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Role of Angiography in Modern Era

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Role of Angiography in Modern Era

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Using X-rays, an angiography is performed to examine inside blood vessels. Learn about various types and applications of angiography.

Medically reviewed by

Dr. Sneha Kannan

Published At December 30, 2014
Reviewed AtSeptember 29, 2023

Introduction

With approximately 4 million procedures performed annually, coronary angiography is the second most common operative procedure in the United States. It is interesting to know that although angiography is most commonly done to diagnose Coronary Artery Disease (CAD) of the heart, this technique was first discovered and used to diagnose the various vascular disorders of the brain instead of the heart when a neurologist named Egas Moniz first performed cerebral angiography in 1927. In 1929, Dr.Forssmann first introduced this technique for diagnosing heart disorders when he himself passed a catheter from a vein in his arm, pushing it into the right chamber of his heart and demonstrating its position by taking an x-ray. In 1977, coronary angiography was performed for the first time in an awake patient, earlier it used to be performed under anesthesia.

What Is Angiography?

The word angiography originated from the combination of two Greek words i.e., angion meaning 'vessel' and graphein meaning 'to record'.

  • Angiography is a technique used to see the inside the lumen of blood vessels specifically arteries/arterioles/capillaries (blood vessels carrying oxygenated blood from the heart to the different body parts and organs). It is different from venography which involves the imaging of veins (blood vessels carrying deoxygenated blood from various body parts to the lungs).
  • Angiography is performed by injecting some radio-opaque dye into the blood vessel and then taking images of the concerned vessels using techniques based on X-ray imaging.
  • Angiography is considered one of the most specific laboratory imaging investigations in the assessment of the anatomy and physiology of arterial blood vessels.
  • The procedure was associated with some complications as it involved the introduction of the catheter in the blood vessels which could puncture and damage the blood vessels, but with time Seldinger technique was discovered in which no sharp device was required to stay inside the vessels.

How Is Angiography Done?

The location of the large or medium-sized artery that provides access for angiography varies depending on the technique. For treatments involving the iliac arteries, the abdominal and thoracic aorta, the femoral route is typically employed as a retrograde approach. It can accommodate larger devices like stents or occlusive aortic balloons because of its large diameter. As compared to the previous femoral or brachial routes, the radial approach has a lower risk of complications and is now frequently used in coronary angiography. The femoral route is well suited for larger-size sheaths, and collagen plugs and percutaneous suture devices are frequently employed. For angiography of the lower limbs, an antegrade femoral approach or a popliteal approach is used.

Depending on the procedure, a system of guide wires is used to insert the appropriate catheter through the access site and move it to the appropriate vessel. In order to outline the vasculature proximal to the catheter tip, a contrast medium is introduced. Using the digital subtraction angiography (DSA) method, images are taken at a rate of two to three frames per second and can be still or fluoroscopic. Visual inspection allows for the determination of the degree of stenosis or other abnormalities.

Imaging of the thoracic aorta starts by taking a look at the aortic root, the rising aorta, the aortic curve, and the proximal diving aorta. For better access to the branches, the patient's head is in a chin-up position and tilted to the right. At the beginning of the procedure, an image of the arch at 40° (left anterior oblique) is frequently taken because it lets one identify the type of aortic arch and predicts how difficult the procedure will be. Type II and III arches make cannulation of the common carotid more difficult.

The patient is placed in the supine position for imaging of the abdominal aorta, and pulmonary artery and 90° lateral views are utilized. The first angiogram run is taken with the pigtail catheter positioned at the level of the first lumbar vertebra (L1), and the field of view extends from the top of the diaphragm to the border of the iliac wings. After this, the catheter is typically advanced to the level of the aortic bifurcation (L4), where anterior oblique projections are used to image the iliac vessels.

What Are the Indications for Angiography?

Angiography is an excellent investigative method to diagnose a variety of vessel disorders in various parts and organs of the body as below

  • Coronary Angiography: It is done to diagnose the narrowing of coronary arteries which supply blood to the walls of the heart as narrowing/blockage leads to myocardial infarction/ischemia.
  • Cerebral Angiography: It is done to diagnose abnormalities of the blood vessels of the brain.
  • Pulmonary Angiography: It is done to diagnose pulmonary embolism (blockage of the main vessel of the lung).
  • Peripheral Angiography: It is done to diagnose the occlusive disease of the arteries of limbs specifically legs.
  • Renal Angiography: It is done to diagnose renal artery stenosis (narrowing of arteries that supply blood to the kidneys).
  • Spinal Angiography: It is done to diagnose vascular malformations and certain tumors of the spine.

What Are the Contraindications for Angiography?

1. Absolute Contraindications

  • There is a 350-pound weight limit on some North American conventional angiography tables. Patients who are morbidly obese and weigh more than this limit may not be able to undergo angiography due to technical safety concerns.

