Overview

A 71-year-old female came to the emergency with a heart block ( heart rate of 35 beats per minute) and low blood pressure. She had a prior history of smoking, chronic obstructive airway disease, hypertension, and hypothyroidism and was on multiple medications. Immediately, a temporary pacemaker was placed through the jugular vein ( a neck vein ) for the heart block, and medications were started. She was found to have high troponin levels ( a marker of cardiac muscle damage). Her lung condition was poor due to chronic obstructive airway disease. She required bronchodilators, oxygen support and IV antibiotics for stabilisation.

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Ninety percent stenosis in proximal right coronary artery[/caption]

After stabilisation, coronary angiography was done through the right wrist artery, which revealed a 90% block in the right coronary artery, which was stented. The heart block recovered subsequently, the temporary pacemaker was removed, and the patient was discharged the next day. Placing the temporary pacemaker via a neck vein and performing the angiography from the wrist artery significantly improved patient comfort and outcomes.

She was not immobilised in bed, which would not have been possible had she undergone the procedures via the thigh artery and vein. This mobility not only increases patient comfort but also reduces the chances of thromboembolic complications, which are more common when the patient is immobilised.

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Post angioplasty and stenting of right coronary artery[/caption]

How is Coronary Angiography Performed?

Coronary angiography can be performed via the thigh ( femoral artery) or the hand ( radial artery). Performing angiography via the radial artery is more comfortable for the patient, as it allows early mobilisation and is associated with fewer bleeding complications and faster recovery. However, the radial artery is smaller than the femoral artery. At times, it may not be feasible to perform angiography via the radial route, and one has to switch to the femoral artery. The femoral artery is bigger and can accommodate larger-sized catheters and devices. However, it is less comfortable for the patient and may also be associated with a higher risk of bleeding events. In elderly individuals, the risk of bleeding complications is higher when compared to younger individuals.

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Temporary pacemaker inserted via jugular vein[/caption]

Females also tend to have higher bleeding complications when compared to males. Our patient was both elderly and female. In addition she was frail and had multiple comorbidities. All these placed her at high risk of overall complications, including bleeding complications. Coronary artery disease is less common but more aggressive in female patients, and many females may have atypical presentations of heart attack, unlike the typical symptoms of chest pain. It was also the case in our patient, who had no chest pain at presentation and complained only of uneasiness and feeling of being unwell.

We perform most of our procedures via the radial route to enhance patient comfort and reduce complications. However, in some cases, we have to use the femoral route, especially in acute emergencies with cardiogenic shock, post CABG (post bypass) patients, patients requiring mechanical circulatory support like IABP (Intra Aortic Balloon Pump), etc. Both radial and femoral angiographies are relatively safe procedures with low ( albeit not negligible) complication rates. However, radial procedures are more comfortable for the patient, allowing early mobilisation and recovery, with relatively low bleeding complications and same-day discharge in many of them.

Dr Samir Kubba - MD, DNB, MNAMS, DM, FACC, FSCAI (USA), FESC (Europe) - Director and Unit Head, Cardiology

Dr Raghav Aggarwal- MD, DM, Associate Consultant Cardiology

published and written by Dr Samir Kubba