Coronarography: what it is and when it is needed

By Cristiano Antonino On Feb 9, 2023

First of all, it should be said that, despite making use of radiological support,coronarography is an examination performed by interventional cardiologists and is not a surgical procedure, even if, involving the puncture of an artery, it is defined as an invasive test

The problem is that, no matter how much progress modern radiology has made, with CT and Nuclear Magnetic Resonance, the greater sensitivity and specificity in visualizing the coronary arteries remains the prerogative of coronary angiography itself which also allows us to intervene on them, at the same time as the angiographic examination.

How a coronarography is performed

It is necessary to reach the coronary arteries at their origin, inject a radiopaque substance into them and only then take a series of x-rays (generally it is a real film) which allow you to visualize the vessels and their possible narrowing.

The coronarography therefore involves a catheterization at the origin of the cardiac organ and it is precisely this that often frightens the patient, for a sort of fear in learning that a foreign body will be introduced and maneuvered near or inside of one’s heart, violating every protection of a vital organ jealously guarded and protected inside one’s chest.

This type of catheterization is certainly not a new experimental technique, having been practiced for many years now, in millions of patients.

Coronarography is an examination that is performed with particular radiological equipment in an ad hoc room, which is the hemodynamics room, which looks a lot like an operating room, but it is not an operating room.

Even the haemodynamic cardiologists who perform the exam are dressed in caps, masks, gloves, aprons and leggings like surgeons, but they are not surgeons; in fact they are not armed with scalpels and scissors; they just have to, like their fellow surgeons, respect the rules of asepsis and sterility.

The precise knowledge of the procedures for carrying out the examination is very useful for reducing the patient’s worries and anxieties, obtaining his informed consent and his full collaboration: understanding and rationalizing is the best way to overcome fear, because very often the fear is caused or increased by the unknown, that is, by the lack of information.

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Coronarography, is it necessary to undergo anesthesia?

Anesthesia is not required for coronarography; rather, on the contrary, the patient must be wide awake and collaborate in the examination, breathing deeply, holding his breath on command of the doctor and reporting any disturbances; the bravest can even follow the various stages of the exam with their own eyes on a special monitor.

The introduction of the catheters (if more than one is used), which are very thin flexible tubes, the result of high bioengineering technology, takes place through the groin, where a large artery passes, the femoral artery, or the wrist pertains to the approach from the radial artery.

The puncture of the vessel is preceded by local anesthesia, which is practiced with a normal needle and a normal syringe, just like the anesthesia performed by the dentist for the extraction or treatment of a tooth.

This is the only pain that is felt, in fact coronary angiography is not a painful exam.

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But is it dangerous?

The risk assessment of a given procedure or therapy must always be done in relation to the need for the procedure itself, its opportunity, the expected ‘gain’ in terms of diagnostic accuracy and therapeutic choices and on the basis of the general clinical context.

Faced with the risk of carrying out a specific procedure, the risk of not carrying it out should be assessed exactly, and with the same firmness.

It follows that the exact and complete risk assessment implies a complex logical process that belongs entirely to the doctor and requires great experience, culture, professionalism and responsibility.

However, the widespread opinion of authoritative opinions is that the specific risk of coronary angiography is very low and in any case far less than the importance of the information obtained from it, once the need for its execution has been correctly postulated.

The decision to proceed with coronarography is obviously not motivated by pure curiosity or thirst for knowledge.

It is now known that heart attack treatment today is not based exclusively on drugs, but that there are alternatives to medical treatment: bypass surgery and dilatation of the narrowed vessel with a balloon (angioplasty).

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Coronarography is the obligatory step to access non-medical care

It follows that the indication for coronarography is placed where the clinical context and the results of non-invasive tests, previously implemented, suggest that interventional treatments, as an alternative or in addition to medical ones, could be necessary or preferable in that particular patient .

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Where to take the exam?

It is absolutely useless to go abroad to perform coronarography; it is also useless to move to another city in our country; it is probably sufficient to go to the hospital or clinic located a few kilometers from your home.

In fact, in Italy, the sections of Hemodynamics are about 200, the average level of the operators is generally more than sufficient and sometimes very high, the equipment and materials used are of excellent quality and are generally the same as those found in the treatment rooms. hemodynamics of Paris, London, Lyon, Houston, etc.

The hemodynamists who perform coronarography and angioplasty are generally part of international teams of experts, with continuous exchange of information, data, case studies, updates and improvements of techniques.

Therefore, once the ‘learning curve’ has been overcome, which is related to the number of exams taken and which, obviously, is a mandatory step everywhere and for everyone, the skill level of the various teams is generally equal.

A curiosity! The first cardiac catheterization on a man was performed by Werner Forssman in 1929 on… himself.

He introduced a tube into a vein in his arm up to the right heart, then with the catheter positioned inside the heart he climbed the stairs to Radiology to perform an x-ray and thus be able to document the event.