Popular Posts

Tuesday, September 3, 2013



What is angiography?

Angiography is an x-ray study of the blood vessels. An angiogram uses a radiopaque substance, or dye, to make the blood vessels visible under x ray. 

Why is an angiography done?

Angiography is used to detect abnormalities or blockages in the blood vessels throughout the circulatory system and in some organs. The procedure is commonly used to identify atherosclerosis; to diagnose heart disease; to evaluate kidney function and detect kidney cysts or tumours; to detect an aneurysm (an abnormal bulge of an artery that can rupture leading to haemorrhage), tumour, blood clot, or arteriovenous malformations in the brain; and to diagnose problems with the retina of the eye. It is also used to give surgeons an accurate ‘map’ of the heart prior to open-heart surgery, or of the brain prior to neurosurgery.

What happens during the procedure?

Angiography is performed at a hospital by a trained radiologist and assisting technician or nurse. Angiography requires the injection of a contrast dye that makes the blood vessels visible to x-ray. The dye is injected by an arterial puncture. The puncture is usually made in the groin area, armpit, inside elbow, or neck. Depending on the type of angiography procedure being performed, the contrast medium is either injected by hand with a syringe or is mechanically injected with an automatic injector connected to the catheter. An automatic injector is used frequently because it is able to propel a large volume of dye very quickly to the angiogram site. The patient is warned that the injection will start, and instructed to remain very still. The injection causes mild to moderate discomfort. Possible side effects or reactions include headache, dizziness, irregular heartbeat, nausea, warmth, burning sensation, and chest pain, but they usually last for a short time. 

Throughout the dye injection procedure, x-ray pictures and/or fluoroscopic pictures (or moving x rays) are taken. Because of the high pressure of arterial blood flow, the dye will dissipate through the patient's system quickly, so pictures are taken in rapid succession. Once the x-rays are complete, the catheter is slowly and carefully removed from the patient. A pressure bandage is then applied.

Coronary angiography 


In a coronary angiography, the arterial puncture is typically given in the femoral artery, and the cardiologist uses a guide wire and catheter to perform a contrast injection and x-ray series on the coronary arteries. The angiogram procedure takes several hours, depending on the complexity of the procedure.
How to prepare for an angiography?

Patients undergoing an angiography are advised to stop eating and drinking eight hours prior to the procedure. If the arterial puncture is to be made in the armpit or groin area, shaving may be required. A sedative may be administered to relax the patient for the procedure. An IV line will also be inserted into a vein in the patient's arm before the procedure begins in case medication or blood products are required during the angiogram. Prior to the angiography procedure, patients will be briefed on the details of the test, the benefits and risks, and the possible complications involved, and asked to sign an informed consent form.

What happens after the procedure?

Because life-threatening internal bleeding is a possible complication of an arterial puncture, an overnight stay in the hospital is sometimes recommended following an angiography procedure, particularly with cerebral and coronary angiograms. If the procedure is performed on an outpatient basis, the patient is typically kept under close observation for a period of at least six to 12 hours before being released. Pain medication may be prescribed if the patient is experiencing discomfort from the puncture, and a cold pack is applied to the site to reduce swelling. It is normal for the puncture site to be sore and bruised for several weeks. Angiography patients are also advised two to three days of rest and relaxation after the procedure in order to avoid placing any undue stress on the arterial puncture site. Patients who experience continued bleeding or abnormal swelling of the puncture site, sudden dizziness, or chest pains in the days following an angiography procedure should seek medical attention immediately. Patients undergoing a fluorescein angiography should not drive or expose their eyes to direct sunlight for 12 hours following the procedure.

What are the risks associated with the procedure?

Because angiography involves puncturing an artery, internal bleeding or haemorrhage are possible complications of the test. As with any invasive procedure, infection of the puncture site or bloodstream is also a risk, but this is rare. A stroke or heart attack may be triggered by an angiogram if blood clots or plaques on the inside of the arterial wall are dislodged by the catheter and form a blockage in the blood vessels or artery. The movement of the catheter through its chambers may also irritate the heart during pulmonary and coronary angiography procedures, and arrhythmias may develop. Patients with kidney disease or injury may suffer further kidney damage from the contrast mediums used for angiography. Patients who have blood clotting problems, have a known allergy to contrast mediums, or are allergic to iodine, a component of some contrast mediums, may also not be suitable candidates for an angiography procedure. Because x-rays carry risks of ionising radiation exposure to the fetus, pregnant women are also advised to avoid this procedure.


