Angiography (Coronary Angiography)

By: Prof. Dr. Şükrü Akyüz

Angiography is an abbreviation for angiography. Angiography means “visualisation of blood vessels” in medical language. Angiography can be performed on any vessel in the body. What we mean by angiography in this section is the visualisation of the heart vessels.

Who undergoes angioplasty?

Angiography is performed to check for stenosis or blockage of the heart vessels. Patient groups in whom this condition is suspected are as follows:

  • Those with typical chest pain or similar complaints (e.g. pain, burning or pressure in the chest when walking or climbing uphill)
  • Abnormal results of preliminary examination tests (ECG, ECO, stress test or scintigraphy)
  • Those whose virtual angiography (CT angiography) reveals serious problems in the vessels or whose decision cannot be made due to unclear images
  • Heart attack victims
  • Those with heart failure
  • Some patients with heart rhythm disturbances

Who can't have angioplasty?

Some patients who should normally have an angiogram may have special conditions or other comorbidities that make an angiogram risky or unhelpful. Examples include:

  • Failure to give permission after informed consent (In the case of mentally unstable patients, the first-degree relatives do not give permission)
  • Active infection
  • Active bleeding (menstrual bleeding is not an obstacle)
  • Severe renal failure
  • Severe anaemia (anaemia)
  • Severe hypertension that cannot be controlled with medication

What are the risks of angiography?

Like any procedure, angiography has its risks. Serious complications occur in 2 out of every 1000 people. The risk actually varies from person to person. For example, emergency angioplasty for heart attacks and angioplasty for patients with serious diseases in other organs are riskier. However, not performing angiography, i.e. not starting the treatment process for problems in the heart vessels, can be much more risky. Therefore, the decision on whether or not to perform an angioplasty is based on a cost-benefit balance.

Possible complications of angiography are:

  • Damage to a blood vessel in the leg or wrist: Severe bleeding or blockage of a blood vessel in the leg (groin) or wrist can occur. Therefore, blood transfusions or emergency vascular surgery may rarely be necessary.
  • Heart rhythm disturbances: Short-term rhythm disturbances that resolve spontaneously are common during angiography, but are of no significance. Rarely, emergencies may occur that impair consciousness and require medication or electroshock.
  • Kidney failure: The dye called contrast dye, which allows us to obtain images in angiography, impairs the kidneys in 5 out of every 100 patients. The risk is even higher in patients who already have kidney problems. For example, the risk is five times higher in advanced kidney failure. If kidney deterioration develops, it usually resolves completely with intravenous fluid replacement. In rare cases, temporary dialysis may be required. Permanent dialysis is extremely rare.
  • Allergy Allergy may rarely develop due to the contrast material. Itchy rashes may occur on the skin; this is temporary. Very rarely, allergic reactions are serious enough to prevent breathing. All the necessary equipment for such emergencies is available in the angiography suite.
  • Heart attack: If the patient’s heart vessels are very fragile, the catheter can damage them. This can lead to blockage of the heart vessels, which can cause a heart attack. In this case, a stent must be inserted immediately to open the vessel. Very rarely, emergency heart surgery (bypass) may be required.
  • Cardiovascular rupture (dissection) or perforation (rupture): These problems are rare. In most cases, the problem is solved by emergency interventions during the procedure. Very rarely, emergency heart surgery (bypass) may be required.
  • Paralysis: In rare cases, small fats or clots that break off when the catheter touches the delicate areas of the vessels that allow access to the heart can escape into the brain vessels. This can cause temporary or permanent paralysis.

Is there a risk of death in angiography?

In the event of a complication, emergency interventions usually solve the problem. Very rarely, interventions do not work and the patient dies. This probability is also related to the experience of the physician. On average, death occurs in 1 out of every 1000 angiograms.

I am concerned about these risks, what should I do?

You may be right to be concerned, but remember: These complications are very rare. The important question is whether angiography is really necessary. If the decision to undergo an angioplasty is made in accordance with current scientific data and guidelines, avoiding this procedure means that you are exposing yourself to a much higher risk of heart attack and death.

What should I pay attention to before angiography?

  • Ask your doctor which medicines you should and should not take on the day of the angioplasty. A few days before the angioplasty, you may be asked to stop taking some blood-thinning medicines, or sometimes to continue taking them. The same applies to medicines for diabetes.
  • Be sure to tell your doctor if you have a known allergic predisposition (medication, iodine, contrast media, latex products such as rubber gloves, etc.).
  • Depending on the results of the angiography, your doctor may tell you that you need to stay in hospital for a few more days. This means that you may not be able to go home that day. For this reason, we recommend that you bring your personal belongings (slippers, toothbrush, etc.) with you to make you more comfortable while you are in hospital. Also, plan to have a relative drive you home when you are discharged. A

How long does an angioplasty take?

The angiogram usually takes 30 minutes. However, sometimes the anatomical features of the site of entry, the vessels extending from the site of entry to the heart or the cardiac vessels can be complex. In these cases, the duration is longer.

Is there pain during angiography?

During the angioplasty, only the site of entry into the vein is anaesthetised. You will be awake during the angioplasty. However, you may be given relaxing medication to relieve your tension. These medicines may make you sleepy; this is normal.

