
Acute coronary syndrome (ACS), 141. 131–133
See also Acute myocardial infarction American Heart Association (AHA),
Acute kidney injury (AKI), contrast- guidelines for the management
induced, 23–24, 24t of patients with valvular heart
prevention of, 24–25 disease, 131–133
Acute limb ischemia, 105, 183, 193 Amplatz catheter
Acute marginal branches, 41 for coronary angiography, 32–34,
Acute myocardial infarction 33f, 43, 45
cardiac catheterization for, 3, 4t, for left ventriculography, 73
5t, 6–7, 10t and risk of coronary dissection,
AF (Atrial fibrillation), 140 180, 189
AHA (American Heart Association), Amplatz left 2 (AL2) catheter,
guidelines for the management 182, 191
of patients with valvular heart Anaphylactoid reactions, to contrast
disease, 131–133 agents, 26t
Air, elimination from system of, 43 Anemia, as contraindication to cardiac
Air embolism catheterization, 11
due to carotid angiography, 91 Aneurysm
due to coronary angiography, 57 history of, 1, 2
due to left ventriculography, 78t post-cath pseudo-, 171–174
195
78852_Index 18/06/10 5:28 PM Page 196
196 Index
Angina Aortic pressure, 130

Canadian Cardiovascular Society Aortic regurgitation, ACC/AHA
classification of, 8, 8t guidelines for, 132
as indication for cardiac catheteri- Aortic root
zation, 4t, 5t, 8, 10t anatomy of, 79t
unstable measuring size of, 81, 81f
as indication for cardiac Aortic stenosis (AS), 143–144
catheterization, 10t ACC/AHA guidelines for, 131
risk factors with, 9 left ventriculography with, 72–73
Angiographic catheter. See pressure gradients across,
Catheter(s) 113–115, 114f, 115f
Angio-seal closure device, 155–156 Aortic valve, pullback across,
Antagonists, for preprocedural seda- 114–115, 115f
tion, 21t Aortic valve orifice area, 113, 115
Anterior tibial artery (AT), 101, Aortic valve prosthesis, left ventricu-
101f, 102, 102f lography with, 73, 77, 78f
Antiemetics, for contrast reactions, Aortography, 79–83, 182, 191
26t analysis of, 81–82, 81f –83f
Antihistamines of aortic dissection, 81–82, 82f
for contrast reactions, 26t, 27 of aortic insufficiency, 80t
for preprocedural sedation, 21t aortic root dimensions in, 81, 81f
Aorta of coarctation of aorta, 82, 83f
abdominal, anatomy of, 66f contraindications for, 79t
anatomy of, 79t indications for, 79t
ascending, 182, 191 to locate bypass grafts, 82
anatomy of, 79t of normal aorta, 80f
origin of right coronary artery preparation for, 79–80
from, 50, 52f views for, 80, 80f, 80t
descending, anatomy of, 79t, APTT (activated partial thromboplas-
97–98, 98f tin time ), 152
dilated, difficulty engaging left Arm approaches, 37–39
main trunk with, 43 percutaneous brachial approach
Aortic aneurysm for, 37, 39
for coronary angiography, 143 percutaneous radial approach
history of, 1, 2 for, 39
Aortic arch, anatomy of, 79t, 86–87, Arrhythmias
87f due to left ventriculography, 78t
Aortic arch angiography with pulmonary artery catheter,
cerebrovascular system and, 90 109
upper extremity and, 92–93 AR (right Amplatz) catheter, 33f, 34
Aortic bulb, anatomy of, 79t Arteriovenous fistula, post-cath
Aortic coarctation, aortography of, complications, 170
82, 83f Arteriovenous oxygen difference, 126
Aortic dissection AS (Aortic stenosis), 143–144
aortography of, 81–82, 82f Ascending aorta, 182, 191
in coronary angiography, 56 anatomy of, 79t
78852_Index 18/06/10 5:28 PM Page 197
Index 197
origin of right coronary artery internal mammary artery, 62–65,

from, 50, 52f 63f
As low as reasonably achievable radial artery, 65
(ALARA) principle, 27, 28t saphenous vein, 59–62, 60f
Aspirin, prior to coronary angiogra- views in, 61t
phy, 16, 16t, 179, 186 Bypass graft(s), 182, 191
AT (anterior tibial artery), 101, 101f aortography of, 82
Atherosclerosis, catheterization catheter selection for, 32, 33f, 34
with, 38
Ativan (lorazepam), for preproce-
dural sedation, 21t C
Atrial fibrillation (AF), 140 CAD (coronary artery disease), as
Atrioventricular (AV) fistula, 50, 53f indication for cardiac catheteri-
Atrioventricular (AV) node depression, zation, 10t
due to contrast agents, 22–23 Cardiac catheterization
Atropine classification of, 8–9, 8t
for contrast reactions, 26t complications of, 13–16
AVO2 difference, 130 local, 170–175
Axillary artery, 92, 92f, 93 symptoms suggestive of, 169,
170t
contraindications to, 9, 11, 12t,
B 179, 186
Back bleed, 43 hospitalization after, 13
Benadryl (Diphenhydramine) indications for, 3–9, 4t–6t,
for contrast reactions, 26t, 27 10t–11t
for preprocedural sedation, 21t informed consent for, 13
Benzodiazepines, for preprocedural medication considerations prior to,
sedation, 20, 21t 16–17, 16t, 179, 186
Bleeding Cardiac index, 125, 127, 130
post-cath complications, 170–171 Cardiac output, 124–126, 127, 127t
risk of, with thrombocytopenia, Cardiac performance, 124–129
148–149 cardiac output in, 124–126, 127,
BMI. See Body mass index (BMI) 127t
Body mass index (BMI), 170 left ventricular filling pressures in,
Brachial approach, for percutaneous 128
vascular access, 37–39 vascular resistance in, 128–129
Brachial artery, 37, 93 Cardiac tamponade
Brachial pulse, 37, 39 due to left ventriculography, 78t
Bradycardia, 137–139 intracardiac pressure waveforms in,
due to contrast agents, 23 119, 120, 121f
Brockenbrough–Braunwald–Morrow Cardiogenic shock, coronary angiog-
sign, 119, 120f raphy with, 144–148
Bundle branch block, left Cardiomyopathy, hypertrophic
cardiac catheterization for, 3 obstructive hemodynamic meas-
Bypass graft angiography, 59–66 urements with, 118–119, 119f,
gastroepiploic artery, 65–66, 66f 120f
78852_Index 18/06/10 5:28 PM Page 198
198 Index
Carotid angiography, 90 for right coronary arteries, 44

