Coronary angiography is a radiopaque endovascular examination of the state of the coronary vascular bed. Coronary angiography is indicated for objective signs of myocardial ischemia, postinfarction or unstable angina, acute coronary syndrome, before elective heart surgery, etc. conditions in order to determine further medical tactics (drug therapy, balloon angioplasty, coronary artery bypass grafting). Coronary angiography is performed through a puncture of the femoral or radial artery with the introduction of a special catheter into the lumen of the heart vessels to supply radiopaque substance and subsequent image recording.
Indications
Diagnostic coronary angiography can be performed according to planned and urgent indications. The planned procedure is carried out with objective signs of myocardial ischemia: typical cardiac pain syndrome; transient ischemic changes recorded on a standard ECG or during daily ECG monitoring; a positive exercise test (based on the results of bicycle ergometry, treadmill test, stress echocardiography, myocardial scintigraphy); ineffectiveness of drug therapy for angina pectoris. Cardiography is mandatory before planning surgery on heart valves in patients over 35 years of age.
As planned, coronary angiography is performed to differentiate non-coronary myocardial diseases, with the development of early postinfarction angina, as well as in persons with minimal and fuzzy signs of ischemia, whose profession is associated with increased risk (pilots, drivers, military, etc.). Dynamic coronary angiography is performed to monitor the condition of heart vessels after previously performed operations. An emergency procedure is indicated for sudden progression of angina pectoris in patients receiving planned treatment; deterioration of the condition after endovascular interventions (development of cardiac syndrome, increased enzymes, negative ECG dynamics).
Contraindications
High risks of coronary angiography do not allow the study to be conducted in patients with renal insufficiency (with creatinine > 150 mmol / L), circulatory insufficiency of III-IV degree, threatening cardiac arrhythmias; with high and uncontrolled blood pressure, decompensated diabetes mellitus, endocarditis, polyvalent allergy, severe lesions of the arteries of the brain and extremities, acute conditions (peptic ulcer, stroke, fresh myocardial infarction up to 7 days duration, etc.).
Preparation
At the preparation stage, after determining the indications, a set of additional examinations is carried out. During the examination and interview of the patient, the presence and severity of symptoms, assessment of the functional class of angina pectoris, clarification of background diseases (allergic history, peptic ulcer, diabetes mellitus, hypertension, circulatory insufficiency, acute thrombophlebitis, menorrhagia, hemorrhoidal bleeding, etc.) are determined, the coronary anamnesis (presence and number of heart attacks) is specified.
Special studies before coronary angiography include ECG registration, daily ECG monitoring, EchoCG, chest X-ray, ultrasound of the subclavian and ilio-femoral segment arteries. The mandatory laboratory minimum includes the study of markers of hepatitis, RW and HIV; general urine and blood tests; the study of coagulogram, blood electrolytes (K and Na), glucose, creatinine, urea, transaminases.
Methodology of conducting
Coronary angiography is performed by a specialized team of endovascular surgeons in an angiographic operating room equipped with resuscitation equipment. The procedure is usually carried out according to the Judkins or Sones method. After premedication and local infiltration of the puncture site, an intravascular catheter is inserted into the aorta and then into the lumen of the coronary arteries. Judkins coronary angiography involves the introduction of special catheters, separate for the left and right coronary arteries, through the femoral artery. The Souns technique is based on catheterization of the brachial artery and sequential probing of the right and left coronary arteries with one catheter.
After catheterization of the arterial bed, heparin is simultaneously administered at a dose of 5000 units. Then an X-ray contrast agent is injected and a series of coronarogram images is performed. During coronary angiography, the left coronary artery is examined in 5 projections to enable an accurate assessment of each of its segments, the right coronary artery is examined in at least two projections. Coronary angiography is always combined with ventriculography. All stages are carried out under continuous ECG monitoring and with periodic measurement of intravascular pressure.
In the process of coronary angiography, the degree and extent of damage to the coronary arteries are revealed, which determine the subsequent therapeutic tactics. If necessary, with the consent of the patient, balloon dilation or installation of an intravascular stent can be performed during coronary angiography. In this case, the price of coronarography will include the cost of consumables and additional manipulations. After removal of intravascular catheters, a pressure bandage is applied to the puncture site, the patient is transferred to the ward for observation.
Interpretation of results
When interpreting coronary angiography, the type of blood supply to the heart is evaluated (uniform, with a predominance of the left or right coronary artery), the condition of the myocardial zone fed by the affected vessel, the total hemodynamic effect of coronary artery stenosis is determined, the collateral blood supply and the nature of collateral connections are analyzed. After diagnosis, the patient is given a conclusion on the results of the study and its digital record.
Complications
Coronary angiography is associated with minimal risks. A local complication may be bleeding from a punctured vessel. 0.9% of patients after coronary angiography have ventricular fibrillation, 0.33% have acute myocardial infarction. Mortality in coronary angiography is 0.24% and is usually associated with an unfavorable general background. The occurrence of allergy to contrast, thromboembolism, false aneurysm is not excluded.
