cor et vasa 57 (2015) e419–e424

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journal homepage: http://www.elsevier.com/locate/crvasa

Review article – Special issue: Imaging in Coronary Artery Disease

The coronary angiography – An old-timer in great

shape

Viktor Kočka *
Cardiocenter, Third Medical Faculty, Charles University in Prague, Ruská 87, Prague 10, 100 00, Czech Republic

article info abstract

Article history: The invasive coronary angiography is the gold standard in coronary artery disease evalua-
Received 17 August 2015 tion. It is one of the most common operative procedures worldwide. This topic covered in
Received in revised form detail would be extensive and the author provides his own, personal view of the indications,
13 September 2015 technique and complications of this diagnostic test. The advantages and disadvantages are
Accepted 14 September 2015 provided together with the opinion about the current role of invasive coronary angiography
Available online 25 October 2015 in modern cardiology.
# 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z. o.o. All rights
Keywords: reserved.
Coronary angiography
Coronary artery disease
Cardiac catheterization
Vascular access

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e420
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e420
Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e420
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e421
Strong and weak points of invasive coronary angiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e421
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e422
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e423
Ethical statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e423
Funding body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e423
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e423
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e423

* Tel.: +420 267162701.

E-mail address: viktor.kocka@fnkv.cz
http://dx.doi.org/10.1016/j.crvasa.2015.09.007
0010-8650/# 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z. o.o. All rights reserved.
e420 cor et vasa 57 (2015) e419–e424
Introduction
Selective coronary angiography was pioneered by Sones in
1958 [1]. The ease of selective coronary artery engagement
was significantly improved with the development of specifi-
cally preformed catheters by Judkins [2] and Amplatz [3] few
years later. The invasive coronary angiography (ICA) has
since then revolutionized our understanding of pathophysi-
ology and management of heart disease. This procedure is
one of the most common operative procedures worldwide;
approx. 50,000 patients undergo the ICA in the Czech
Republic every year (unofficial data). There is a chapter
devoted to the ICA in most of cardiology textbooks (for
example the Czech language Kardiologie edited by Ascher-
mann; the English language The PCR-EAPCI Textbook etc.)
and an excellent historical review has been published by
Ryan [4]. In fact, the book ‘‘Koronarografie’’ authored by
Vančura and Aschermann and published by Avicenum in
1971 was one of the first books on this subject. I will therefore
not attempt to provide a detailed comprehensive review of
this topic but rather a personal, i.e. necessarily subjective
opinion about the role of the ICA in the current cardiology
arena.
Indications
The ICA is indicated whenever the information regarding the
presence and/or the severity of coronary artery disease is
required to improve patient symptoms or prognosis. There are
detailed ESC guidelines on the management of: stable
coronary artery disease [5]; acute coronary syndromes without
ST-segment elevation [6] and acute myocardial infarction with
ST-segment elevation [7]. The general idea appears to be
simple: the higher the clinical risk and the more severe
symptoms are present, the stronger the indication for the ICA.
I would like to present my view on few potentially problematic
clinical issues:
(1) Coronary artery disease and the ICA should be considered
in angina-free patients with recently diagnosed heart
failure, reduced left ventricle systolic function or arrhyth-
mia, especially of ventricular origin.
(2) Patients presenting with persistent symptoms suggestive
of acute myocardial infarction but no ST-segment eleva-
tion detectable on repeated electrocardiogram should be
considered for ICA to exclude acute coronary artery
occlusion, most often in left circumflex territory.
(3) There are patients with unclear/atypical symptoms and/or
equivocal results of non-invasive testing. The ICA will
provide a definitive answer; even the normal finding can
reassure the patient and therefore significantly improve
the quality of life.
(4) Patients with low clinical risk and mild non-limiting
symptoms should not undergo the ICA without having
non-invasive evaluation of myocardial ischaemia first. Any
complication of the ICA in this setting might be difficult to
justify.
There are no absolute contraindications for the ICA in the
urgent setting. Elective ICA should be postponed until the
patient cardiac and non-cardiac condition is stable.
Technique
The pre-procedure phase is important. Written informed
consent should obviously be obtained; ideally by the medical
staff who is educated and experienced at coronary angiogra-
phy. Routine pre-operative tests are reviewed (biochemistry
including renal function, full blood count, coagulation, ECG,
echocardiography and other non-invasive testing), anti-
allergic premedication and pre-hydration for renal protec-
tion should be considered. The optimal management of
patients on chronic oral anticoagulation therapy remains
unclear [8]. Should we interrupt the anticoagulation and risk
the thrombosis; or should we perform the ICA (sometimes
even followed by ad hoc stenting with a dual antiplatelet
therapy) without stopping the anticoagulation and risk the
bleeding complication? The advent of the new oral antic-
oagulants with a short half-life might help in the future.
Certainly the approach to this issue must be tailored to the
individual patient profile in the absence of clear scientific
data.
The procedure itself is carried out in the catheterization
laboratory [9] in local anaesthesia and typically takes less
than 10–15 min. A conscious sedation is optional; we perform
the majority of procedures without it (sedation in the elderly
population is not risk free) but have low threshold to sedate
any anxious or uncomfortable patient. The arterial access is
gained by standard Seldinger technique. The vascular sheath
is inserted and over the wire technique is used to cannulate
both coronary ostia. Very gentle manipulation is crucial,
should any resistance be felt the operator should proceed
under X-ray visualization only. There is a clear trend to use
the small diameter catheters, most operators use 5Fr (i.e.
1.7 mm) equipment. The use of pre-warmed contrast
agents reduces their viscosity and improves the filling of
coronary arteries. Multiple views of both coronary arteries
are required for complete visualization of branched and
often tortuous coronary tree. Radiation time and dose are
recorded for every patient [10,11]. This enables the indepen-
dent audit of radiation safety by national authorities,
following the ALARA (As Low As Reasonably Achievable)
principle. National and local radiological standards applica-
tion protects both patients and staff against radiation-
induced injuries.
The vascular sheath removal and careful patient observa-
tion are the routine of post-procedure phase. Radial artery
access enables patients to mobilize immediately after the ICA,
femoral access typically requires few hours of bed rest. The
femoral vascular closure devices (VCD) have been used for over
20 years to improve patient's comfort and reduce time to
ambulation. Recently few studies have demonstrated the
lower bleeding rate with VCD use [12,13]. Interestingly, the
design of a randomized trial comparing the radial access with
femoral artery puncture sealed by VCD has been published
[14].
 cor et vasa 57 (2015) e419–e424 e421