air embolism due to, 91 for saphenous vein grafts, 59
clot embolism due to, 91 for left ventriculography, 73
Judkins catheters for, 90, 91 multipurpose, 33f, 34
ostial stenosis of vertebral artery, 91 Omni Flush
right anterior oblique view for, 90 for abdominal angiography, 95
views for, 90–91 for lower extremity angio-
Catalyst closure device system, graphy, 103
162–163 pigtail, 32, 33f
Catheterization. See Cardiac catheter- for aortic arch angiography, 90
ization for aortography, 79
Catheterization laboratory, setting up for left ventriculography,
of, 19–39 70–71, 71f
access needle, 30 for lower extremity angiography,
catheter selection. See Catheter(s) 103
contrast agents, 21–27 pulmonary artery, 109, 181, 190
dilators, 31–32 Straight Flush
guidewire, 30–31 for lower extremity angiography, 103
manifold, 34–35 Swan-Ganz, 181–190
radiation safety, 27–30 Vitek, for carotid angiography, 90
sheaths, 31–32 Catheter sheaths, 31–32
time-out protocol, 19–21 Caudal angulation, 46
vascular access, 35–39 Cavernous segment, internal carotid
Catheter(s) artery, 89
Amplatz CCA (common carotid artery)
for coronary angiography, left, 87–88, 87f, 88f, 90
32–34, 33f, 43, 45 right, 87, 87f, 90
for left ventriculography, 73 Celiac trunk, anatomy of, 93–94, 95f
and risk of coronary dissection, Cerebral angiography
180, 189 cerebrovascular system, 86–91
Amplatz left 2, 182, 191 anatomy of, 86–90, 87f
back bleed by, 43 aortic arch angiography and, 90
Cobra, 66 complications related to, 105–106
for coronary angiography, 32–34, Cerebreovascular accident, 105
33f Cerebrovascular system, 86–91
coronary bypass, 32, 33f, 34 anatomy of, 86–90, 87f
3DRC (No Torque Right), 34 aortic arch angiography and, 90
Feldman, for left ventriculography, Cervical segment, internal carotid
73 artery, 89
JoMed, 34 CFA (common femoral artery) can-
Judkins, 32, 33f, 182, 191 nulation, 85–86
for abdominal angiography, 96 Chest pain
for aortic arch angiography, 93 causes of, 8–9
for left coronary arteries, 42 post-cath complications, 170t
for left internal mammary artery CHF, cardiac catheterization for. See
grafts, 63, 64 Congestive heart failure (CHF),
for left ventriculography, 73 cardiac catheterization for
78852_Index 18/06/10 5:28 PM Page 199
Index 199
Chronic kidney disease (CKD), 23 high-osmolar, 22

CIA (common iliac artery), 97 ionic, 22, 22t
CIN (contrast-induced nephropa- low osmolar, 22, 22t
thy), 174–175, 182, 192 myocardial function with, 22–23
Cineangiography overview of available, 21–22, 22t
breath before, 46 peripheral angiography and, 86
radiation safety with, 29, 188 reactions to, 2, 14
Circle of Willis, 89 renal function with, 23–24
CKD (chronic kidney disease), 23 Contrast-induced acute kidney injury
Claudication, history of, 2 (AKI), 23–24, 24t
Clopidogrel (plavix), prior to coro- prevention of, 24–25
nary angiography, 16, 16t, Contrast-induced nephropathy
179, 186 (CIN), 174–175, 182, 192
Clot embolism Coronary angiography
due to carotid angiography, 91 air embolism in, 57
Coagulopathy, as contraindication to aortic dissection in, 56
cardiac catheterization, 1 catheter not engaged and damped
Coarctation of aorta, aortography of, waveform, 43
82, 83f clinical evaluation for, 1–3, 2t
Cobra catheter, 66 complications of, 13–16
Collagen-based biosealant devices, contraindications to, 9, 11, 12t
for hemostasis, 154–158 coronary anomalies in, 50,
Collaterals, to right coronary artery, 51f–54f
49f, 50f coronary dissection in, 56, 57f
Common carotid artery (CCA) dampened or ventricularized, pres-
left, 87–88, 87f, 88f, 90 sure waveform in, 45
right, 87, 87f, 90 with dilated aorta, 43
Common femoral artery (CFA) engaging coronary arteries in,
cannulation, 85–86 42–44
anatomy of, 98, 99f left, 42–44
Common iliac artery (CIA), 97, 185, right, 44
194 image quality in, 54–56
Comorbid conditions, 1, 2t indications for, 3–9, 4t–6t,
Complete heart block 10t–11t
due to left ventriculography, 78t left main trunk with unusual take-
Complications, of cardiac catheteriza- off in, 43
tion, 13–16 medication considerations prior to,
local, 170–175 16–17, 16t
Congestive heart failure (CHF), myocardial bridging in, 54, 55f
cardiac catheterization for, native, 41–57
2, 4t complications of, 56–57
Constrictive pericarditis, intracardiac no back bleed by catheter in, 43
pressure waveforms in, 120, no waveform observed in pressure
122–123, 122f, 123f tracing in, 43
Contrast agent(s), 21–27 views in, 44–50, 46t
classification of, 22, 22t left, 46–48, 47f–48f, 49f
electrophysiologic effects, 23 right, 48–50, 49f–50f
78852_Index 18/06/10 5:28 PM Page 200
200 Index
Coronary anomalies, 50, 51f–54f, Diphenhydramine (Benadryl)

