Coronary angiography and angioplasty

What it is

Coronary angiography is the reference test for the anatomy of the coronary arteries. Under local anaesthesia and light sedation the cardiologist places a sheath in the radial artery (preferred, fewer bleeding complications) or the femoral artery, passes catheters to the openings of the coronary arteries and injects iodinated contrast while fluoroscopy records the images. It shows where and how severely the arteries are narrowed; the pressure in the left ventricle can be measured and pressure-wire tests can show whether a borderline narrowing limits flow. Percutaneous coronary intervention (PCI, angioplasty) can follow in the same sitting: a guidewire crosses the lesion, a balloon widens it and a stent, usually drug-eluting, holds it open. Primary PCI is the preferred treatment of ST-elevation myocardial infarction when it can be done quickly. The risks come from the arterial puncture (bleeding, haematoma, pseudoaneurysm), the contrast (allergy, kidney injury), the catheters (arrhythmia, coronary dissection, embolism and stroke) and the radiation. After a stent the patient needs dual antiplatelet therapy for a period set by the cardiologist: stopping it early can cause stent thrombosis and infarction. The ward doctor prepares the patient, checks the results that change the risk, explains the consent and looks after the puncture site and the kidneys afterwards.

Indications

• ST-elevation myocardial infarction: primary PCI as soon as possible.
• High-risk non-ST-elevation acute coronary syndrome: early invasive strategy.
• Stable angina with high-risk non-invasive results or symptoms despite optimal medical treatment.
• Resuscitated cardiac arrest or ventricular arrhythmia of possible coronary cause; new heart failure or cardiomyopathy to exclude coronary disease.
• Before valve or other heart surgery, to define the coronary anatomy.

Contraindications

• In an emergency such as STEMI there are no absolute contraindications; the benefit is weighed against the risk.
• Acute kidney injury or severe chronic kidney disease (contrast injury): delay if possible, hydrate, minimise contrast.
• Active bleeding, uncorrected coagulopathy or a recent stroke: bleeding risk with anticoagulation and antiplatelets.
• Previous severe reaction to contrast: premedication and precautions per protocol.
• Correct first: hypokalaemia, digoxin toxicity, fever or active infection, decompensated heart failure (cannot lie flat), uncontrolled hypertension.

Preparation and what happens

1. Explain the test, the possibility of angioplasty in the same sitting and the main risks, and obtain written consent — the plan may change on the table.
2. Check creatinine, haemoglobin, platelets, coagulation and potassium, and correct what you can — they predict kidney and bleeding risk.
3. Ask about contrast or iodine reactions, anticoagulants, antiplatelets and metformin, and follow the local plan for each — they change the risk.
4. Fasting per local protocol and an intravenous cannula; intravenous fluids for patients at kidney risk — fluids protect the kidneys.
5. Check both radial and femoral pulses and mark them — a baseline helps to detect a vascular complication later.
6. In the room the patient is awake with light sedation; local anaesthetic at the wrist or groin, then the sheath and catheters are placed.
7. Contrast is injected and images recorded; the patient may feel warmth or need to hold the breath — the images guide any angioplasty.
8. The sheath is removed at the end: a compression band at the wrist, or pressure or a closure device in the groin — this stops arterial bleeding.
9. After femoral access the patient lies flat with the leg straight for some hours — moving early increases bleeding at the site.

Puncture-site and contrast complications: clues and first action

Risks and complications

• Access site: haematoma, bleeding, pseudoaneurysm (pulsatile mass with a bruit), arteriovenous fistula, radial artery spasm or occlusion.
• Retroperitoneal bleeding after high femoral puncture: hypotension, falling haemoglobin, back, flank or abdominal pain.
• Contrast: allergic reactions from mild urticaria to anaphylaxis; contrast-associated acute kidney injury.
• Cardiac: arrhythmias, coronary dissection or perforation, periprocedural myocardial infarction, tamponade, and stent thrombosis later.
• Embolic: stroke, and cholesterol embolism (livedo, blue toes, kidney injury, eosinophilia); rare death; radiation skin injury after long procedures.

Next step

• Check the puncture site, distal pulses, blood pressure and heart rate frequently in the first hours; call a senior for swelling, hypotension or a cold limb.
• New chest pain or ST changes after PCI: 12-lead ECG and call the cardiologist at once (acute stent occlusion).
• Measure creatinine 48–72 hours after the procedure in patients at kidney risk, and restart metformin only when kidney function is stable.
• Explain dual antiplatelet therapy, its duration and its bleeding signs; it is never stopped without speaking to the cardiologist.
• Start secondary prevention: statin, blood pressure and diabetes control, stopping smoking and referral to cardiac rehabilitation.

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Elsewhere in DurgiPedia

• Iodinated contrast: reactions and the kidney
• Radiation in medical imaging: risk, ALARA and pregnancy
• Coronary circulation and myocardial ischemia
• The ECG in ischemia and infarction

Connections

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Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: Cardiac Catheterization Risks and Complications (StatPearls (NCBI Bookshelf), 2023).

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Representative model, for educational purposes only.