What is angioplasty? 

Angioplasty is a procedure in which a balloon catheter (thin tube) is inserted into a blocked artery to remove the blockage. The blockage may be in an artery in the arm, leg, or in the heart.

The catheter is inserted into a blood vessel either at the elbow or groin. It is pushed through the inside of the blood vessel so that the tip of the catheter is at the point of the blockage in the artery. Inflating a balloon at the tip of the catheter stretches the narrowed artery allowing blood to flow normally through the artery again. The doctor then removes the catheter and balloon.


How to prepare for it? 

Before surgery, a consent form needs to be signed by the patient for angioplasty, bypass surgery and angiography (X-ray study of the blood vessels using dye). This consent form is needed in case complications arise during the angioplasty and emergency surgery is needed.
Blood tests, electrocardiogram (ECG) and an X-ray of the chest will be done. Do not eat or drink anything after midnight on the night before the procedure.

The area where the catheter will be inserted (arm or groin) will be shaved and washed with antibacterial soap to prevent infection. Before the procedure is performed, an intravenous line (tube into a vein) will be set up. Medicines to relax the patient will be given.

What happens during the procedure? 

Before angioplasty, a local anaesthetic is given where the catheter will be inserted. Using X-ray imaging, a doctor will guide a thin wire into the blocked artery through a needle that has been inserted into the blood vessel in the arm or groin.

The doctor will guide a catheter with a balloon at the tip along the wire. When the catheter reaches the narrowed artery or vessel, the balloon is inflated and deflated several times, widening the blocked passage. Then the deflated balloon, catheter, and wire is removed.

What happens after the procedure? 

Monitoring in a cardiac care unit or a hospital room is done from several hours to a couple of days, depending on the location of the blockage and the medical condition.

If the catheter was inserted into the groin, the patient will have to lie flat on their back and not move the leg or groin for about 6 hours. A sandbag may be placed on the groin to apply pressure and prevent excess bleeding. The patient will be up and walking in 12 to 24 hours after the procedure. When the condition is stable, the patient will be released to rest at home.

What are the benefits of angioplasty? 

It can restore the function of the artery without major surgery.
It does not require removing blood vessels from another part of the body (as is often necessary in bypass surgery).
It can be performed without using general anaesthesia.


This surgery is done to by-pass clogged arteries supplying blood to the heart. It creates a ‘bypass’ around the blocked part of a coronary artery to restore the blood supply to the heart muscle. The surgery is called Coronary Artery Bypass Grafting, or CABG. Commonly known as bypass surgery.
Why is it done?
Coronary arteries are blood vessels that supply the heart muscle with oxygen and nutrients. Fats and cholesterol can accumulate inside these arteries, and the arteries can gradually become clogged. (This buildup of fat and cholesterol plaque is called atherosclerosis) . When one or more of the coronary arteries becomes partially or totally blocked, the heart does not get an adequate blood supply. This is called ischaemic heart disease or coronary artery disease (CAD). It can cause heart pain (angina) or a heart attack (myocardial infarction). The first symptom of CAD may be a heart attack (myocardial infarction).

Coronary artery bypass surgery is one of the treatment options for ishcaemic heart disease (too little blood reaching the heart muscle). Bypass surgery is indicated for disease of the left main coronary artery disease or multiple blockages in one or more arteries. It is also done for a failure of nonsurgical management. Nonsurgical management includes medication and/or angioplasty. 
How is the surgery done?
After the patient is anesthetised and becomes unconscious, the surgeon makes an incision in the middle of the chest and separates the breastbone. Through this incision, the surgeon can see the heart and aorta (the main blood vessel leading from the heart to the rest of the body). After surgery, the breastbone is rejoined with wires and the incision is closed.

