Coronary Angiography

Coronary angiography is a method of imaging the vessels that supply the heart. It is performed in the catheterization laboratory. A radiopaque substance (contrast agent) visible on X-ray is injected into the coronary arteries, allowing the anatomy of the heart vessels to be observed.

Why is it performed? (What kind of complaints should a person have for it to be performed?)

It is performed when the coronary arteries are thought to be insufficient in supplying the heart muscle and there is evidence of this. It is a unique diagnostic method used to plan diagnosis and treatment in patients with exertional chest pain and an abnormal exercise stress test performed for this reason, in prolonged chest pain that has recently been increasing or has begun to occur even at rest, and in sudden heart attacks.

When is it performed?

Angiography can be performed almost at any time; for elective (planned) angiography, the patient is asked to fast for 6 hours. In emergencies, it is performed as soon as possible after the necessary precautions have been taken.

Is it a risky procedure? What are the risks?

Angiography is an interventional procedure and is therefore not completely risk-free. The most serious risks are death, stroke and the possibility of having a heart attack during angiography; however, these risks are less than 1 in 1,000 in total. Other, more common risks include:

• Allergy to the radiopaque substance used,

• Complications in the vessel at the angiography access site (such as hematoma, a fistula between the artery and vein, or an aneurysm, i.e. ballooning of the vessel wall).

• Rarely, acute kidney failure in some patients, again due to the radiopaque substance used.

Is the radiation received during angiography harmful?

During angiography, as the radiopaque substance passes through the vessel, X-ray images are taken for 2-3 seconds, producing an average of 6-7 images; the amount of radiation received is not harmful to health.

What should be considered when preparing for angiography?

Certain medications need to be stopped before angiography. The patient will be informed about this by their doctor. In addition, 6 hours of fasting is required for planned cases. Apart from this, no special preparation is needed unless specified by the patient's doctor.

From which parts of the body is angiography performed?

It is most often performed through the artery in the groin, called the femoral artery, and through the wrist artery, called the radial artery. Less commonly, if these two vessels are not suitable, it can be performed through the artery on the inner side of the elbow, called the brachial artery.

Is it a painful procedure?

It is a procedure performed under local anesthesia. Although it varies depending on the person's pain threshold, generally no more pain is felt than the needle prick during the local anesthetic injection.

Is the agent used during angiography harmful?

It can rarely cause allergy. In addition, in some high-risk patients (those with known kidney failure or at risk of kidney failure, and diabetics using certain medications), it can cause kidney failure.

Is it healthier to perform it through the groin or the arm?

This varies according to the physical characteristics of the person undergoing angiography. If the patient has known blockages in the abdominal and leg vessels, and especially in people who are overweight in the groin and abdominal area, angiography through the arm is healthier in order to reduce complications. On the other hand, in people with a thin wrist and therefore a thin wrist artery, for example petite, slim women, performing angiography through the groin artery will be easier and healthier for both the patient and the physician performing it.

What are the differences, advantages and disadvantages of angiography performed through the arm versus the groin?

Once the coronary arteries are reached, there is no difference between the two approaches in terms of the images obtained and their interpretation. However, there is no vein or nerve adjacent to the artery used for wrist angiography (the radial artery). Moreover, because this artery runs more superficially, bleeding control after angiography is easier to achieve than in the groin artery. In short, access-site complications (bleeding, swelling) are almost non-existent in wrist angiography. On the other hand, the wrist artery is thinner than the groin artery and more prone to constriction during the procedure, called spasm. This can prevent reaching the coronary arteries by this route, especially in people with a slender build.

What does the patient feel during angiography? Is it performed under general anesthesia?

It is usually performed under local anesthesia. Apart from a mild burning sensation felt while the local anesthetic is being injected, no additional pain is felt. Palpitations may be felt due to rhythm disturbances that occur while the catheter is in the coronary artery or inside the heart. Rarely, nausea and vomiting may occur due to the radiopaque substance. For this reason, elective (planned) angiographies are performed after 6 hours of fasting. The 20-30 cc of radiopaque substance injected into the heart chamber to assess the contraction of the heart during angiography usually causes a temporary burning sensation in the chest and face (lasting about 20-30 seconds).

What information is obtained through angiography?

By imaging the coronary arteries during angiography, information is obtained on the size of the vessels, their diameter, whether there is narrowing, and if so, how severe it is, where the narrowing is located, its length, whether there is calcification in the narrowing, whether there is a clot inside the vessel, and whether the vessel is straight or tortuous. Coronary angiography is a purely diagnostic method. Treatment (medication, balloon, stent, bypass) is planned according to the results.

If there is a blocked vessel, is angioplasty performed?

In coronary artery disease, there are narrowings in the vessels, which vary in degree, or complete blockages. The decision for angioplasty, i.e. opening the coronary arteries with a balloon and/or stent, is made according to the location and degree of the narrowing or blockage, the vessel diameter and the length of the narrowing. Especially in sudden heart attacks, after the angiography performed in the first minutes and hours, the blocked vessel can usually be opened with angioplasty.

How is angioplasty performed?

If the narrowing or blockage detected by angiography is suitable for opening with angioplasty, a guide wire is advanced through the catheter placed at the entrance of the coronary artery and passed through the narrowing inside the vessel. Depending on the physician's decision based on the characteristics of the vessel, the narrowing may first be widened with a balloon followed by a stent, or a stent may be placed directly without using a balloon.

What is a stent? What is it used for? What are its features?

When a balloon is applied to the narrowed area inside the vessel, the plaque causing the narrowing is spread and pressed against the vessel wall. To prevent this plaque from narrowing the vessel again, stents are used: they can be described as a steel mesh placed against the inner vessel wall, holding the plaque against it. Although stent technologies are changing rapidly today, stents can roughly be divided into two groups: drug-eluting stents and bare-metal (normal) stents. The most important disadvantage of normal stents is the need for re-intervention within 6 to 8 months due to re-narrowing of the implanted stent. This risk is lower with drug-eluting stents (less than 10%). This does not mean that a drug-eluting stent is the right choice for every patient. The choice between a normal stent and a drug-eluting stent is made by the physician according to the patient's characteristics (such as the presence of diabetes or previous narrowing of an implanted stent) and the characteristics of the vessel to be stented (based on the answers to questions such as whether the vessel diameter is small or the narrowing is long).

How long is rest needed after angiography (in hospital and at home)?

After angiography through the groin artery, the patient needs to rest lying down for 4-6 hours to control bleeding. After this, if there is no problem in the groin area under the physician's supervision, the patient is mobilized and discharged after 1-2 hours of observation in the hospital. In wrist angiography, the patient can be mobilized immediately after the procedure and can again be discharged after 1-2 hours of observation. At home, unless the patient's doctor has specified otherwise, the person can return to normal life the next day.

What should a person pay attention to after angiography?

After angiography through the groin, long journeys and lifting heavy objects are not recommended for 1-2 days. Likewise, after wrist angiography, heavy lifting is not recommended for a few days.

Will there be pain?

Normally, pain at the access site is not expected after angiography. However, mild pain may be felt.

In which situations should a physician be contacted immediately?

• Bleeding at the angiography access site,

• Swelling,

• Bruising covering a large area or severe pain,

• Signs of low blood pressure: in these cases, it is advisable to go to the hospital and be evaluated by a physician.

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