Angiography - St. Martinus University

A brief case based introduction to the
catheterisation laboratory and
coronary angioplasty
Copyright 2015 ©
All rights reserved. No part of this book may be reproduced without the
permission of the authors
Dr Adam Ioannou
Dr Kare Tang
Prof Nimal Raj SMU
Edited by
Dr Derek Saville
1
Introduction
This book provides a brief and basic case based guide on how to look at angiography
pictures. It discusses fifteen cases of patients who have been treated with coronary
angioplasty. Each case starts with a brief background history and is followed by a
sequence of pictures that demonstrate the blood flow through the coronary arteries before,
and after intervention.
FOREWARD
Foreword
by
Dr Kare H Tang, Consultant Cardiologist.
Adam George Andrew Loannou
Adam is a talented young doctor who achieved first class honor’s in his medical education
with both distinction and merit awards.
He shows immense dedication to his chosen career and is a keen teacher with vast
experience. It has been a pleasure to work with Adam in producing this educational
manual on complex coronary artery intervention.
Adam has demonstrated rewarding enthusiasm for this topic when exposed to this
complex condition in a short spell of time and has grasped the principles and pitfalls
encountered in the treatment of this condition well.
All the cases shown are true cases which demonstrate the skill and ability of the operator
in achieving a successful result both for the patient and the operator. This small book
extends the educational resource which Adam has created for other colleagues who have
interest in this specialty.
Many thanks.
Dr Kare H Tang
2
Case 1
This was a 55 year old male with a previous history of ischaemic heart disease and
hypertension, who presented with worsening chest pain at rest. Five years previously he
had a pacemaker fitted following an admission to hospital for a ventricular tachycardia. His
angiography is shown below.
3
This is a picture of this patient’s
s angiography prior to any new intervention.
There is clear stenosis of the Right Coronary Artery (RCA)(A)
.
This can be seen clearly in two Places.
There is also touristy of the circumflex artery (B),
This is likely to be due to chronic hypertension.
The pacing wire can also be seen (C).
4
5
This is a picture of this patient’s angiography following the placement of a stent in the right
Coronary artery to open up the artery (A).
This is improved flow down the right coronary artery and it has taken up a more regular shape.
The circumflex artery (B)
and pacing wire (C) can also be seen.
seen
This patient was discharged following their procedure on their regular medications
medicatio which
consisted of aspirin, Bisprolol, Ramipril and Simvastatin, and a six month course of
Clopidogrol due to the insertion of a drug eluting stent. Following the procedure he no
longer experienced chest pain at rest and his exercise tolerance improved.
6
Case 2
This was a 65 year old female who was a lifelong heavy smoker and had a strong family
history of heart disease. She was referred to a cardiology clinic by her general practitioner
following spontaneous episodes of cardiac sounding chest pain that occurred at rest.
Following basic investigations that included an ECG and blood tests an angiography was
performed and is shown below.
7
patient angiography prior to any interventional treatment.
This is a picture of the patient’s
The arrow points towards stenosis of the second diagonal branch (D2))
of the Left Anterior Descending artery (LAD).
8
9
This is a picture of the angiography following intervention and insertion of two drug eluting stents.
This technique is known as bifurcation stenting, and is where two stents are inserted at the
bifurcation of the coronary arteries.
One stent has been inserted into the second diagonal branch (A)
and another into the left anterior defending artery distal to the second diagonal branch (B).
The cardiologist will aim to have minimal overlap between the stents to ensure there is good flow
through the coronary arteries.
This patient was discharged following their procedure, and no longer experienced any
chest pain at rest. She was also prescribed the following medications by her cardiologist,
aspirin, Bisprolol, Atorvastatin and Captopril. She also took a short course of Prasugrel to
prevent stent-induced thrombosis.
10
Case 3
This patient was a 70 year old male who had a long history of stable angina. He currently
takes aspirin, atorvastatin and atenolol. His symptoms began worsening so he was also
prescribed Amlodipine. Despite this he still developed pain and shortness of breath on
minimal exertion. His angiography is shown below.
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This angiography shows a chronic total occlusion of the Right Coronary Artery (RCA), from the
proximal part of the artery to the bifurcation.
This line demonstrates the normal pathway the artery would take (A).
The proximal RCA alsohave areas of stenosis that are characteristic of coronary artery disease.
There is retrograde
Filling of the RCA from collaterals that have formed from the other coronary arteries (B).
12
13
The picture above shows the restoration of flow through the Right Coronary Artery (RCA) following
Insertion of a stent (A).
