Selective Coronary Arteriography: Part I: A Percutaneous Transfemoral Technic

Abstract

Until recently, there has been a reluctance to subject the coronary patient to the “added risk” of coronary arteriography. The recognition that coronary arteriography is no more hazardous than selective cardioangiography, that coronary visualization can depict precisely the presence and extent of disease, and that something can be done about coronary artery occlusive disease has extended the indications and increased the demand for detailed coronary delineation. Numerous technics for coronary visualization have been proposed (2, 4, 5, 8–11). In general, the various forms of the aortic root flush have been favored in Europe, while more selective technics have gained acceptance in the American centers. The new technic reported here facilitates consistent, rapid selective catheterization of both coronaries with a minimum of catheter manipulation; takes advantage of the ease, rapidity of performance, and low complication rate of percutaneous femoral catheterization; facilitates both direct serial and ciné filming; and is readily taught to residents, fellows, and practicing angiographers. Material One hundred consecutive patients between the ages of twenty-one and sixty-nine years were examined for suspected coronary disease. In each, both coronary arteries were selectively catheterized from the femoral artery, and contrast injections were filmed by direct serial radiography and cinephotofluorography. Over one-third of the patients were examined on an outpatient basis. Technic Initially two 100-cm 8F Ducor catheters2 (12) were shaped over preformed stainless steel bending wires (Fig. 1). The original configuration was removed, and a new one set by heating in boiling water for about two minutes. This basic Ducor catheter (a polyurethane catheter with internal stainless steel wire braid) has been modified, (a) The tip was changed from the usual “pencil tip” to a “bullet nose” configuration to minimize the chance of intimal injury. (b) The distal 2 cm was thinned to 5.5F (1.8 mm) to avoid coronary wedging, (c) The side-holes were eliminated to reduce possibility of clotting in the catheter tip distal to the side-holes and to improve pressure monitoring. This modified catheter, developed with the aid of Robert Stevens,3 is preshaped into right and left configurations (Fig. 2) over the bending wires similar to those shown in Figure 1. Left Coronary: The catheter is introduced percutaneously from the common femoral artery and advanced to the descending thoracic aorta; the leader is then removed, and the catheter cleared and advanced to a relaxed position in the aortic arch (Fig. 3, A). With the patient in a 20° right posterior oblique position to the table, the catheter tip is advanced down the left wall of the ascending aorta until it drops into the sinus of Valsalva and coronary orifice (Fig. 3, B and C).