If a vein from the leg is to be used for the bypass, an incision is made in the leg and the saphenous vein removed by another surgeon operating simultaneously. This vein is located on the inside of the leg running from the ankle to the groin. It normally does only about 10% of the work of circulating blood from the leg back to the heart. Therefore, it can be taken out without harming the patient or adversely affecting the leg. It is common for the leg from which the vein is taken to swell slightly during recovery from the surgery, but this is only temporary and treated with elevation of the leg, and special stockings.

Alternatively the internal mammary artery (IMA) can also be used for the graft. This has the advantage of staying open for many more years than the vein grafts, but there are some situations in which it cannot be used. Other arteries are also now being used in bypass surgery. The most common other artery used is the radial artery. This is one of the two arteries that supply the hand with blood. It can usually be removed from the arm without any impairment of blood supply to the hand.

In the traditional surgery, the patient is connected to the heart-lung machine, or bypass pump, which adds oxygen to the blood and circulates blood to other parts of the body during the surgery. This is necessary because the heart muscle must be stopped before the graft can be done. One end of the graft is stitched to an opening below the blockage in the coronary artery. If the grafted vein is from the leg or the radial artery, its other end is stitched to an opening made in the aorta. If the grafted vessel is the mammary artery, its other end is already connected to the aorta.

The entire surgery usually takes four to six hours. After the surgery, the patient is kept in the Intensive Care Unit. For a few days after the surgery, the patient is connected to monitors and tubes. Other techniques to do this surgery are used more and more frequently. One popular method is to avoid the use of the heart-lung machine. This is called off-pump coronary artery bypass or OPCAB. This operation allows the bypass to be created while the heart is still beating. The advantage being a quicker recovery and fewer complication especially in elderly patients and in patients with problem like kidney failure and previous brain strokes etc
What are the risks of surgery?
  • Heart attack can occur during 5% of these surgeries
  • Stroke can also occur in 5% of these surgeries
  • Blood clots in legs and their migration to lungs.
  • Death may occur in 1-2% of those who have the surgery (95-98% have no serious complications)
  • Wound infection may occur in 1-4% of these surgeries. This complication is most often associated with obesity, diabetes, or a previous CABG. 
  • The incision in the chest or the graft site (if the graft was from the leg or arm) can be itchy, sore, numb, or bruised
The complications are affected by the following factors:

  • Previous heart surgery puts a person at a higher risk 
  • Having another serious medical condition (such as diabetes, peripheral vascular disease, kidney disease, or lung disease) adds to the risk for complications.
What to expect after surgery?
In the majority of people who have the surgery, the grafts remain open and functioning for 10 to 15 years. CABG improves blood flow to the heart but does not prevent the eventual recurrence of coronary blockage. Lifestyle changes are necessary - such as not smoking, improved diet, regular exercise, and treating high blood pressure and high cholesterol.

After the operation, the patient spends 5-7 days in the hospital, with the first few days in an intensive-care unit (ICU). In the ICU, heart function is monitored continuously. Patients may require the temporary assistance of a breathing tube for a few hours after surgery. Two to three tubes in the chest drain fluid from around the heart and are usually removed one to three days after surgery. A urinary catheter in the bladder drains urine until the patient is able to void on his own. When constant monitoring is no longer needed, usually within 12-24 hours, the patient is moved to a regular care unit. Activity is gradually resumed and the patient and the incision in the chest does not bother most people after the first 48-72 hours. 
After surgery, it takes 4-6 weeks to start feeling better. 
During recovery it is normal to have:
  • A poor appetite - it will take several weeks for it to return
  • Swelling in the leg if the graft was taken from the leg
  • Difficulty sleeping at night - this improves with time 
  • Constipation
  • Mood swings and feel depressed - this will get better
  • Difficulty with short-term memory or feel confused - this also improves with time. 
  • The full benefits from the operation may not be apparent until 3-6 months after surgery. Sexual activities may be resumed 4 weeks after surgery. All activities that do not cause fatigue are permitted, and the schedule for resuming normal activities is determined by the doctor.
Follow the mentioned tips to lead a healthy and a happy life.

No comments: