J INVASIVE CARDIOL 2017;29(8):E88-E89.
Key words: angiography, supine position, sitting position
Transradial coronary angiography has significantly increased in the United States over the last decade. From 1.2% of the total coronary angiograms in 2007 and over 16% in 2012, today most modern cardiac catheterization labs perform the majority of their cases transradially.1 They are associated with improved quality of life after the procedure and reduced hospital costs.2 Radial access has been successfully used in acute coronary syndromes (ACS), complex coronary and chronic total occlusion (CTO) interventions, peripheral upper-extremity and lower-extremity arterial procedures, renal, visceral, carotid and neurointerventions, and as a secondary access for transcatheter aortic valve replacement (TAVR).3 In ACS patients, transradial interventions have been associated with reduced mortality, major bleeding, major adverse cardiac events, and length of hospitalization, with similar procedural success rates.4 Transfemoral and transradial coronary angiograms are traditionally performed with the patient lying in the supine position; however, it is not uncommon to raise the head of the patient up to 30° in cases of severe back pain or shortness of breath. When the patient is unable to lie down despite analgesia and conscious sedation, general anesthesia may be recommended.
A 73-year-old gentleman was seen in our clinic with worsening shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. His past medical history included coronary artery disease post myocardial infarction in 2002 and stent placement in the proximal left anterior descending artery, an ascending thoracic aortic aneurysm of 47 mm under annual follow-up with thoracic surgery, a new-onset atrial fibrillation with controlled ventricular response, morbid obesity (body mass index, 34 kg/m2), hypertension, severe chronic obstructive pulmonary disease on continuous nasal oxygen at 3 L, prostate cancer post radiation, and severe osteoarthritis of the spine. His echocardiogram showed a dilated left ventricle of 61 mm in diameter, and dyskinesis of the mid and apical inferoseptal and inferior walls with an estimated ejection fraction (EF) of 35%-40%, which was significantly decreased compared with his previous echocardiogram in 2012 (EF, 60%). The right ventricular size was normal, as was the right ventricular systolic pressure (24 mm Hg). The patient was placed on appropriate medical therapy and referred for an outpatient coronary angiography with the indication of “newly recognized LV systolic dysfunction of unknown etiology.”5
After an abnormal Allen’s test in the right artery, the left radial artery was deemed appropriate for a cardiac catheterization. The patient was brought to our cardiac cath lab, but refused to lie flat for the procedure. He stated that he had severe spine osteoarthritis and that he had not been able to lie flat for over 5 years. During that period, he slept in his recliner. Despite analgesia with opiates, he reported extreme discomfort and refused to lie down. General anesthesia was considered but was deemed high risk due to his co-morbidities. We elected to perform the coronary angiogram in the catheterization lab in a sitting (90°) position via left transradial access. A JL-5 was used for the selective angiogram of the left coronary artery and a JR-4 for the right one. Extreme caudal/apical and right/left views were impossible due to collision of the C-arm with the patient or the table (Figure 1). His coronary angiogram showed a patent stent in the proximal left anterior descending and otherwise mild to moderate atherosclerosis. Percutaneous coronary intervention was not performed. The patient was sent home 3 hours after the procedure. At follow-up 9 days later, he was improved clinically on medical therapy and without any procedural complications.
The use of transradial access during coronary angiogram has been steadily increasing over the last decade. Patients with severe back pain or respiratory disease are often unable to lie flat without strong analgesia, sedation, or general anesthesia.
We experienced important limitations in the extent of views that could be taken with the patient in a sitting position. Moreover, the change of the heart position combined with the reduced range of the C-arm provided angiographic images slightly different than the traditional or expected ones. Previous reports described increased heart rate, blood pressure, rate pressure product, and oxygen consumption (VO2), which were not appreciated in our case.6
The risk of the patient falling off the table during the procedure appeared to be increased compared with regular cases. A safety belt is routinely used in our patients; however, two nurses remained in close proximity.
The risk of radiation to the patient and the operator may be higher in a sitting position. Due to significantly increased abdominal girth, the caudal views required higher doses of radiation and they were of suboptimal quality.
Finally, when compared with a patient in a supine position, a patient in a sitting position has a theoretical increased risk of cerebral embolization if inadvertent air injection occurs.
To our knowledge, this is the first reported case of coronary angiogram in a patient in a sitting position. This approach may be important, assuming it is carefully done, in patients unable to lie in a supine position. Larger case series are needed to establish the safety of coronary angiography in a sitting position.
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2. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: a randomized comparison. J Am Coll Cardiol. 2013;61:420-426. Epub 2012 Dec 19.
3. Voudris KV, Georgiadou P, Charitakis K, Marmagkiolis K. Radial interventions: present and future indications. Curr Treat Options Cardiovasc Med. 2016;18:2.
4. Del Furia F, Giustino G, Chieffo A. Targeting transradial approach: an updated systematic review and meta-analysis of randomized controlled trials. Panminerva Med. 2016;58:329-340. Epub 2016 Jun 30.
5. Patel MR, Bailey SR, Bonow RO, et al. CCF/SCAI/AATS/AHA/ASE/ASNC/HFSA/HRS/SCCM/SCCT/SCMR/STS 2012 appropriate use criteria for diagnostic catheterization: American College of Cardiology Foundation Appropriate Use Criteria Task Force Society for Cardiovascular Angiography and Interventions American Association for Thoracic Surgery American Heart Association, American Society of Echocardiography American Society of Nuclear Cardiology Heart Failure Society of America Heart Rhythm Society, Society of Critical Care Medicine Society of Cardiovascular Computed Tomography Society for Cardiovascular Magnetic Resonance Society of Thoracic Surgeons. Catheter Cardiovasc Interv. 2012;80:E50-E81. Epub 2012 Jun 7.
6. Jones AY, Dean E. Body position change and its effect on hemodynamic and metabolic status. Heart Lung. 2004;33:281-290.
From 1Pepin Heart Institute Florida Hospital, Tampa, Florida; 2Arkansas Heart Hospital, Little Rock, Arkansas and Koc University, School of Medicine, Istanbul, Turkey; and 3Hofstra Northwell School of Medicine, Northwell Health, and North Shore University Hospital, Manhasset, New York.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted April 20, 2017.
Address for correspondence: Konstantinos Marmagkiolis, MD, MBA, FACC, FSCAI, 1945 Noor Street, Apt 212, Wesley Chapel, FL 33544. Email: firstname.lastname@example.org