The operator chose to restore flow through the larger posterior left ventricular branch of the RCA,
This is why the bifurcation of the RCA can no longer be seen clearly.
retrograde filling via
Due to the RCA being re-opened by this procedure there is no longer any retrog
Collaterals.
This patient remained in hospital for observation, and was subsequently discharged on his
regular medications, and a short course of Clopidogrel. He was reviewed in a cardiology
clinic one month later and his symptoms had improved.
14
Case 4
This was a 65 year old woman with a history of atrial fibrillation who presented to her
general practitioner with worsening chest pain. She is currently taking diltiazem for rate
control management of her atrial fibrillation. She was subsequently referred to a cardiology
clinic for further investigation. Her initial angiography is shown below.
15
This is a picture of her initial angiography, which shows total chronic occlusion of the Right Coronary
Artery (RCA).
The normal pathway is shown by a line which connects the proximal and distal parts of the blood
Vessel
Due to the severe blockage of the RCA, (A)
There is retrograde filling from the septal collaterals (B),
Which are branches of the Left Anterior Descending artery (LAD).
16
17
The picture above shows an angiography following insertion of a stent in the right coronary artery
(RCA) (A).
This has opened up flow throughout the artery and the septal collaterals are no longer required to
supplyblood to the right side of the heart. Due to the total chronic occlusion off the RCA, the operator
was unable to pass the guide wire through the natural lumen of the artery.
Therefore it was passed through the tunica intima of the vessel, creating an iatrogenic dissection of
theartery. Once the guide wire was back in the true lumen of the vessel the stent was inserted to
create a new pathway for the blood to flow.
Following the angiography and subsequent intervention this patient was given an official
diagnosis of ischaemic heart disease, which meant she now met the criteria to be started
on warfarin to prevent a mural thrombus and subsequent ischaemic stroke. Oral
anticoagulation therapy was commenced during her hospital stay, along with atorvastatin
and Amlodipine.
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Case 5
This was a 76 year old man with a history of hypertension, hypercholesterolemia and type
2 diabetes mellitus who presented with gradually worsening chest pain. He was currently
taking Amlodipine, atorvastatin, Ramipril and metformin. He was admitted to hospital for
an angiography which can be seen below.
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rtery (RCA),
This picture shows a total chronic occlusion of the Right Coronary Artery
and the linedemonstrates the natural path of the RCA (A).
There is retrograde filling of the RCA via septal collaterals (B).
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21
A).
This picture shows the right coronary artery (RCA) after insertion of a stent (A
There is clear widening of the artery and restoration of the normal ante grade blood flow.
This stent was inserted by use of a micro catheter.
The operator used a retrograde approach and passed the catheter through the septal collaterals to
unblock the RCA (B).
This patient was commenced on duel anti platelet therapy (consisting of Aspirin and
Clopidogrel). He was also prescribed Bisoprolol and his regular medications remained the
same. Following the procedure his symptoms vastly improved.
22
Case 6
A 40 year old male with a strong family history of heart disease was rushed into hospital
after developing severe chest pain. His ECG showed ST-depression in leads V5, V6, lead I
and aVL. His twelve hour troponin
troponin-T level was significantly raised, indicating a lateral
myocardial infarction. He was subsequently taken to the catheterisation laboratory and his
angiography is shown below.
23
This picture shows narrowing of circumflex artery (A),
caused by atherosclerotic plaque rupture. Contrast can still be seen at the level of the
stenosis meaning this is not a complete occlusion.
The left main stem (B)
and left anterior descending artery (C)
can also be clearly seen.
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25
This is a picture of an angiography following stent insertion into the circumflex artery (A).
The operator was able to clearly visualise a path through the natural lumen of the vessel
and therefore would have passed the catheter directly through the lumen in order to open
up the lumen.
This patient remained in hospital for a few days following his treatment and was
commenced on the following medications as a form of secondary prevention, aspirin,
Clopidogrel, Bisprolol, Ramipril
amipril and Atorvastatin. He was followed up two weeks later in a
cardiology clinic.
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Case 7
This was a 65 year old lady with a history of uncontrolled hypertension who presented to
her general practitioner with worsening chest pain. At first this only occurred on exertion,
but then progressed to occur at rest. She is currently taking Amilodipine, Losartan,
Indapamide and Doxazosin, and despite this still has a raised blood pressure. She was
referred to a cardiologist who suggested further investigation. Her initial angiography is
shown below.
27
This is a picture of the patient
patient’s initial angiography.
There is clear stenosis of the Left anterior descending artery (A).