Table 1 – The femoral and radial artery access compar-

Complications ison, based on subjective author opinion.
Femoral Radial Comment
The ICA is associated with risks and complications [15]. I
Access site related +++ + Clear benefit of the
typically divide these risks into three categories:
bleeding radial approach
Occlusion of + ++ Most radial occlusions
(1) The serious risks with a severe long term consequences – femoral/radial are clinically silent
the composite rate of death, stroke or myocardial infarc- artery
tion is 0.1–0.2% in elective procedures [16] and around 1% in Access route + ++ Approx. 5% failure
patients with acute coronary syndromes [17]. Contrast failure rate of radial approach
Radiation dose + ++ Some conflicting
nephropathy is known to have a negative impact on long
evidence
term prognosis [18] and the importance of excellent patient
Pain during + ++ Occasional radial
hydration cannot be overemphasized. procedure artery spasm
(2) The most frequent risks – the vascular access site related Post-procedure + +++ Immediate
complication, mostly bleeding, occurs in 0.5–1% of patients independence mobilization after
after femoral access diagnostic ICA and 2–3 times more radial access
often after the percutaneous coronary intervention (PCI) ICA as a day case + ++ Radial approach
seems safer in this
with more intensive anticoagulation and antiplatelet
setting
therapy [19]. Radial artery access clearly reduces local
ICA, invasive coronary angiography; PCI, percutaneous coronary
bleeding.
intervention.
(3) Risks which are infrequent and/or associated with a small
chance of long term consequences – allergic reactions to
contrast agents, supraventricular or even ventricular repeatedly proven as prognostic indicators [21,22]. Huge
arrhythmias, vasovagal reaction, large vessel dissection majority of revascularization studies have enrolled
are just few examples from a long list of documented patients based on the result of ICA.
complications. b. Excellent resolution of coronary arteries filled selec-
tively by non-diluted contrast agent is around 100 mm.
I feel that the first two categories should be actively The image quality is documented in Fig. 1. Due to this
communicated with our patients during the informed consent excellent image quality is the ICA considered as the gold
debate. On the other hand, I typically do not talk about all standard in coronary artery imaging. It is currently the
possible complications in category 3 and only discuss these only method able to evaluate the distal part of coronary
based on patient question. vessels.
The radial or femoral artery access debate is ongoing [20]
and sometimes perhaps unnecessary. Rather than topic of
scientific confrontation I view the radial artery as another
excellent option for the clinician and his patient. The modern
interventional cardiologist should be proficient in both
approaches and make individual decisions based on patient
risk of bleeding, type of procedure needed etc. Importantly, the
patient and also his/her operator might have their individual
preferences. The ideal scenario for radial approach is the
patient with high risk of bleeding in need of ‘‘simple’’
interventional procedure with only few catheter exchanges.
The ideal scenario for femoral approach is the patient with low
risk of bleeding who requires complex procedure often with
large bore access and multiple catheter exchanges. Most of our
patients would fall somewhere between these two extremes.
Table 1 summarizes the pros and cons of both approaches.