2. Relative Contraindications

  • History of severe iodinated contrast medium allergy that manifested as bronchospasm, laryngospasm, angioedema, and cardiovascular collapse. Steroids and antihistamines can be used as a pretreatment for patients who have had mild allergic reactions in the past.
  • Pregnancy, except in the presence of intractable hemorrhage with a risk of maternal death. When available, carbon dioxide angiography could be performed on these patients.
  • After being exposed to a contrast medium, people who are dehydrated or have underlying renal impairment are more likely to develop renal dysfunction. For this group of patients, ultra-low contrast or zero contrast techniques have been proposed.
  • Bleeding is more likely in patients with coagulopathy, an INR greater than 2, and a platelet count below 50,000/microliter. However, the risk of bleeding is now minimal thanks to the development of vascular closure devices.
  • Metformin-treated diabetics are more likely to experience lactic acidosis and impairment of renal function, particularly if they also have diabetes.
  • Conscious sedation may be required for patients who are unable to lie still or have excessive anxiety.

What Are the Complications of Angiography?

The risk of complications following conventional angiography is higher in the elderly, patients with reduced cardiac reserve, calcified non-compliant arteries, renal disease, and patients with multiple comorbidities, despite the fact that overall angiography-related complications remain low.

Minor Complications

  • Bruising
  • Nausea
  • Pain at the puncture site
  • Minor allergic reactions like hives, rashes, or itching
  • A brief decline in renal function
  • A brief sensation of burning or hot flushes

Major Complications

  • In less than 5% of angiograms, there is significant bleeding, a hematoma, or a false aneurysm. One in 100 patients needs to spend the night in the observation unit, and one in 500 to 1000 patients needs a second intervention or a blood transfusion to stop the bleeding.
  • Severe allergic reaction (anaphylactoid reaction)
  • Acute renal failure

Conclusion

For angiography to be successful, the entire healthcare team must work together across disciplines. The angiography team is made up of registered nurses, nurse managers, and radiologic technologists who are skilled in both technical and critical care. It is advised not to waste essential time, rather hurry to the closest medical center when one is impending or approaching respiratory failure or cerebral stroke. Because the outcomes are better when interventional procedures aided by angiography are started quickly. In fact, in patients with coronary artery blockage (heart attack), the best outcome of angiography-aided angioplasty is when the procedure is performed less than two hours after the onset of symptoms.

Frequently Asked Questions

1.

What Is Angiography, and How Is It Performed?

Angiography (Angiogram) examines blood vessels by injecting an iodine dye, commonly called the contrast medium, and viewing it under X-rays. Physicians perform it in the angio laboratories. It is performed when the patient is lying on his back, where a unique sheath and then the catheter are moved up in the vein with the groin or wrist's arteries.

2.

Can an Angiography Test Be Painful?

Angiography is a painless procedure where the pain felt is less than the pain in a routine blood test. There is no pain during the angiogram as there are no nerves present in the arteries.

3.

Why Is Angiography Needed?

Angiography is needed to detect and treat conditions like:
- Heart-related problems.
- To identify narrowing of blood vessels in patients with leg cramps or claudication.
- Renal stenosis (to prevent high blood pressure).
- In head to detect and repair stroke.
- To locate blockages in the lungs.

4.

How Much Time Does It Take to Perform Angiography?

Angiography can usually take 30 minutes to 1 hour, but it may also take a long time if combined with other catheterization procedures. The duration also depends upon the medical condition of the patient.

5.

How Do You Differentiate between Angiography and Angioplasty?

Angiography gives detailed information about the heart's functions and the amount of oxygen present in the blood as it passes through the heart. Angioplasty is used to narrow the arteries or reconstruct the blocked blood vessels, followed by an angiogram. Local anesthetics are used in both procedures.

6.

Can I Eat before Angiography?

It would be best if you did not eat anything eight hours before the angiography to pinpoint problems in your heart and arteries.

7.

How Is Angiography Conducted?

Angiography is an imaging technique that examines blood vessels by injecting a special like iodine dye, commonly called the contrast medium, and viewing it under X-rays. It is done when the patient is lying on his backbone, where a single sheath and then the catheter are passed up in the vein with the groin or wrist's arteries.

8.

Do I Have Any Risk in Taking Angiography?

Angiography is a safe procedure across all age groups, but it also has minor side effects like soreness and bruising and a small risk of serious complications.

9.

What Are the Types of Angiography?

There are various types of angiography which include: - Coronary angiography. - Peripheral angiography. - Pulmonary angiography. - Cerebral angiography. - Retinal angiography. - Digital subtraction angiography. - Magnetic resonance angiography. - Radionuclide angiography. - Computed tomography angiography.

10.

What Are the Advantages of Angiography?

The advantages of angiography are:
- This provides proper localization of the bleeding.
- It has a therapeutic benefit that includes vasopressin infusion or embolization.
- It does not require the preparation of the bowel.

11.

Is There Any Alternative Method for Angiography?

An alternative for angiogram is the non-invasive test called CT angio, which has limited sensitivity and specificity. But also to proceed for angioplasty to eliminate the block, one needs the conventional angiogram where CT angio is not helpful.
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Dr. Rathee Rahul
Dr. Rathee Rahul

General Medicine

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