The angiography experience

By Dr. Muhammad Hafizullah

“It wasn't that bad!” I announced after the procedure. It took about fifteen minutes and I was over the most dreaded episode of my life. My right hand was a little numb but otherwise I felt well. I was made comfortable in a chair and served a hot cup of tea after the procedure. I had little pain in my wrist that slowly waned and disappeared totally in a few minutes. I could not believe that it was all over!

I developed pain in the middle of my chest three weeks ago. The pain became worse and followed even mild exertion. My initial tests like ECG at rest and blood tests including cholesterol level were reported as within normal range. Echocardiogram - a test which looks at the structure of heart and gives useful information on the function was, also, reported as normal. On my doctor's recommendation I underwent exercise tolerance test. ECG was recorded at rest and then I was made to walk on treadmill. Serial ECGs were recorded and blood pressure was checked after ever few minutes. This was reported as positive after walking for only 6 minutes.

My cardiologist suggested angiography to document 'blockages in tubes supplying blood to heart'. What is angiography and what are tubes and what does a blockage imply? My curious nature encouraged me to look for more information. Heart like all living tissues requires nutrition offered by blood. This is supplied by three main tubes called coronary arteries as they sit like a 'crown' on heart. They are left and right coronary arteries: left subdivides into two branches called left anterior descending (LAD) and circumflex (Cx). Coronary arteries can be assessed by classical angiography in which catheters - long hollow plastic tubes — are used to engage coronary arteries. Radio opaque material called dye is injected in the vessels and recorded by X ray.

The camera records from different angles to document the tree in entirety. Previously this used to be recorded on cine film and seen on projector. Things have changed now and now it is recorded on hard disk and recorded on a CD that can be played on any computer - desktop or laptop. With recent advances in technology, now, coronary arteries can also be documented on CT scanning. Heart is an eternally restless organ which contracts longitudinally and radially. Its apex moves clockwise and base rotates anticlockwise. Besides this it moves with breathing.

Previous technology was not fast enough to arrest the motion and record small coronary arteries. Recently with 64 slice CT technology, where one slice can be subdivided into 64 slices, heart motion can be arrested.

Dye is injected in a vein in forearm with the help of pump and breath is held for a few seconds. In a few seconds coronary arteries can be imaged and recorded. This is a wonderful technique allowing us to assess coronary arteries without poking catheters and is completed in a few minutes.

If both technologies can document coronary arteries then when should one choose one or the other was the big question for me. I looked for more information on net and gleaned more while discussing with my doctor friends. CT angiography is an excellent technology and the reliability factor is very high when it documents normal blood flow.

But when it documents blockages, sometimes it may over or under estimate. Most doctors would use this when they want to exclude the disease or in special circumstances like documenting bypass grafts or total blockages. Whereas conventional angiography, which requires administration of local anaesthesia and insertion of catheters, provides better details of coronary arteries from different angles.

Decision making - especially for angioplasty and surgery — can only be made on more reliable information offered by angiography. In days to come with advances in technology the need for conventional angiography may be totally obviated. As I was having recurrent chest pains and my ETT was positive, the chances of having disease were very high hence I opted for conventional angiography. I needed some blood tests before angiography to document sugar level and kidney functions. I was given a choice of two approaches: femoral - from leg and radial — from wrist. Leg approach has been used for a long time and has the advantage of familiarity, ease of puncturing a large vessel and choice of different sizes and shapes of catheters. It takes lesser time - in most cases as less as five to ten minutes. The downside is the compulsory rest in bed after the procedure of four to six hours. No stitch is applied on the site of entry therefore the patient is required to lie flat for a few hours. As it is more like a 'once in a life time' phenomenon so it's not a big consideration.

On the other hand newly developed technique - radial angiography, a small vessel has to be punctured which some time may take longer time. At times the vessel may go into spasm and maneuvering of catheters becomes difficult. But the best point about this technique is that the person need not be confined to bed and can literally walk from catheterization table. Patient can be discharged home after a couple of hours. Similar catheters are used by both techniques and rarely if wrist technique is not successful femoral can be used.

My angiography was performed from the wrist and after the initial sting while administering local anesthetic there was little more pain while introducing catheters. The operator changed catheters and I used to feel hot flushes while different views were being recorded. The camera swung in different directions around me and produced a hissing noise. The operator kept chatting with me and the staff. Overall ambience was friendly! Once the procedure was over and catheters were pulled out, a technician, applied pressure on the wrist for fifteen minutes. Making sure that there was no leak, he applied a gentle dressing. I was wheeled on a wheel chair to a lounge and offered a comfortable sofa. I had the luxury of sitting up and have water and tea. The dressing was checked after two hours and I was allowed to go home after that.

I was amused to learn that around thirty patients underwent a procedure on that day in three cath labs and most left for home by evening. Those who underwent angioplasty were retained for the night.