180, 189 for contrast reactions, 26t, 27
Coronary artery disease (CAD), as for preprocedural sedation, 21t
indication for cardiac catheteri- Dissection
zation, 10t aortic, 81–82, 82f
Coronary artery(ies) coronary, 56, 57f
anatomy of, 41–42 of left internal mammary artery
engaging of, 42–44 graft, 57f
left retrograde subintimal, 38
anatomy of, 41 DM (diabetes mellitus)
engaging of, 42–44 contrast-induced AKI and, 25
views of, 46–48, 47f–48f, 49f 3DRC (No Torque Right)
right catheter, 34
anatomy of, 41 DSA (digital subtraction angiography)
engaging of, 44 for peripheral angiography, 85
views of, 48–50, 49f–50f D-stat dry patch, 153
Coronary bypass catheters, 32, 33f, 34 DuettPro sealing device, 156–157,
Coronary dissection, 56, 57f 156f
risk of, Amplatz catheters and, Dyskinetic wall motion, 181, 190
180, 189 Dyspnea, post-cath complications,
Coronary dominance, 42 170t
Coronary sinus (CS), 139
Coronary spasm, 56
Costocervical trunk, 91 E
Cranial angulation, 46 ECA (external carotid artery),
CS (coronary sinus), 139 88–89, 88f
Echocardiogram, prior, 3
EIA (external iliac artery), 97–98
D Electrocardiogram precatheteriza-
Dampened waveform, 43, 44, 45, tion, 3
180, 188–189 Electrophysiologic effects, of contrast
Demerol (Meperidine), for preproce- agents, 23
dural sedation, 21t Embolism, air
Descending aorta, anatomy of, 79t, due to coronary angiography, 57
97–98, 98f due to left ventriculography, 78t
Diabetes mellitus (DM) Endocardial staining, due to left ven-
contrast-induced AKI and, 25 triculography, 78t
Diagnostic coronary catheter, selec- Epinephrine, for contrast reactions,
tion of, 32–34, 33f 26t
Diagonal branches Evaluation
saphenous vein grafts to, 59, 60f post-cath complications, 169, 170t
views of, 46, 47f–48f, 48 preprocedural, 1–3, 2t
Diaphragmatic artery, 41 EVS vascular closure system,
Diazepam (Valium), for preproce- 161–162, 162f
dural sedation, 21t External carotid artery (ECA),
Digital subtraction angiography (DSA) 88–89, 88f
for peripheral angiography, 85 External iliac artery (EIA), 97–98
Dilators, 31 dissection, 183, 192
78852_Index 18/06/10 5:28 PM Page 201
Index 201
F Glomerular filtration rate (GFR),

Famotidine, for contrast reactions, 26t 23, 175
Feldman catheter, for left ventricu- Glycoprotein IIb–IIIa inhibitor, prior
lography, 73 to coronary angiography, 16t
Femoral approach, for percutaneous Gorlin formula, 113, 115, 116, 118
vascular access, 35–37, 36f Graft(s), 182, 191
Femoral artery, 35, 36f aortography of, 82
Femoral artery grafts, prosthetic, 38 catheter selection for, 33f, 34
Femoral artery pseudoaneurysm, femoral artery, 38
173, 173f, 183, 192 femoropoliteal bypass, 184, 194
Femoral bifurcation, 35 gastroepiploic artery, 65–66, 66f
Femoral head, identification of, 35 internal mammary artery, 62–65,
Femoral iliac artery dissection, 63f
183, 192 left
Femoral introducer sheath and iatrogenic dissection of, 57f
hemostasis (FISH) device, 163 patency of, 62
Femoral pulse, 35, 38 views of, 61t
Femoropoliteal bypass graft, radial artery, 65
184, 194 saphenous vein, 59–62, 60f, 61t
FemStop device, for vascular hemo- Groin infection, post-cath complica-
stasis, 154f tions, 174
Fentanyl, for preprocedural sedation, Groin pain, post-cath complications,
21t 170t
Fever, post-cath complications, 169 Guidewire, 30–31
Fick method, for measuring cardiac for left ventriculography, 73
output, 125–126, 127t, 180, resistance to advancing of, 38
189–190 GUSTO I trial, 144
FISH (Femoral introducer sheath
and hemostasis device), 163
Flumazenil (Romazicon), for prepro- H
cedural sedation, 21t Hakki formula, 113, 115–116, 118,
Fluoroscopy, radiation safety with, 180, 189
29, 182, 188, 191–192 Heart block, complete
Foot, arterial supply of, 102, 102f due to left ventriculography, 78t
Frame rate, for peripheral angio- Heart valves, prosthetic, left ventricu-
graphy, 85 lography with, 73, 76–77, 77f,
78f
Hematoma, post-cath complications,
G 170–171, 172f
Gastroepiploic artery grafts, Hemodynamic effects, of contrast
65–66, 66f agents, 23
Gastrointestinal bleeding, as con- Hemodynamic measurements,
traindication to cardiac catheter- 107–133
ization, 11 of cardiac output, 124–126, 127,
Gauge, of needle, 30 127t
GFR (glomerular filtration rate), of cardiac performance, 124–129
23, 175 of cardiac tamponade, 119, 120,
Glidewire, 30, 93 121f
78852_Index 18/06/10 5:28 PM Page 202
202 Index
Hemodynamic measurements collagen-based biosealant devices,