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How is angiography performed?

<b>How is angiography done?</b> The arm of the X-ray machine will move around your head and chest to take films of your heart vessels from many angles. Either before you arrive in the angiography room or while you are in the angiography room, an intravenous cannula will be inserted into your back or arm to give you fluids or medication if necessary. Electrodes will be attached to your chest so that we can monitor your heart rhythm. You will also have a device (oximeter) attached to your finger or toe so that we can monitor your blood oxygen level. If you have a lot of hair, your groin or wrist will be shaved with a machine and then disinfected. Next, your vascular access site will be anaesthetised with medicine in a syringe with a fine needle so that you do not feel pain, and a plastic sheath will be placed over the access site. Through this sheath, first a long wire and then a long, flexible tube (catheter) will be inserted into your heart. After the catheter has been inserted into the entrance to your heart, a dye will be injected. This dye may cause you to feel a brief sensation of warmth; do not be afraid. Thanks to the dye, it will be possible to see whether there is stenosis or blockage in the vessels that are now visible.

Wrist angiography is better or groin angiography?

Most patients can undergo angiography both through the wrist and through the leg (groin). The details are as follows:

  • The most common complication of angiography is bleeding at the site of vascular access. This occurs less frequently at the wrist access site than in the groin and is less likely to be serious. Even if it occurs, it can be easily controlled by pressing by hand.
  • The wrist is more comfortable for the patient than the leg. The inguinal route is more comfortable for the doctor.
  • After an angioplasty in the wrist pathway, you do not have to lie on your back for 4-6 hours. In fact, if the inguinal vein access site is closed with special groin closure devices rather than by pressing on the groin vein by hand, it is not necessary to lie on the back for a long time in the groin pathway.
  • As the wrist vein has a thinner diameter, it is much more likely to become blocked than the groin vein; this occurs in 1 in 10 patients. However, because there is an additional (backup) vein in the wrist, even if the wrist vein is blocked by a clot, the backup vein does not cause any problems; in fact, it is extremely rare. The inguinal vein is less likely to become blocked, but because it is the only vein leading to the leg, it may require emergency stenting or surgery if it becomes blocked.
  • The wrist vein is more prone to catheter-induced spasm (constriction). This can cause the vein to compress the catheter, which in some patients can lead to difficulty in retracting the catheter and severe pain.
  • Infection is much less likely to develop at the wrist vein entry site than in the groin. If infection develops in the groin, this can sometimes lead to very serious consequences.
  • Not all procedures and not all patients are technically suitable for wrist procedures. Both the anatomy of the wrist must be appropriate (for example, the wrist vein must not be too thin or tortuous) and the doctor must be experienced in wrist procedures.
  • In some patients, it may be necessary to use the inguinal route or the wrist route for clinical and anatomical reasons.
  • The images obtained in angiography are the same whether the inguinal or wrist route is used.
Consequently, the wrist should be preferred if possible. The most important reason for the recommendation to prefer the wrist is that bleeding, which is the most common complication, is less frequent and severe than the inguinal route. However, due to the details mentioned above, it is best to leave the final decision to the physician who will perform the angiography.

How long will I stay in hospital after the angioplasty?

If the angioplasty is performed via the wrist, most patients are discharged after 1.5-2 hours. In the inguinal route, this period is 4-6 hours. During this time, some doctors ask the patient to place a heavy sand bag over the groin area to prevent bleeding. Although it is thought that this reduces bleeding by pressurising, this is not the main mechanism; it restricts the movement of the leg. Personally, I (Dr Şükrü Akyüz) do not prefer a sandbag if I am sure that the patient understands that he/she should not move his/her leg. Because, if there is bleeding in the groin vein, the bleeding under the sandbag may be overlooked and the necessary intervention may be delayed. This can have serious consequences, including a risk to life. In addition, the sandbag can cause the patient to have a bad experience by disturbing the patient’s comfort considerably. However, if special closure devices are used for the inguinal vein, the patient can stand up after 1 hour, i.e. he does not have to lie on his back for a long time and can be discharged earlier.

What should I pay attention to after angiography?

After the angioplasty, your nurse will regularly check your vein entry site (groin or wrist). However, bleeding may still occur. If bleeding occurs, you should press on the bleeding site with your hand to stop the bleeding before informing the healthcare team. You should tell your nurse if your fingers or toes tingle or go numb. You should also drink plenty of water after the angioplasty (except for people with heart failure). This will reduce the chance of your kidneys becoming impaired by the contrast medium.

Once you have been discharged, it is fine to go for a walk and return to your usual daily routine from the next day. However, you should not do any heavy work or heavy lifting for a few days. You should also inform your doctor if you experience the following at the site of the angioplasty (groin or wrist)

bleeding (in this case, you should press on the bleeding area with your hand and call 112)
Increasing swelling (swelling that does not exceed the size of a hazelnut is normal)
Increasing redness (slight redness, swelling, bruising or tenderness is normal)
Inflammatory discharge (occasional small amounts of transparent discharge is normal)
Excessive pain (this is normal if your pain decreases over time)
Numbness in the leg or wrist that does not go away