CORONARY ANGIOGRAM

Coronary Angiogram
- is a procedure that

uses X-ray imaging to

see the heart's blood

vessels.
general procedures

Coronary
group known of as

angiograms are part of a

cardiac catheterization.

Heart
procedures and

catheterization
can both vessel coronary

diagnose and treat heart blood A conditions.

angiogram, which can help diagnose heart conditions,

is the most common type of

heart catheter procedure.

Indications for Coronary Angiography:

Coronary angioplasty, initially used in the

treatment of patients with stable angina and discrete

lesions in a single coronary artery, currently has multiple indications, including unstable angina, acute myocardial infarction (AMI), and multivessel CAD. With the combination of sophisticated equipment, experienced operators, and modern drug therapy, it has evolved into an effective nonsurgical modality for

treating patients with CAD.

Contraindications:

comorbidities (e.g. Weakened vessels, and/or severely blocked and narrowed artery)

ANATOMY OF THE HEART

Equipments/Materials:
Fluoroscope (Native Imaging and/or DSA) Cardiac Monitor IV Lines

Oxygen
Introducer needle Guidewires

Plastic Sheaths
Diagnostic Catheters Non-ionic dye/radiopaque dye

Nursing Considerations:
Assess the clients and familys knowledge and understanding

of the procedure. Provide additional information as needed.

Provide routine preoperative care as ordered. Although the client remains awake, sedation may be given. Signed consent is required, and pre-procedure fasting may be ordered. Administer ordered cardiac medications with a small sip of

water unless contraindicated. Regularly ordered medications

are continued to prevent cardiac compromise or dysrhythmias during the procedure.

 Assess for hypersensitivity to iodine, radiologic contrast media, or seafood. An iodine-based radiologic contrast dye is typically used for an angiogram. Iodine or seafood allergy

increases the risk for anaphylaxis and requires an alternative

dye or special precautions. Record baseline assessment data, including vital signs, height, and weight. Mark the locations of peripheral pulses; document their equality and amplitude. The data provide a

baseline for evaluating changes after the procedure.

Instruct to void prior to going to the cardiac catheterization laboratory, to promote comfort.

Procedure and Patient Preparation:

1. have the patient change from ordinary clothes
to a patients gown 2. Position the patient supine in the procedure bed 3. Hook all necessary equipments (ECG, BP, pulse ox., IV lines) and secure the patients extremities in order to prevent incidents of fall.

4. Cover the patient with sterile drapes and

expose only the site of coronary access; do a sterile skin prep. to the access site. 5. Prime all the catheters and wires to be used 6. Set-up the system (fluoro, monitors, contraptions, etc.) 7. The cardiologist will do an incision to the chosen access site (femoral/brachial) using an introducer needle.

8. A guidewire will be inserted then the introducer needle will be removed and replaced with a plastic sheath 9. A diagnostic catheter will be advanced into the artery 10. Once the catheter is in place, the dye will be injected and images will be captured by the fluoroscope. 11. After the angiography, the wires/ catheters and plastic shield will be removed.

POST-OP. CARE:
Assess vital signs, catheterization site for bleeding or hematoma, peripheral pulses, and neurovascular status every 15 minutes for first hour, every 30 minutes for the next hour, then hourly for 4 hours or until discharge. Maintain bed rest as ordered, usually for 6 hours if the femoral artery is used, or 2 to 3 hours if the brachial site is used.

Keep a pressure dressing, sandbag, or ice pack in place over the arterial
access site.

Instruct to avoid flexing or hyperextending the affected extremity for 12 to 24

hours.
Unless contraindicated, encourage liberal fluid intake. An increased fluid intake promotes excretion of the contrast medium, reducing the risk of

toxicity (particularly to the kidneys).

 Promptly report diminished peripheral pulses, formation of a new hematoma or enlargement of an existing one, severe pain at the insertion site or in the affected extremity, chest pain, or dyspnea. While the risk of complications is low, myocardial infarction or insertion site complications may occur. These necessitate prompt intervention. Provide instructions about dressing changes, follow-up appointments, and potential complications prior to discharge.