(Continued) 154–158
in clinical scenarios, 110f–112f complications for, 163–164
common sources of error in, 107, cost analysis, 165
109t hemostatic pads, 152–153
in constrictive pericarditis, 120, manual compression, 151–152
122–123, 122f, 123f mechanical compression,
of hypertrophic obstructive car- 153–154, 154f
diomyopathy, 118–119, 119f, novel devices, 162–163
120f percutaneous suture devices,
insertion of PA catheter for, 109 158–161
of intracardiac pressure waveforms. sheath size, 164–165
See Intracardiac pressure wave- staple and clip devices, 161–162
forms Hemostatic pads, for hemostasis,
methodology of, 107–119 152–153
hypertrophic obstructive car- Heparin
diomyopathy, 118–119, 119f with brachial approach, 39
oximetry measurements, 108, prior to coronary angiography,
110 16t, 179, 186
pressure gradients across with radial approach, 39
stenoses, 113–118, 114f, 115f, Hiccups, post-cath complications,
117f 170t
pressure measurements, 107, High-osmolar contrast media
108f, 109t (HOCM), 22
temperature measurements, 110 High-risk patient, 135–149, 135t
normal parameters for, 110f–112f, acute coronary syndrome, 141
130 airway compromise/respiratory
of oximetry, 108, 110 failure, 140
of pressure, 107, 108f, 109t aortic dissection/aneurysm, 143
left ventricular filling, 128 aortic stenosis, 143–144
pulmonary artery, 112f bleeding risk of, 148–149
pulmonary capillary wedge, with bradycardia, 137–139
112f cardiogenic shock, 144–148
right atrial, 111f with hypotension, 136–137
right ventricular, 111f left main trunk coronary artery
in various cardiac chambers, disease, 141–143
110f pulmonary hypertension, 148
of pressure gradients across with tachycardia, 139–140
stenoses, 113 HOCM (high-osmolar contrast
aortic, 113–115, 114f, 115f media), 22
mitral, 115–118, 117f Hospitalization, after cardiac
of shunts, 123–124 catheterization, 13
of temprature, 110 Hydrocortisone, for contrast reac-
of valvular regurgitation, 121f tions, 26t, 27
of vascular resistance, 128–129 Hypertension
Hemostatic devices as contraindication to cardiac
arterial access site, 164–165 catheterization, 11, 12t
78852_Index 18/06/10 5:28 PM Page 203
Index 203
Hypertrophic obstructive cardiomy- Internal carotid artery (ICA), 88,

opathy (HOCM) 88f, 89
hemodynamic measurements with, segments of, 89
118–119, 119f, 120f Internal iliac artery (IIA), 97
Hypoglycemics, prior to coronary an- Internal mammary artery (IMA)
giography, 16t, 17 left
Hypotension, 184, 193 anatomy of, 62–63, 63f
by contrast allergy, 136 cannulation of, 62–64
during right heart catheterization, catheter selection for, 33f, 34
137 iatrogenic dissection of, 57f
during vascular access, 137 right
Hypoxemia, 184, 193 catheterization of, 64–65
catheter selection for, 34
Internal mammary artery (IMA)
I grafts, 62–65, 63f
IABP. See Intra-aortic balloon pump left, 62–64
(IABP) iatrogenic dissection of, 57f
ICA (internal carotid artery), 88, patency of, 62
88f, 89 views of, 61t
segments of, 89 right, 64–65
ICH (intracranial hemorrhage), International normalized ratio
105–106 (INR), 149
IIA (internal iliac artery), 97 Intra-aortic balloon pump (IABP),
IMA. See Internal mammary artery 144–148
(IMA) adjustment of timing and triggers,
Image intensifiers, radiation safety 145, 147f
with, 29 with aortic stenosis, 144
IMA (inferior mesenteric artery), ballon size for, 144
94 with cardiogenic shock, 144
Indications, for cardiac catheteriza- complications of, 148, 148t
tion, 3–9, 4t–6t, 10t–11t indications and contraindications
Infections, post-cath complications, for, 144, 145t
174 monitoring of, 146
Inferior mesenteric artery (IMA), placement of, 144–145, 146f
94, 97 Intracardiac pressure waveforms,
Inferior vena cava (IVC), 139 119–124
Informed consent, 13 in cardiac tamponade, 119, 120,
Infrapopliteal vasculature, poor 121f
opacification of, 103 in constrictive pericarditis, 120,
Inguinal ligament, 35, 36f 122–123, 122f, 123f
Innominate artery, 87, 87f in shunt calculation, 123–124
angiography, 93 in tricuspid regurgitation, 119,
INR. See International normalized 121f
ratio (INR) in valvular regurgitation, 121f
Insulin, prior to coronary angiogra- Intracranial circulation, right, 89, 90f
phy, 16t, 17 Intracranial hemorrhage (ICH),
Intermittent claudication, 183, 193 105–106
78852_Index 18/06/10 5:28 PM Page 204
204 Index
Intravascular ultrasound (IVUS), 97 LBBB (left bundle branch block)

Inverse square law, 29, 187–188 cardiac catheterization with, 3
Iodixanol (Visipaque 320), 22t LCA. See Left coronary artery (LCA)
Iohexol (Omnipaque), 22t LCB (left coronary bypass) catheter,
Iopamidol (Isovue 370), 22t 33f
Ioversol (Optiray 320), 22t LCX coronary artery. See Left cir-
Ioxilan (Oxilan 350), 22t cumflex (LCX) coronary artery
Ischemia, after percutaneous coro- Lead aprons, 28, 187
nary intervention, 8 Lead glasses, 28, 187
Isovue 370 (Iopamidol), 22t Lead shields, 29
IVC (inferior vena cava), 139 Left Amplatz (AL) catheter, 32–34,
IVUS (intravascular ultrasound), 97 33f
Left anterior descending (LAD)
anastomosis, 182, 191
J Left anterior descending (LAD)
JL (left Judkins) catheter, 32, 33f, 42 coronary artery
JoMed, 5-Fr., catheter, 34 anatomy of, 41
JR (right Judkins) catheter, 32, anomalies of, 50, 51f
33f, 44 catheter selection for, 32
J-tip guidewire, 31 obstruction of, 50f
for left coronary arteries, 42 saphenous vein grafts to, 59, 62
for left ventriculography, 73 views of, 46–48, 47f–48f, 49f
for right coronary arteries, 44 Left anterior oblique (LAO) view,
Judkins catheters, 32, 33f, 182, 191 181, 190
for abdominal angiography, 96 for aortic arch angiography, 90
for aortic arch angiography, 93 for aortography, 80, 80f
for carotid angiography, 90, 91 for celiac trunk angiography, 97
for left coronary arteries, 42 for coronary angiography, 46, 46t
for left internal mammary artery left coronary, 48, 48f, 49f
grafts, 63, 64 right coronary, 48, 49f, 50f
for left ventriculography, 73 for left ventriculography, 74–75,
for right coronary arteries, 44 75f
for saphenous vein grafts, 59 of aortic valve function, 76–77,
Jugular venous pressure, post-cath 78f
complications, 169 Left aorto-coronary bypass graft,
180, 190–191
Left atrial pressure, 110f, 130
L Left bundle branch block (LBBB)
Laboratory evaluation cardiac catheterization with, 3
post-cath complications, 176 Left circumflex (LCX) coronary artery
precatheterization, 3 anatomy of, 41
LAD coronary artery. See Left ante- anomalies of, 50, 52f
rior descending (LAD) coro- catheter selection for, 32
nary artery saphenous vein grafts to, 59, 60f
LAO view. See Left anterior oblique views of, 46, 47f, 49f
(LAO) view Left common carotid artery, 87–88,
Latex allergy, 2 87f, 88f, 90
78852_Index 18/06/10 5:28 PM Page 205
Index 205
Left coronary artery (LCA) Left ventricular pressure, 110f,