Strong and weak points of invasive coronary

angiography

There is a plethora of emerging diagnostic tests potentially

useful in coronary artery disease evaluation. It might be
interesting to review the strong and weak points of the ICA.
(1) Advantages
a. ICA findings (number of diseased vessels, severity of
luminal obstruction, lesion location, etc.) have been
Fig. 1 – Excellent spatial resolution of invasive coronary
angiography (approx. 100 mm) provides diagnostic
information about both proximal and distal part of
coronary tree.
e422 cor et vasa 57 (2015) e419–e424

Fig. 2 – (A) Complex, excentric lesions pose a problem for summation imaging, can be detected only as lower density of
contrast agent, often seen as ‘‘haziness’’; (B) Diffuse disease with no ‘‘normal’’ segment available. If the interpreter considers
2 mm as normal vessel size than the lesion severity is underestimated; (C) bifurcation imaging requires optimal viewing
angulation to ‘‘open up’’ the branching point; (D) very short ‘‘flap’’ lesions are also difficult to image, the true significance of
lesion severity is possible only with coaxial view. RAO, right anterior oblique projection; LAO, left anterior oblique projection;
LAD, left anterior descending artery; D, diagonal branch.

c. Evaluation of collateral circulation can provide infor-
mation about myocardial viability [23] and the length of
chronic occlusion. The vasomotion can be studied; a
diffuse or focal spasm is typically relieved by intracor-
onary nitroglycerin administration and provoked by
acetylcholine or cold. Coronary artery flow can be
measured [24].
d. Left ventriculography can be performed at the time of
angiography. This is not a routine anymore with high
quality of echocardiography and increased radiation
awareness but can be occasionally useful in the acute
setting or unclear non-invasive results. Similarly,
aortography, renal angiography etc. can be added to
the ICA in case of clinical need.
e. Right-heart catheterization with the haemodynamic
study can provide extremely helpful information
f. ICA is easily available with short waiting lists in
developed countries. Ad hoc PCI can in selected cases
be efficient, cost-saving and convenient for the patient.
(2) Disadvantages
a. ICA is associated with the above mentioned complica-
tion rate, including the risks of ionizing radiation.
b. ICA is a two-dimensional luminogram based on
summation of images and it will never visualize the
vessel wall. This poses problems in interpretation of
asymmetric lesions and in diffuse disease with no
‘‘normal’’ part (see Fig. 2A and B).
c. ICA requires optimal angiographic views for lesions in
tortuous segments, in bifurcations and in very short
lesions (see Fig. 2C and D).
d. ICA interpretation has a wide interobserver variability
[25]. This lead to development of quantitative coronary
angiography (QCA) with the computer assisted border
detection. The visual assessment often leads to the
overestimation of lesion severity [26].
Conclusion
The ICA remains one part of medicine in 21st century which
combines the art and science. It is typically taught in an
individual, peer-to-peer, fellowship manner. The element of art
is involved when confident and calm doctor speaks to his patient
 cor et vasa 57 (2015) e419–e424
providing reassurance and comfort often better than sedative
medication. On the other side, all the accumulated scientific
evidence can be used to patient benefit in providing safe
procedure and establishing correct diagnosis as a foundation of
effective therapy. In my opinion, the invasive coronary
