Coronary Angiogram

When I first started working in the cardiac cathlab, I was nervous because it is a very new experience for me. I have no full experience in the theatres nor worked in a cardiology unit. Although I have handled patients with cardiac problems, working inside the lab is totally different.

At this point, I am not an expert in this field but I dream to be a good one someday. I am thrilled to know more stuff about cardiology. This is a similar feeling when I was aiming to be really good at becoming an Infection Control Nurse (ICN) back home. I have subscribed to different newsletters and joined various trainings just to be really good at what I do. It became fruitful. Looking back, I think I did my best despite the lack of resources and overwhelming workload. Quite honestly, the experience made me resilient. Filipino Nurses are really good at multitasking. Anyway, I thought I’d continue my career path as an ICN here in the UK but my journey so far lead me to cardiology.

I am looking for ways on how to improve myself as a cath lab nurse. My grandfather used to say that one way to enhance your capabilities is to have the knowledge in a chosen field. I must have the drive, discipline and determination to succeed. I plan to document my journey as a Cathlab nurse and share whatever learnings I have gained to everyone. I feel like there is so much to share.

Let us start with Coronary Angiogram. What is it?

A Coronary Angiogram is a special type of procedure done in the Cathlab to radiographically view the arteries of the heart using an x-ray machine and the injection of a contrast, which helps the cardiologists to generally determine if there are any narrowing or blockage in any of the coronary vessels of the heart.

It is also known as Cardiac Catheterisation because we use specialised intravascular catheters and wires. It is usually done in 20 to 30 minutes but sometimes the procedure takes longer if there is a need to gather more data such as Pressure Wire Studies or Intravascular Ultrasound (IVUS).

A doctor may require a patient to have an angiogram if the patient is diagnosed to have symptomatic Coronary Artery Disease (CAD) meaning a patient with chest pain or angina, congenital heart anomalies, heart valve concerns that require surgery and coronary blood vessel problems.

I mentioned in my blog post “Introduction to Cardiac Catheterisation for Nurses” the preparations we do for patients going into to the lab. This includes the proper identification of patient, obtaining consent, ensuring that patient is NBM at least 4 hours prior and administering pre-op medications or performing essential diagnostic tests like bloods and ECG. As nurses, we are usually the first to come in contact with the patient and determine if patient needs urgent cardiac intervention. Although it is the doctor who performs the thorough cardiac assessment and the one who explains the risks and benefits of the procedure, we generally steward the preparation of the patient in all aspects including emotional support and make safety a priority.

Once the patient steps in the lab, we place him on the operating table and we’d all do the standard World Health Organisation (WHO) checklist. We will connect the patient to the monitor, check the cannula if it is flushing and patent and administer sedation if needed and more importantly, maintain the sterility of the environment.

The access site for angiogram is either the wrist (Radial artery) or the groin (Femoral artery). The operator (cardiologist) administers the local anaesthesia (Lidocaine 2%) and creates access using a radial or femoral sheath (normally French 6 in size). If it is a radial approach, the operator will give a radial cocktail (a mixture of heparin and verapamil) to prevent spasms and promote ease in introducing the wires and catheters. The wires and catheters are inserted to the sheath guided by x-ray.

It is important to note that while the operator is already creating an access, everyone inside the lab should be wearing a lead gown as personal protection from radiation. Also, at this point, everyone should be aware that the patient’s kidney is at its optimum function, which means that creatinine is within the normal parameters and that female patients are absolutely not pregnant.

Once the catheter is intubated to the artery, a dye is injected to visualise the coronary arteries. To perform Angiogram, Judkins Right (JR4 diagnostic catheter) to view the Right Coronary Artery (RCA) and JL3.5 or JL4 diagnostic catheter is used to visualise the left system, which includes the Left Circumflex and Left Anterior Descending (LAD) Coronary artery. Depending on the patient’s anatomy, sometimes operators use a Tiger (TIG) catheter or other diagnostic catheters to perform angiogram.

After an angiogram, the access site will be closed and secured by a TR band, a pressure device, if radial and an AngioSeal, a collagen plug, for femoral approach procedures. The standard recovery time for patient is 4 hours and the patient may have something to eat and drink. They are encourage to increase fluid intake to flush out the contrast introduced in their system. If the patient had an angiogram using the femoral artery, the patient can start to sit up an hour after the operator removed the sheath.

The complications of this procedure are bruising (haematoma), bleeding, tiredness, infection or allergic reaction to contrast, stroke, arrhythmia and kidney damage. It is normal to bleed a little and to have a small haematoma and tenderness around where the catheter went in but this should go down in a few days. In addition, there is a small risk of heart attack, stroke and death but the benefit of this procedure outweighs the risks.

References:

https://www.ahajournals.org/doi/pdf/10.1161/01.cir.99.17.2345

https://www.mayoclinic.org/tests-procedures/coronary-angiogram/about/pac-20384904

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