anatomy of, 41 117f, 130
engaging of, 42–44 Left ventricular systolic dysfunction,
saphenous vein grafts to, 59, 62 8–9
views of, 46–48, 46t, 47f–48f, 49f Left ventricular systolic function,
Left coronary bypass (LCB) catheter, 75–76, 76t
33f Left ventriculography, 69–79
Left internal mammary artery advancing guidewire in, 73
(LIMA) analysis of, 75–77
anatomy of, 62–63, 63f with aortic stenosis, 72–73
cannulation of, 62–64 complications of, 77, 78t
catheter selection for, 33f, 34 with elevated left ventricular end-
iatrogenic dissection of, 57f diastolic pressure, 72
to LAD anastomosis, 182, 191 entering ventricle in, 70–74, 71f
Left internal mammary artery entrapment in mitral valve
(LIMA) grafts, 62–64 apparatus, 72
iatrogenic dissection of, 57f indications for, 69t
patency of, 62 of left ventricular systolic function,
views of, 61t 75–76, 76t
Left Judkins (JL) catheter, 32, 33f for measuring cardiac output,
Left lateral view, for left ventriculog- 126, 127t
raphy, 75 placement of pigtail catheter in,
Left main (LM) trunk coronary ar- 70–71, 71f
tery disease, cardiac catheteriza- preparation for, 69–70, 70t
tion with, 141–143, 142f of prosthetic valves, 73, 76–77,
Left main trunk 77f, 78f
anatomy of, 41 of regional wall motion, 75t
anomalies of, 50, 54f standard settings for, 70, 70t
difficulty in engaging, 43 of valvular anatomy and function,
spasm of, 44 70, 76, 76t
stenosis of, 44 ventricular ectopy in, 71f, 72
unusual takeoff of, 43 views for, 74–75, 74f, 75f
views of, 47f, 49f Leg pain/numbness, post-cath
Left subclavian artery complications, 170t
anatomy of, 63–64, 63f, 87, LIMA. See Left internal mammary
87f, 91 artery (LIMA)
Left-to-right shunts, 123 LIMA grafts. See Left internal
Left upper extremity, 93f mammary artery (LIMA)
Left ventricular ejection fraction grafts
(LVEF), 174 LOCM (low osmolar contrast
Left ventricular end-diastolic pressure media), 22
(LVEDP), 72, 128 Lorazepam (Ativan), for preproce-
Left ventricular filling pressure, 128 dural sedation, 21t
elevation of, due to contrast Lower extremity, 97–105
agents, 22 anatomy of, 97–103
Left ventricular outflow tract (LVOT), angiography of, 103–105
pullback to, 118, 119f rules prior to, 103
78852_Index 18/06/10 5:28 PM Page 206
206 Index
Lower extremity arterial disease, Mitral regurgitation

catheterization with, 1 ACC/AHA guidelines for, 133
Low osmolar contrast media intracardiac pressure waveforms in,
(LOCM), 22 121f
LVEDP (Left ventricular end-dias- left ventriculography of, 70, 74,
tolic pressure), 72 76t
LVEF (Left ventricular ejection Mitral stenosis
fraction), 174 ACC/AHA guidelines for, 132
LVOT (left ventricular outflow pressure gradients across,
tract), pullback to, 118, 119f 115–118, 117f
Mitral valve apparatus, entrapment of
catheter tip within, 72
M Mitral valve orifice area, 115, 116,
Mallampati classification, for tongue 118
size, 140 Mitral valve prosthesis, left ventricu-
Mammary artery, internal. See lography of, 76–77, 77f
Internal mammary artery (IMA) Mixed venous saturation, 123, 181,
Manifold, 34–35 190
Manual compression, for hemostasis, Morphine sulfate, for preprocedural
151–152, 183, 192 sedation, 21t
Mean arterial pressure, 130 Mortality, from coronary angio-
Mechanical compression, for hemo- graphy, 13
stasis, 153–154, 154f Mucomyst (acetylcysteine), for renal
Medical conditions, concomitant, dysfunction, 15, 16t
1, 2t Multipurpose A (MPA) catheter, 33f
Medication(s) Multipurpose B (MPB) catheter, 33f
allergy to, 2 Multipurpose catheters, 33f, 34
prior to coronary angiography, Myocardial bridging, 54, 55f
16–17, 16t Myocardial depression, due to con-
prior to peripheral angiography, trast agents, 22
86 Myocardial function, effect of con-
Medrad powered flow injector, 69 trast agents on, 22–23
Meperidine (Demerol), for preproce- Myocardial infarction (MI)
dural sedation, 21t acute
Mesenteric arteries, 93–97 cardiac catheterization for, 3,
abdominal angiography, 95–97 4t, 5t, 6–7, 10t
anatomy of, 93–94, 95f, 96f indications for transvenous pace-
inferior. See Inferior mesenteric makers, 137–138, 138t
artery (IMA) periprocedural, 14
superior. See Superior mesenteric
artery (SMA)
Metformin N
prior to coronary angiography, N-acetylcysteine (NAC), 24. See also
16t, 17, 179, 186 Acetylcysteine (Mucomyst), for
prior to peripheral angiography, 86 renal dysfunction
Midazolam (Versed), for preproce- Naloxone (Narcan), for preproce-
dural sedation, 20, 21t dural sedation, 21t
78852_Index 18/06/10 5:28 PM Page 207
Index 207
Narcan (Naloxone), for preproce- PCI (percutaneous coronary inter-