PERCUTANEOUS CORONARY INTERVENTION

Percutaneous Coronary Intervention (PCI)

is a treatment for persons experiencing

myocardial ischemia (inadequate blood flow to the heart) or myocardial infarction (heart attack). The goal of PCI is to open up a coronary artery (blood vessel

that brings blood and oxygen to the heart muscle) and

restore blood flow. Primary PCI is an emergency

treatment performed to reduce the amount of heart

muscle permanently damaged by a heart attack. Primary PCI reduces the mortality (death) rate from heart attack.

Contraindications:

Severe LV dysfunction Malignancies Pulmonary disease Vein graft diseases Severe multiple CAD

Materials/Paraphernalias for PCI:

Cath. Pack Sterile pack Percutaneous set Oxygen via mask/cannula Introducer needle Guidewires Introducer catheters Balloon catheters Inflators Pressure dressings

Procedure and Patient Preparation:

1. have the patient change from ordinary clothes
to a patients gown 2. Position the patient supine in the procedure bed 3. Hook all necessary equipments (ECG, BP, pulse ox., IV lines) and secure the patients extremities in order to prevent incidents of fall.

4. Cover the patient with sterile drapes and

expose only the site of coronary access; do a sterile skin prep. to the access site. 5. Prime all the catheters and wires to be used 6. Set-up the system (fluoro, monitors, contraptions, etc.) 7. The cardiologist will do an incision to the chosen access site (femoral/brachial) using an introducer needle.

8. A guidewire will be inserted then the introducer needle will be removed and replaced with a plastic sheath 9. A diagnostic catheter will be advanced into the artery 10. Once the catheter is in place, small amount of dye will be injected to obtain radiographic images 11. PTCA wire will be inserted into the guiding catheter for tracking of balloon into the target vessel.

12. The balloon catheter should be connected

in the PTCA in a negative pressure

13. Balloon is inflated

14. Angioplasty done. Balloon is deflated and

removed.
15. Introducer sheaths are sutured in place 16. Incision site is dressed aseptically

Cerebral Angiogram Coiling and Stenting

Coiling
a technique developed as a safer alternative to

surgical clipping, coiling does not involve open

cranial surgery, and is typically performed in less

time with quicker recovery. The only evidence of the

procedure afterward is a small scar in the leg. During the procedure, a small catheter is advanced from a blood vessel in the patients leg up into the blood vessels in the neck.

Indications
Coiling is used to treat cerebral aneurysms.

The main goal is prevention of rupture in

unruptured aneurysms, and prevention of

rebleeding in ruptured aneurysms. In ruptured

aneurysms, coiling is performed quickly after rupture because of the high risk of rebleeding within the first few weeks after initial rupture.

Anatomy of the Brains blood Pathway:

The human brain requires a constant supply of oxygen. A lack of oxygen of just a few minutes results in irreversible damage to the brain. The brain requires a rich blood supply, and the space between the skull and cerebrum contains many blood vessels. These blood vessels can be ruptured during trauma, resulting in bleeding.

4 MAJOR ARTERIES OF THE BRAIN:

1. Circle of Willis located at the base of the brain; it

forms a circle of communicating

arteries
the

(ACA,
entire

MCA, PCA) which branches throughout brain. 2.

Anterior Cerebral Artery (ACA) - extends upward and forward from the internal carotid artery; it supplies the frontal lobe of the brain which controls logical thoughts, personality and movements esp. In the legs. Damage

to ACA can cause profound mental symptoms.

3. Middle Cerebral Artery (MCA) has small deep penetrating arteries called Lenticulostriate Artery (LA); occlussion of these vessels causes lacunar strokes. About 20% of CVA are lacunar in origin. 4. Posterior Corinerebral Artery (PCA) mostly in the

basilar artery but sometimes originates from ipsilateral

internal carotid artery; it supplies the temporal and occipital lobes of the LEFT cerebral hemisphere. Damage in PCA can lead to color blindness, visual field defects, dyslexia, hallucinatons, hemiplegia and others.

