Coronary angiogram and angioplasty/PCI

A coronary angiogram (sometimes called ‘cardiac catheterisation’) is an X-ray study which takes pictures of the blood flowing through the coronary arteries which supply the heart with blood. It can highlight narrowings or blockages in these arteries caused by fatty calcified deposits – coronary artery disease. 

The angiogram gives a detailed assessment of the arteries to give doctors extra information to help them decide on the appropriate treatment. If you have a narrowing coronary (heart) artery, that can be treated with ‘balloon coronary angioplasty and stent’ (PCI). This can be done in the same procedure or sometimes separately at a later date.  

Coronary angioplasty, often called PCI (Percutaneous Coronary Intervention), is a procedure where a balloon is used to open a blockage in a coronary artery. It is very similar to an angiogram procedure and is performed in the same room, under the same conditions, and the recovery is similar. The main difference is that an angiogram only collects information (pictures), whereas an angioplasty performs a treatment (inserting a stent). 

An angioplasty/PCI takes approximately 1-2 hours to perform. The length of time will vary from person to person depending on the complexity of the coronary artery disease. A balloon is used to stretch the artery and a stent (wire mesh tube) is then put in the narrowed artery and acts as internal scaffolding, keeping the artery open.

Generally it is a very safe procedure. Potential complications are uncommon but include: 

Damage to the blood vessels in the leg or arm. Bleeding or haematoma (a lump/bruise under the skin) around the puncture site.

• A small risk of stroke.
• A small risk of heart attack.
• A small risk of emergency cardiac surgery. 
• A small risk of death.
• Very rarely an allergic reaction to the injected substance.
• X-ray is used in this procedure but with modern equipment the risk from the X-ray is very low.

You will be invited to attend pre-assessment clinic/ telephone consultation, where we will explain the procedure to you and collect information. If you need an interpreter, please let us know as soon as possible. An ECG will be performed and you might be asked for a blood sample. 

You will need someone to take you to and from the procedure and who will stay with you at home overnight. If this is not possible, let us know in advance and we will arrange an overnight bed. They will not be able to stay with you on the day of the procedure.  

Please let us know if you might be pregnant. Also, let us know of any allergies, and bring a list of your current medication. 

• If you take diuretics (water tablets), do not take them on the morning of your procedure as you may find it inconvenient.
• If you are taking metformin (glucophage), ideally it should be stopped 48 hours prior and not re-started until 48 hours after your procedure. 
• If you take warfarin, stop taking it 4 days prior to the procedure. 
• If you take any other anticoagulant (blood thinner, e.g. rivabaxan, dabigatran, apixaban, edoxaban) stop taking it 2 days prior to the procedure.

It is now very common to have combined ‘angiogram and angioplasty (PCI)’ and it is very important that you take dual anti-platelet medication leading up to, and on, the morning of the procedure. This is usually a combination of aspirin and clopidogrel, or aspirin and ticagrelor. This will be discussed in pre-assessment, and prescribed if necessary. These medications are vital for the procedure to go ahead as they prevent blood clotting in the stent.

• Have nothing to eat after 6:30am if your procedure is in the morning.
• Have nothing to eat after 10:30 am if your procedure is in the afternoon.  
• You can drink water up until the procedure. 
• Bring all your usual medication in with you on the day of the procedure.
• Your wedding ring can be taped to your finger but please leave other valuables at home. Please remove all nail varnish.
• Bring a newspaper or a book with you so that you will have something to do when the procedure is over.
• Bring slippers and a dressing gown, but as few other possessions as possible. 
• Take/stop taking medication as instructed. You should take your usual regular medication unless instructed otherwise.

You will arrive at the Imaging Department (Gate 19) and be accompanied into our day case area. A cardiologist will explain the procedure to you, and the benefits and potential risks. You will have an opportunity to ask questions. If you choose to go ahead with the procedure you will need to sign a consent form, which may be done during your pre-assessment visit. Please let us know of any allergies too. From there, you will be asked to change into a hospital gown and paper pants and a nurse will go through the procedure checklist and place a small plastic tube called a cannula, in a vein in your forearm to allow medications to be given if necessary during the procedure.

You will be taken to the Cardiac Catheterisation Laboratory (Cath Lab). You will be asked to lie down flat on the X-ray table with a pillow for the procedure. There will be a small team of nurses, doctors, cardiac physiologists and radiographers with you throughout. 