dural sedation, 21t vention), 152
Nausea, post-cath complications, ischemia after, 8
170t PCWP. See Pulmonary capillary
Needle(s), access, 30 wedge pressure (PCWP)
Neurologic examination, post-cath PDA (posterior descending artery),
complications, 169 41–42, 49f, 50f, 179–180, 188
Nitroglycerin, for ostial spasm, 45 gastroepiploic artery grafts to, 66
Noncoronary angiography. See Peak systolic pressure, 130
Peripheral angiography PEA (pulseless electrical activity),
No Torque Right catheter, 34 144
Novel devices, for hemostasis, Perclose proglide, 158–159, 183,
162–163 192
Percutaneous coronary intervention
(PCI), 152
O ischemia after, 8
Obtuse marginals, 41 Percutaneous suture devices, for
Omni Flush catheter hemostasis, 158–161
for abdominal angiography, 95 Perclose Proglide, 158–159, 159f,
for lower extremity angiography, 183, 192
103 SuperStitch, 159–160, 159f, 160f
Omnipaque (Iohexol), 22t X-Press, 160–161
Open-bore needles, 30 Pericarditis, constrictive, intracardiac
Opioids, for preprocedural sedation, pressure waveforms in, 120,
21t 122–123, 122f, 123f
Optiray 320 (Ioversol), 22t Peripheral angiography, 85–86
Ostial spasm, 45 arterial access for, 85–86
Ostial stenosis, of vertebral arteries, complications related to, 105–106
91 contrast agents and, 86
Oxilan 350 (Ioxilan), 22t digital subtraction angiography
Oximetry measurements, 108, 110 for, 85
for shunt calculation, 123 frame rate for, 85
Oxygen consumption, 126, 130 image intensifier used for, 85
Oxygen content, 108, 126 limitation of, 103
Oxygen saturation, 108 of lower extremity. See Lower
for shunt calculation, 123 extremity
medication considerations prior
to, 86
P mesenteric. See Mesenteric arteries
PA. See Posteroanterior (PA) view, renal. See Renal arteries
for coronary angiography rules prior to, 103
PAD (peripheral arterial disease), 103 trace subtract fluoroscopy for, 85
PA (pulmonary artery) catheter, 181, Peripheral arterial disease (PAD),
190 103, 185, 194
insertion of, 109 Peripheral vasodilation, due to con-
Patient’s refusal, as contraindication to trast agents, 22–23
cardiac catheterization, 179, 186 Peroneal artery, 101, 101f
78852_Index 18/06/10 5:28 PM Page 208
208 Index
Petrosal segment, internal carotid medication considerations in,

artery, 89 16–17, 16t
PFA (profunda femoris artery), renal dysfunction in, 1, 14, 15
99–100 Preprocedural sedation, 20–21, 21t
P-G1cNAc (poly-N-acetyl glu- Preprocedural time-out, 19, 20t
cosamine), 153 Pressure damping, 45
Phenergan (Promethazine), for pre- Pressure gradients, across stenoses,
procedural sedation, 21t 113
Physical examination precatheteriza- aortic, 113–115, 114f, 115f
tion, 2–3 mitral, 115–118, 117f
Physical limitations, post-cath com- Pressure measurements, 107, 108f,
plications, 175–176, 175t 109t
Pigtail catheter(s), 32, 33f Pressure(s)
for aortic arch angiography, 90 aortic, 130
for aortography, 79 end diastolic, 130
for left ventriculography, 70–71, left atrial, 110f, 130
71f left ventricular, 110f, 117f, 130
for lower extremity angiography, left ventricular end-diastolic, 128
103 left ventricular filling, 128
Plavix (clopidogrel) , prior to coro- mean arterial, 130
nary angiography, 16, 16t peak systolic, 130
Poly-N-acetyl glucosamine pulmonary artery, 110f, 112f, 130
(p-G1cNAc), 153 pulmonary capillary wedge, 110f, 112f
Popliteal artery, 101, 101f and left ventricular filling pres-
Post-cath complications, 169–176 sures, 128
evaluation in, 169, 170t in mitral regurgitation, 121f
indications for routine labs in, 176 in mitral stenosis, 117f
local, 170–175 right atrial, 111f, 130
physical limitations in, 175–176, in constrictive pericarditis, 122f
175t right ventricular, 110f–111f, 130
symptoms suggestive of, 169, 170t systemic arterial, 130
Posterior descending artery (PDA), in various cardiac chambers, 110f
41–42, 49f, 50f, 179–180, 188 Pressure transducer, 34–35
gastroepiploic artery grafts to, 66 Pressure underdamping, 107, 108f
Posterior tibial artery (PT), 101, Pressure waveform, dampened or
101f, 102–103, 102f ventricularized, 43, 44, 45
Posteroanterior (PA) view Procaine
for abdominal angiography, 95 allergic reaction, 37
for coronary angiography, 46, 46t allergic reaction to, 37
left coronary, 46, 47f, 48 for percutaneous femoral
right coronary, 48 approach, 35
for lower extremity angiography, Prochlorperazine, for contrast agents,
104 26t
Preprocedural evaluation, 1–17 Profunda femoris artery (PFA),
clinical evaluation for, 1–3, 2t 99–100
concomitant medical conditions, Promethazine (Phenergan), for pre-
1, 2t procedural sedation, 21t
78852_Index 18/06/10 5:28 PM Page 209
Index 209
Prostar XL device, 158 Radial pulse, 37