There is also radiological evidence of atheromatous disease in the circumflex artery.
However this is not flow limiting.
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29
This is an angiography following insertion of a stent into the left anterior descending artery (A).
Due to the occlusion not being compete the catheter could easily be passed through the lumen
of the artery, making this a relatively simple procedure.
This patient was subsequently discharged from hospital, but referred on to both a
cardiology clinic for routine follow up and a hypertension clinic, with the aim to control her
blood pressure.
30
Case 8
This was a 52 year old lady, with a history of asthma, was admitted to hospital following a
period of severe chest pain, and accompanied by sweating, nausea and vomiting. Her
ECG showed evidence of ischaemic changes in the lateral leads. She was taken to the
catheterisation laboratory for further investigation and intervention. Her initial angiography
is shown below.
31
).
This is an angiography showing occlusion of the circumflex artery (A).
The stenosis of this vessel can clearly be seen. The Left Anterior Descending artery (LAD)
Doesn’t fill with contrast.
Its natural path cannot be seen but has been marked out (B).
The reason for this is this patient has a short left main stem (C),
and the catheter is selectively intubating the circumflex artery (A),
and therefore not filling the LAD with contrast (B).
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33
This angiography has been taken after the circumflex artery has been stented (A).
There is clear widening of the artery and restoration of normal blood flow.
The catheter has now moved back, and is filling both the circumflex (A)
and the left anterior descending artery (B)
with contrast.
This patient was discharged without any further complications and was commenced on
dual anti platelet therapy, Diltiazem, Captopril and Atorvastatin, to prevent any further
ischaemic events.
34
Case 9
This was a 74 year old male patient who had a history of a previous myocardial infarction.
He presented to his general practitioner with worsening episodes of chest pain, which
started to occur on minimal exertion. His current medications include aspirin, Bisprolol,
simvastatin and Glyceryl TriNitrate
itrate (GTN) spray. He was referred to a cardiologist who
decided that further investigation was required. His initial angiography is shown below.
35
This is an angiography taken prior to any intervention, and shows a total chronic occlusion
of the Right Coronary Artery (RCA).
The natural pathway has been marked out (A, D).
However its territory is now being supplied by a collateral from the circumflex artery and
also there is retrograde filling of the RCA from the septal collaterals (C).
).
These septal collaterals (C)
Can be used for a retrograde approach when looking to re-open the RCA.
This patient has also had previous stenting of the left anterior descending artery (B).
36
37
This angiography was taken following insertion of a stent into the Right Coronary Artery (RCA).
This has restored flow within the RCA despite two severe blockages.
As a result the maincollaterals that were supplying the vascular territory of the RCA,
are no longer filling with contrast.
This patient was discharged on his regular medications, and also with a six month supply
of Clopidogrel to prevent stent induced thrombosis. Following the procedure he noticed a
vast improvement in his exercise tolerance.
38
Case 10
This patient presented to accident and emergency with severe crushing chest pain. An
ECG was carried out and showed ST elevation in V1, V2, V3, and V4. Following
Follow
administration of aspirin, Clopidogrel, Morphine and Metaclopramide, she was rushed
straight to the catheterisation laboratory.
lab
39
This angiography shows severe occlusion of the left anterior descending artery (A),
just distal to the bifurcation of the first diagonal branch (B).
There is evidence of atheromatous disease in the left main stem and the circumflex artery (C).
The right coronary artery (D)
and the posterior left ventricular branch (E)
of the right coronary artery, can also clearly be visualised.
40
41
This angiography is taken following intervention. The aim was to restore TIMI 3
flowthrough the Left Anterior Descending artery (LAD).
TIMI is a score which correlates with stent patency following primary angioplasty.
One stent was inserted into the LAD at the level of the occlusion (A)
and another into the first diagonal branch (B)
to maintain its patency. There is narrowing of the distal LAD (C)
However the operator believed from experience that this would remodel to produce a
satisfactory result, and therefore it didn't require angioplasty.
This patient remained in hospital following her procedure for routine monitoring. She was
discharged with a cardiology follow up appointment scheduled for two weeks’ time.
42
Patient 11
This patient was a 67 year old male with a history of hypertension, diabetes mellitus type 2
and hypercholesterolemia. Over the past few years he began to develop cardiac sounding
chest pain on exertion. He was commenced on Bisoprolol, Amlodipine, Aspirin and
Atorvastatin. Despite this his symptoms continued to progress. He was referred for further
investigation and his initial angiography is shown below.
