[Transfemoral coronary angiography. II. Technical aspects of risk lowering]

Based on an experience of 4950 coronary arteriographies and a review of the literature common complications of transfemoral coronary arteriography are named, their mechanisms are analyzed and technical modifications of the procedure are suggested that we found useful to decrease the risk associated with this diagnostic test. Since throboembolic complications are a central problem of the transfemoral technique, various mechanisms producing myocardial and cerebral emboli are carefully analyzed. The significance of routine systemic heparinization has been emphasized repeatedly, but the contribution to safety of mechanical catheter tip debridement that can be reliably achieved by a meticulous ritual of appropriate steps is not universally recognized. These steps include a careful guidewire technique, insisting on spontaneous free back-dripping of blood from newly introduced catheters after removal of the guidewire, aspiration of blood with a syringe and flushing with saline and contrast. Careful observation of the blood pressure contour is mandatory whenever the catheter is advanced. In view of the time-thrombogenicity relation of catheter material, the procedure has to be performed expeditiously. After apparent solution of the problem of thromboembolic accidents, the only major complications occurred in patients with severe left main coronary artery lesions. Whenever disease of the left main coronary artery can be anticipated by a suggestive history, by highly abnormal ECG changes with exercise or by calcifications of the coronary arteries, the number of contrast injections should be reduced to a minimum necessary to adequately demonstrate the severity of the stenosis and the anatomy of the peripheral vessels for possible bypass surgery.