angiography will remain the cornerstone of coronary artery
disease evaluation for the foreseeable future. Its role in acute
coronary syndromes is clear and undisputed. The technological
advances might bring less invasive methods, like computed
tomography, into the diagnostic schemes of stable coronary
patients in the years to come. Also, as mentioned in other part of
this Special Issue, adjunctive techniques providing information
about functional significance of coronary lesions or intracor-
onary imaging can be useful in selected and generally small
patient populations.
High quality invasive coronary angiography provides clear
diagnosis and enables scientifically correct and effective
therapy in large majority of patients.
Conflict of interest
No conflict of interest.
Ethical statement
The author declares that the research was conducted accord-
ing to Declaration of Helsinki.
Acknowledgements
The author acknowledges the support of the Research project
PRVOUK P35 from Charles University in Prague.
Funding body
Third Medical Faculty, Charles University in Prague.
references
[1] F.M. Sones Jr., Cine-coronary arteriography, Ohio Medicine
58 (1962) 1018–1019.
[2] M.P. Judkins, Selective coronary arteriography. I. A
percutaneous transfemoral technic, Radiology 89 (1967)
815–824.
[3] K. Amplatz, G. Formanek, P. Stanger, et al., Mechanics of
selective coronary artery catheterization via femoral
approach, Radiology 89 (1967) 1040–1047.
[4] T.J. Ryan, The coronary angiogram and its seminal
contributions to cardiovascular medicine over five decades,
Circulation 106 (2002) 752–756.
[5] Task Force Members, G. Montalescot, U. Sechtem, et al.,
2013 ESC guidelines on the management of stable coronary
artery disease: the Task Force on the management of
stable coronary artery disease of the European Society
of Cardiology, European Heart Journal 34 (2013)
2949–3003.
e423
[6] C.W. Hamm, J.P. Bassand, S. Agewall, et al., ESC Guidelines
for the management of acute coronary syndromes in
patients presenting without persistent ST-segment
elevation: The Task Force for the management of acute
coronary syndromes (ACS) in patients presenting without
persistent ST-segment elevation of the European Society
of Cardiology (ESC), European Heart Journal 32 (2011)
2999–3054.
[7] Task Force on the management of ST-segment elevation
acute myocardial infarction of the European Society of
Cardiology (ESC), P.G. Steg, S.K. James, et al., ESC Guidelines
for the management of acute myocardial infarction in
patients presenting with ST-segment elevation, European
Heart Journal 33 (2012) 2569–2619.
[8] A.P. Annala, P.P. Karjalainen, P. Porela, et al., Safety of
diagnostic coronary angiography during uninterrupted
therapeutic warfarin treatment, American Journal of
Cardiology 102 (2008) 386–390.
[9] T.M. Bashore, S. Balter, A. Barac, et al., 2012 American
College of Cardiology Foundation/Society for
Cardiovascular Angiography and Interventions expert
consensus document on cardiac catheterization laboratory
standards update: a report of the American College of
Cardiology Foundation Task Force on Expert Consensus
documents developed in collaboration with the Society of
Thoracic Surgeons and Society for Vascular Medicine,
Journal of the American College of Cardiology 59 (2012)
2221–2305.
[10] A.J. Einstein, K.W. Moser, R.C. Thompson, et al., Radiation
dose to patients from cardiac diagnostic imaging,
Circulation 116 (2007) 1290–1305.
[11] R. Padovani, E. Vano, A. Trianni, et al., Reference levels at
European level for cardiac interventional procedures,
Radiation Protection Dosimetry 129 (2008) 104–107.