43
This is an angiography showing the Right Coronary Artery (RCA)
.
There is clear evidence of atheromatous disease throughout the vessel, and the main areas of
).
stenosis have been identified (A).
occluded.
There is tight flow through the blood vessel, but it is not completely occlud
44
45
This is a picture of an angiography following insertion a stent into the right coronary artery (A).
The normal blood flow has been restored as a result.
This patient was discharged following his procedure on all of his regular medications. He
was also prescribed a six month course of Clopidogrel, to prevent stent induced stenosis,
metformin to try and improve his Glycaemic control and Ramipril in order to improve
control of his blood pressure.
46
Patient 12
This patient was a 64 year old man who had a previous history of ischaemic heart disease
that was treated with triple bypass surgery. He present to his general practitioner ten years
later with worsening chest pain, which warranted further investigation. His angiography is
shown below.
47
This angiography shows severe occlusion of the Left Anterior Descending
escending artery (LAD).
The normal pathway of the LAD has been marked out (A).
patient previous surgery.
There is also evidence of this patient’s
The bypass graft can be seen (B
B),
Along with the midline sternotomy wires (C).
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49
stent has been inserted into the
This angiography shows a st
Left Anterior Descending artery (LAD)(A),
and thus has restored blood flow through the vessel.
It also causes retrograde competitive flow through the bypass graft (B)
This means that there is less filling of the bypass graft with contrast.
This patient was discharged on his regular medications and also prescribed a course of
Clopidogrel to prevent stent induced thrombosis. The procedure was successful and at his
follow up appointment he reported a vast improvement in his symptoms.
50
Case 13
This patient was a 55 year old male who was brought into hospital following a period of
severe crushing central chest pain that radiated up towards his jaw and down his left arm.
An ECG showed ST-elevation
elevation in the inferior leads (lead II, III and aVF). He was
immediately transferred to the catheterisation laboratory for primary percutaneous
coronary intervention. His initial angiography is shown below.
51
This angiography shows an occlusion of the Right Coronary Artery (RCA) (A).
52
53
This angiography was performed following insertion of a stent into the right coronary artery (A).
This has resulted in normal flow through the blood vessel.
This patient had an uncomplicated procedure. He remained in hospital for 48 hours for
routine monitoring before being discharged. He was also commenced on the following
medications; aspirin, Clopidogrel, Atorvastatin, Bisoprolol, Ramipril and given a Glyceryl
TriNitrate (GTN) spray to use only when required.
54
Case 14
This was a 64 year old woman who presented to her general practitioner with a three
month history of worsening chest pain and fatigue. Her only significant past medical history
was diet controlled type 2 diabetes mellitus. She was referred for further investigation and
her initial angiography is shown below.
55
The initial angiography demonstrates stenosis of the Right Coronary Artery (RCA) (A).
56
57
This is an angiography following insertion of a stent in the right coronary artery (A).
This demonstrates that normal blood flow has now resumed.
This patient was discharged from hospital on Aspirin, Bisoprolol, Captopril, Atorvastatin
and a six month course of Clopidog
lopidogrel. She was also commenced on M
Metformin therapy to
improve her glycaemic control.
58
Case 15
This was a 53 year old man with a history of ischaemic heart disease who presented with
worsening central crushing chest pain, which would occur on minimal exertion and also
began to occur sporadically at rest. He is currently being treated with Aspirin, Bisprolol,
Ramipril, Amilodipine and Atorvastatin.
torvastatin. He uses his glyceryl trinitrate spray whenever he
experiences pain and it often provides relief, however it was decided further intervention
may be required. His initial angiography is shown below.
59
This angiography shows two areas of stenosis in the left anterior descending artery (LAD).
),
The first is just distal to the bifurcation of the first diagonal branch (A),
and the second is further downstream (B).
The circumflex artery can also clearly be seen (C).
Its irregular contour is further evidence of diffuse atherosclerotic disease.
disease
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61
This is an angiography following insertion of two drug eluting stents in the
Left Anterior Descending artery (LAD). The two stents used overlap.
A wider stent was used to treat the proximal stenosis (A),
and a smaller stent was used to treat the distal stenosis (B).
The end result is a vessel with a more natural width, which becomes narrow as it gets
further away from the left main stem.
There is diffuse atherosclerotic disease downstream (C),
But the calibre of the vessel at this point was deemed too small for intervention.
This patient was discharged on his regular medications, with a six month course of
Clopidogrel. He was followed up regularly in a cardiology clinic and reported great
improvement in his symptoms and exercise tolerance.
62