Prosthetic femoral artery grafts, 38 Radiation dosimeter badges, 27
Prosthetic valves, left ventriculogra- Radiation exposure, 179, 187–188
phy with, 73, 76–77, 77f, 78f techniques used to minimize,
Pseudoaneurysm, post-cath compli- 187–188
cations, 171–174 Radiation safety, 27–30, 28t
PT (posterior tibial artery), 101, RAO view. See Right anterior oblique
101f (RAO) view
Pullback RAS. See Renal artery stenosis (RAS)
across aortic valve, 114–115, 115f RCA. See Right coronary artery
to left ventricular outflow tract, (RCA)
118, 119f RCB (right coronary bypass)
Pulmonary artery (PA) catheter, 181, catheter, 33f
190 Regional wall motion, 75, 75t
insertion of, 109 Renal arteries, 93–97
Pulmonary artery pressure, 110f, abdominal angiography, 95–97
112f, 130 anatomy of, 94–95, 96f
Pulmonary capillary wedge pressure Renal arteriography, 184, 193
(PCWP), 110f, 112f Renal artery ostial disease, 97
and left ventricular filling pres- Renal artery stenosis (RAS), 97
sures, 128 Renal dysfunction, precatheterization
in mitral regurgitation, 121f with, 1, 14, 15
in mitral stenosis, 117f Renal failure, as contraindication to
Pulmonary edema, 184, 193 cardiac catheterization, 11,
Pulmonary hypertension, coronary 179, 186
angiography with, 148 Renal function, effect of contrast
Pulmonary to systemic blood flow agents on, 23–24, 23t
(Qp/Qs), 123, 124 Renal insufficiency, metformin with, 17
Pulmonary vascular resistance, 128, Resistance, 128–129, 130
130 Respiratory failure, 140
Pulse, femoral, 35, 38 Retrograde subintimal dissection, 38
Pulseless electrical activity (PEA), Retroperitoneal hematoma, post-cath
144 complications, 171, 193
Pulsus paradoxus, in cardiac tampon- Right Amplatz (AR) catheter, 33f, 34
ade, 119, 120 Right anterior oblique (RAO) view,
181, 190
for carotid angiography, 90
Q for celiac trunk angiography, 97
Qp/Qs (pulmonary to systemic for coronary angiography, 44, 46,
blood flow), 123, 124 46t
left coronary, 46, 47f, 48
right coronary, 48, 49f
R for left ventriculography, 74, 74f
RACE trial, 160 of mitral valve function, 76–77,
Radial approach, for percutaneous 77f
vascular access, 39 Right atrial pressure, 111f, 130
Radial artery grafts, 65 in constrictive pericarditis, 122f
78852_Index 18/06/10 5:28 PM Page 210
210 Index
Right common carotid artery, 87, SCA (subclavian artery)

87f, 90 for aortic arch angiography, 92–93
Right coronary artery (RCA), 182, left
191 anatomy of, 63–64, 63f, 87,
anatomy of, 41 87f, 91
anomalies of, 50, 52f, 53f right
catheter selection for, 32–34 anatomy of, 87, 87f, 91
collaterals to, 49f, 50f Scatter radiation, 28–29
engaging of, 44 Sedation, preprocedural, 20–21, 21t
occlusion of, 49f Seldinger-type needle, 30
saphenous vein grafts to, 59, SFA (superficial femoral artery),
60f, 62 98–99, 100, 100f
views of, 46t, 48, 49f–50f Sheath(s)
Right coronary bypass (RCB) resistance during placement of,
catheter, 33f 38
Right internal mammary artery Shielding, 27–28, 179, 187
(RIMA) Shock, cardiogenic, coronary angiog-
catheterization of, 64–65 raphy with, 144–148
catheter selection for, 34 Shunt calculation, 123–124
Right intracranial circulation, Sinus arrest, due to contrast agents,
89, 90f 23
Right Judkins (JR) catheter, 32, Sinus bradycardia, due to contrast
33f, 44 agents, 23
Right subclavian artery Sinus node, artery to, 41
anatomy of, 87, 87f, 91 Sinus of Valsalva
Right-to-left shunts, 124 left, origin of right coronary artery
Right ventricular outflow tract from, 50, 53f
(RVOT), 138 right
Right ventricular pressure, origin of left circumflex artery
110f –111f, 130 from, 50, 52f
RIMA (right internal mammary origin of left main trunk from,
artery) 50, 54f
catheterization of, 64–65 origin of right coronary artery
catheter selection for, 34 above, 50, 52f
Romazicon (Flumazenil), for prepro- SMA (superior mesenteric artery),
cedural sedation, 21t 94
Rosen wire, for left ventriculography, Spacer, 30
73 “Spider view,” 48, 49f
RVOT (Right ventricular outflow Staphylococcus aureus, post-cath infec-
tract), 138 tion with, 174
Staple and clip devices, for hemosta-
sis, 161–162
S StarClose devices, 161
Saphenous vein grafts (SVGs), STEMI (STsegment elevation my-
59–62, 60f, 61t ocardial infarction), 141
catheter selection for, 34 Stenosis(es)
78852_Index 18/06/10 5:28 PM Page 211
Index 211
aortic T
ACC/AHA guidelines for, Tachycardia
131 with diagnostic catheterizations,
left ventriculography with, 72–73 139–140
mitral post-cath complications, 169
ACC/AHA guidelines for, Temperature measurements, 110
132 Temporary transvenous pacemaker
pressure gradients across, (TVP)
115–118, 117f ACC/AHA indications for, 138t
ostial, of vertebral artery, 91 Terminal branches, 41
pressure gradients across, 113 Thermodilution method, for measur-
Steroids, for contrast reactions, 26 ing cardiac output, 125, 127t
Straight Flush catheter Thrombocytopenia, as contraindica-
for lower extremity angiography, tion to cardiac catheterization, 1
103 Thyrocervical trunk, 91, 92f
Straight-tipped wire, 31 Thyroid shields, 28–29
Stress test, prior, 3 Tibioperoneal (TP) trunk, 101–102
Stroke, periprocedural, 14 Tilting-disc aortic valve prosthesis,
STsegment elevation myocardial 73, 78f
infarction (STEMI), 141 Tilting-disc mitral valve prosthesis,
Subclavian artery (SCA) 77f
for aortic arch angiography, Time-out protocol, for preprocedural
92–93 verification, 19, 20t
left TP (tibioperoneal) trunk, 101–102
anatomy of, 63–64, 63f, 87, Tricuspid regurgitation, intracardiac
87f, 91 pressure waveforms in, 119, 121f
right TVP (Temporary transvenous pace-
anatomy of, 87, 87f, 91 maker), 137
Superficial femoral artery (SFA),
98–99, 100, 100f
Superior mesenteric artery (SMA), U
94, 98 Ulnar artery, 92
SuperStitch device, 159–160, 159f, Ultrasound-guided thrombin injec-
160f tion, 183, 192
Supraclinoid segment, internal Underdamping, pressure, 107, 108f
carotid artery, 89 Unstable coronary syndromes, car-
SVGs (saphenous vein grafts), 59–62, diac catheterization for, 4t
60f, 61t Upper extremity, 91–93
catheter selection for, 34 anatomy of, 91–92, 92f
Swan-Ganz catheter, 181–190 angiography, 92–93
SYNERGY trial, 164 aortic arch angiography for, 92–93
Systemic arterial pressure, 130 innominate artery angiography
Systemic vascular resistance (SVR), for, 93
128, 129, 130 left, 93f
Systolic area index, 122–123 upper extremity angiography,
SyvekPatch, 153 93, 93f
78852_Index 18/06/10 5:28 PM Page 212
212 Index
V Vascular resistance, 128–129, 130