If you are feeling anxious, you will be offered sedation but will stay awake. The nurse will then cover you with a drape and clean the area at the top of your leg or wrist with antiseptic solution. Then the doctor will inject local anaesthetic into your wrist (if radial) or the area at the top of your leg (if femoral) which will briefly sting and then go numb. 

After this, you may just feel a pushing sensation when a small plastic tube (sheath) is inserted into your femoral or radial artery. A catheter is passed though the sheath and up inside the artery to the heart. Once the catheter reaches your coronary (heart) arteries, contrast liquid is injected into the bloodstream and X-ray images are taken.

The X-ray machine will move around you, but will not touch you. It is important that you stay still throughout to take the clearest pictures possible. Once the doctor has acquired enough images, the X-ray machine will be removed. 

If the doctor used the wrist artery (radial), a pressure device called a TR band will be placed on your wrist and inflated. This will be deflated gradually until it can be removed. Alternatively, if the doctor used the leg artery (femoral), a seal may be used to plug the artery or pressure will be applied either with a pressure device or manual pressure. 

You will be taken back to recovery/day case area initially, so that nursing staff can monitor your observations and the wound site very closely. Relax as much as you can and tell the nurse straight away if you experience any discomfort, notice any swelling or bleeding at the wound site, numbness in the leg/arm, or you feel unwell. You will be able to eat and drink as normal. Please make sure you drink plenty of fluids after this procedure which will help pass the contrast liquid out in the urine. 

Recovery time after an angiogram is usually around 3 hours, but can sometimes be longer. 

Recovery time after an angiogram is usually around 3 hours, but can sometimes be longer. If you have an angioplasty (PCI), your recovery time will be longer (about 6 hours) or you may require an overnight stay in hospital. This will be discussed in your pre-assessment appointment. 

If the doctor used the wrist radial artery:

• The band around your wrist will be slowly deflated over 2-3 hours and then removed. This will be longer, usually 3-5 hours, for an angioplasty/PCI. 
• The band will then be removed and replaced with a small dressing. 
• Try not to move your wrist much while your artery is healing.

• If the doctor used the leg femoral artery:

• If a pressure device or manual pressure was used to stop the bleeding you will need to stay flat for 1 hour and bed rest for a total of 3 hours. 
• If you have had a seal you can sit up straight away if there is no bleeding, and move around after 2 hours. This may be longer if bleeding occurs. require an overnight stay in hospital. This will be discussed in your pre-assessment appointment. 

Before you are discharged, the doctor will discuss the results with you. If you have coronary artery disease that requires further treatment, the doctor will explain the options and there may be a meeting. This may be cardiac surgery (coronary artery bypass grafts – CABG), coronary angioplasty/PCI or drug therapy. You will then be given a discharge letter. 

Do not do any heavy lifting or strenuous exercise, like weight lifting or cycling, for 4-5 days. Do not drive 48 hours after an angiogram and 1 week after an angioplasty/PCI (DVLA advice). Drink lots of water (2L) in the following 24 hours. If you were sedated, don’t sign any legal documentation for 48 hours.

Radial (wrist) puncture: 

• Rest the arm for 2-3 days.
• Avoid flexing/ bending the wrist, lifting and putting weight through the arm. 
• Avoid bathing and washing up for 48 hours after. You may shower the following day, but avoid scrubbing the wound. If wet, replace the dressing with a plaster.

Femoral (groin) puncture: 

• Avoid bending from the hip for 2-3 days or anything that strains stomach muscles. 
• Avoid straining when going to the toilet. 
• Apply light pressure over the puncture site, when coughing, sneezing, or laughing. 
• Avoid bathing for 48 hours post procedure. You may shower the following day, but avoid scrubbing the wound, and pat dry thoroughly. 

Complications are rare but can happen, particularly in the first 24 hours, so make sure you have a responsible adult with you. If the wound starts to bleed or swell suddenly, apply firm pressure to the puncture site for 10-20 minutes. If the wound is in the groin, lie flat while pressure is applied for you. If the bleeding stops, seek medical advice. If you are unable to stop the bleeding, call 999 immediately. 

A bruise around the site is common but should fade after 2-3 weeks. If it becomes swollen, or you develop persistent pain/ tenderness, contact your GP. If you get any chest discomfort after discharge that does not resolve 5-10 minutes after using your GTN spray, call 999.