[12] N.R. Holm, B. Sindberg, M. Schou, et al., Randomised
comparison of manual compression and FemoSeal vascular
closure device for closure after femoral artery access
coronary angiography: the CLOSure dEvices Used in
everyday Practice (CLOSE-UP) study, EuroIntervention 10
(2014) 183–190.
[13] T.A. Sanborn, M.I. Tomey, R. Mehran, et al., Femoral
vascular closure device use, bivalirudin anticoagulation,
and bleeding after primary angioplasty for STEMI: results
from the HORIZONS-AMI trial, Catheterization and
Cardiovascular Interventions 85 (2015) 371–379.
[14] P.B. de Andrade, L.A.E. Mattos, M.A. Tebet, et al., Design and
rationale of the AngioSeal versus the Radial approach In
acute coronary SyndromE (ARISE) trial: a randomized
comparison of a vascular closure device versus the radial
approach to prevent vascular access site complications in
non-ST-segment elevation acute coronary syndrome
patients, Trials 14 (2013) 435.
[15] M. Tavakol, S. Ashraf, S.J. Brener, Risks and complications
of coronary angiography: a comprehensive review, Global
Journal of Health Science 4 (2012) 65–93.
[16] T.J. Noto Jr., L.W. Johnson, R. Krone, et al., Cardiac
catheterization 1990: a report of the Registry of the Society
for Cardiac Angiography and Interventions (SCA&I),
Catheterization and Cardiovascular Diagnosis 24 (1991)
75–83.
[17] S.S. Jolly, S. Yusuf, J. Cairns, et al., Radial versus femoral
access for coronary angiography and intervention in
patients with acute coronary syndromes (RIVAL): a
randomised, parallel group, multicentre trial, Lancet 377
(2011) 1409–1420.
[18] R.J. Solomon, R. Mehran, M.K. Natarajan, et al., Contrast-
induced nephropathy and long-term adverse events: cause
and effect? Clinical Journal of the American Society of
Nephrology 4 (2009) 1162–1169.
e424 cor et vasa 57 (2015) e419–e424
[19] N. Arora, M.E. Matheny, C. Sepke, et al., A propensity
analysis of the risk of vascular complications after cardiac
catheterization procedures with the use of vascular closure
devices, American Heart Journal 153 (2007) 606–611.
[20] J.F. Wagener, S.V. Rao, A comparison of radial and femoral
access for cardiac catheterization, Trends in Cardiovascular
Medicine 25 (2015) 707–713.
[21] M.B. Mock, I. Ringqvist, L.D. Fisher, et al., Survival of
medically treated patients in the coronary artery surgery
study (CASS) registry, Circulation 66 (1982) 562–568.
[22] D.B. Mark, C.L. Nelson, R.M. Califf, et al., Continuing
evolution of therapy for coronary artery disease. Initial
results from the era of coronary angioplasty, Circulation 89
(1994) 2015–2025.
[23] D.P. Ripley, O.E. Gosling, L. Bhatia, et al., The relationship
between the contralateral collateral supply and myocardial
viability on cardiovascular magnetic resonance: can the
angiogram predict functional recovery? International
Journal of Cardiology 177 (2014) 362–367.
[24] C.M. Gibson, A. Schomig, Coronary and myocardial
angiography: angiographic assessment of both epicardial
and myocardial perfusion, Circulation 109 (2004)
3096–3105.
[25] J.J. Fischer, H. Samady, J.A. McPherson, et al., Comparison
between visual assessment and quantitative angiography
versus fractional flow reserve for native coronary
narrowings of moderate severity, American Journal of
Cardiology 90 (2002) 210–215.
[26] B.K. Nallamothu, J.A. Spertus, A.J. Lansky, et al.,
Comparison of clinical interpretation with visual
assessment and quantitative coronary angiography in
patients undergoing percutaneous coronary intervention in
contemporary practice: the Assessing Angiography (A2)
project, Circulation 127 (2013) 1793–1800.