Valium (Diazepam), for preproce- Vascular sheaths, 31
dural sedation, 21t VasoSeal hemostatic devices,
Valve orifice area (VOA) 157–158, 157f
aortic, 113, 115 VCD (vascular closure devices), 151
mitral, 115, 116, 118 Ventricular arrhythmias
Valve(s), prosthetic, left ventriculog- due to left ventriculography, 78t
raphy with, 73, 76–77, 77f, 78f Ventricular ectopy, in left ventricu-
Valvular heart disease lography, 71f, 72
ACC/AHA guidelines for, Ventricularization, 44, 45
131–133 Ventricularized pressure waveform,
coronary angiography for, 9, 11t 188–189
left ventriculography of, 70, 76, Ventriculography, contraindications
76t for, 181, 190
Valvular regurgitation, intracardiac Versed (Midazolam), for preproce-
pressure waveforms in, 121f dural sedation, 20, 21t
Vascular access, 35–39 Vertebral arteries, 89
arm approaches, 37–39 ostial stenosis of, 91
percutaneous brachial approach Vessel tortuosity, catheterization
for, 37, 39 with, 38
percutaneous femoral approach, Visipaque 320 (Iodixanol), 22t
35–37, 36f Vitek catheter, for carotid angiogra-
percutaneous radial approach phy, 90
for, 39 VOA (valve orifice area)
troubleshooting for, 37, 38 aortic, 113, 115
Vascular closure devices (VCD), mitral, 115, 116, 118
151–166, 183, 193
arterial access site, 164–165
collagen-based biosealant devices, W
154–158 Warfarin
complications for, 163–164 prior to coronary angiography, 16,
cost analysis, 165 16t, 17, 179, 186
hemostatic pads, 152–153 prior to peripheral angiography,
manual compression as, 151–152 86
mechanical compression as, Waveform, dampened or ventricular-
153–154, 154f ized, 43, 44, 45
novel devices as, 162–163 Wholey guidewire, 30, 38
percutaneous suture devices as,
158–161
sheath size, 164–165 X
staple and clip devices, 161–162 X-Press device, 160–161

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78852_FM 25/06/10 10:23 AM Page i

Arman T. Askari, MD, FACC

Mehdi H. Shishehbor, DO, MPH

Adrian W. Messerli, MD, FACC, FSCAI

Ronnier J. Aviles, MD, FACC

Acquisitions Editor: Frances R. DeStefano

To our families for their continuous

Foreword to the First Edition vi

2 Setting up the Lab 19

3 Native Coronary Angiography 41

Stephen Gimple, Niranjan Seshadri, Robert E. Hobbs,

4 Bypass Graft Angiography 59

5 Left Ventriculography and Aortography 69

Mateen Akhtar and Frederick A. Heupler, Jr.

6 Cerebral and Peripheral Angiography 85

Inder M. Singh, Steven J. Filby, and Mehdi H. Shishehbor

7 Hemodynamics in the Cath Lab 107

Brian W. Hardaway, Wilson H. Tang, and

8 Approach to the High-Risk Patient 135

9 Hemostatic Devices 151

James E. Harvey and A. Michael Lincoff

10 Post-Cath Complications 169

Arun Kalyanasundaram and Mehdi H. Shishehbor

11 Study Questions 179

Consider you are a novice to the catheterization laboratory. Apparently,

Foreword to the First Edition vii

The trainee beginning in the cardiac catheterization laboratory (physi-

Foreword to the Second Edition ix

The staff in every catheterization laboratory in the world participate in

Mateen Akhtar, MD Steven J. Filby, MD

Kellan E. Ashley, MD Stephen Gimple, MD

xii Contributing Authors

Matthew Kaminski, MD Niranjan Seshadri, MD

Cardiac catheterization is an invaluable tool for both diagnostic and

2 Introductory Guide to Cardiac Catheterization

Table 1-1 Relevant Historical Elements

A. Prior cardiac catheterizations and/or cardiac surgeries

brachial or radial artery access. Any history of claudication in conjunc-

Chapter 1 • Preprocedural Evaluation 3

peripheral edema. Auscultation of any murmurs, particularly those that

4 Introductory Guide to Cardiac Catheterization

Table 1-2 Indications for Coronary Angiography

Unstable Coronary Syndromes

Chapter 1 • Preprocedural Evaluation 5

Table 1-2 (Continued )

6 Introductory Guide to Cardiac Catheterization

Table 1-2 (Continued )

Equivocal noninvasive testing in patient with intermediate clinical risk

new ST depression, signs/symptoms of CHF, hemodynamic or elec-

Chapter 1 • Preprocedural Evaluation 7

8 Introductory Guide to Cardiac Catheterization

Table 1-3 Canadian Cardiovascular Society Classification of Angina

I Ordinary physical activity does not cause angina

Chapter 1 • Preprocedural Evaluation 9

disease by angiography unless the patient is not a candidate for revascu-

10 Introductory Guide to Cardiac Catheterization

Table 1-4 Class IIIa Indications for Coronary Angiographyb

Chapter 1 • Preprocedural Evaluation 11

Table 1-4 (Continued )