Procedure
1. coiling is usually performed by an interventional neuroradiologist with the patient under general anaesthesia. The whole procedure is performed under fluoroscopic imaging guidance.

2. A guiding catheter is inserted through the femoral

artery and advanced to a site close to the aneurysm

after which angiography is performed to localize and assess the aneurysm.

3. A microcatheter is navigated into the aneurysm

4. The treatment uses detachable coils made of

platinum that are inserted into the aneurysm

using the microcatheter. A variety of coils are

available, including Guglielmi Detachable Coils

(GDC) which are platinum, Matrix coils which are

coated with a biopolymer, and hydrogel coated

coils.

5. A series of progressively smaller coils is

inserted into the aneurysm until it is completely

filled. In the case of wide-necked aneurysms, a

stent may be used.

STENTING
a process wherein a tiny
tube is placed into an

artery, blood vessel, or

other hollow structure

(such as one that carries

urine) to hold it open.

Indications:
Most of the time, stents are used to treat conditions that result when arteries become narrow or blocked. Stents are commonly used to treat the following conditions that result from blocked or damaged blood vessels:
Coronary heart disease (CHD) (angioplasty and stent placement heart) Peripheral artery disease (angioplasty and stent replacement peripheral arteries) Renal artery stenosis Abdominal aortic aneurysm (aortic aneurysm repair - endovascular) Carotid artery disease (carotid artery surgery)

Contraindications:

Patients

in

whom

antiplatelet

and/or

anticoagulation therapy is contraindicated. Lesions that are highly calcified or otherwise could prevent access or appropriate expansion of the stent.

PROCEDURE:
1. To detemine whether or not the patient has good blood

flow into the heart muscle, the coronary arteries may

need to be x-rayed. This process is known as angiography. Dye is injeccted into the blood vessels, which will then show up the white on x-ray film. 2. A guide is carefully inserted into the femoral artery

through a small incision in the patients upper thigh.

From there, it is fed up through the aorta and into position.

3. A catheter is then inserted along the guide wire and

positioned so that the dye flows into the coronary arteries. 4. Once the catheter is properly placed, the dye is injected. As the vessels are illuminated areas of narrowing reveal

blockage.
5. After the image is taken, the catheter is withdrawn. If the

coronary arteries are blocked, and the physician

determines that angioplasty/stenting needs to be done next, then the guide wire will be left in place to guide a treatment catheter to the area.

6. A balloon catheter follows a guide wire into the blocked

coronary artery. 7. The guide wire used in the angiography procedure is used to guide a balloon catheter to the site of narrowing in the artery. 8. The balloon is inflated and pushes the plague up against the artery walls. The angioplasty is complete.

9. The inflated balloon expands the stent and pushes the

plaque up against the artery walls.

10. The balloon catheter is deflated and the stent remains expanded to hold the artery open.

11. The catheter and guide wire are removed. The stent will

remain in the artery to keep the artery open.

12. The plaque can reform around the stent, or undergo restenosis, overtime. Drug eluting stents may help prevent this from occurring.

Nursing Considerations:
Identifies baseline cardiac and vascular status and reviews diagnostic evaluations (eg, electrocardiogram [ECG], laboratory test results).

Uses monitoring equipment to assess cardiac and

vascular status (eg, ECG, arterial line, pulmonary artery catheter, Doppler). Assesses peripheral pulses, skin pallor, numbness, and tingling of extremities.

 Observes for signs and symptoms of hypovolemia in

postoperative period related to blood loss. Assesses skin integrity, sensory impairments, and susceptibility for infection. Minimizes length of invasive procedure by planning

care

and

obtaining

necessary

equipment

expeditiously.

Monitors sterile field and perioperative team members

to ensure that asepsis is maintained.

 Dresses wound at completion of procedure. Assesses readiness to learn and coping mechanisms.

Explains sequence of events and reinforces

teaching about cerebral aneurysms, surgical treatment options, and recovery. Provides instruction (for surgical procedure and discharge, including signs and symptoms of

postoperative hemorrhage.
Evaluates for signs and symptoms of skin and tissue injury.