Planning

1.1

Planning

Consent obtained

• Consent needs to be obtained and documented prior to the procedure. Discussion about the risks and benefits of ad hoc PCI is critical, in patients without a prior angiogram.

History :

• Clinical presentation (stable angina, acute coronary syndromes (ACS), other).

• If stable coronary artery disease, is indication for procedure appropriate? (Review appropriate use criteria ).

• Ongoing chest pain?

• Prior cardiac catheterization or other procedure requiring fluoroscopy? If yes, are the prior images and reports available?

• Prior coronary artery bypass graft surgery (CABG)? If yes, is surgical report available?

• Current medications (see Section 1.3 ).

• Comorbidities

  • Valvular heart disease

  • Congestive heart failure

  • Arrhythmias

  • Peripheral arterial disease (PAD)

  • Renal failure

  • Significant lung disease

  • Obstructive sleep apnea

  • Bleeding disorders

  • Back pain or other musculoskeletal disorders that can affect lying flat on the cardiac catheterization table

  • Diabetes mellitus

  • Advanced age

• Is the patient likely to be noncompliant with medications or require noncardiac surgery in the upcoming 6–12 months? If yes, PCI may be best avoided to minimize the risk of stent thrombosis (due to the surgery and the early discontinuation of dual antiplatelet therapy). Medical therapy only or CABG may be preferred.

• In patients with renal failure or those who are anticoagulated, it may be best to stage non-emergent PCI; ultra low or zero contrast PCI, if feasible, may be beneficial in patients with advanced kidney disease.

• Contrast or latex allergy?

Physical examination :

• Radiation skin injury on the back ( Fig. 28.3 )? If yes, may need to postpone or modify procedure to avoid repeat radiation of the affected area.

• Cardiovascular examination that includes all pulses in upper and lower extremities.

• Signs of congestive heart failure (pulmonary rales, high jugular venous pressure, lower extremity edema).

Labs :

• Hemoglobin

• White blood cell count

• Platelet count

• International normalized ratio (INR)

• Potassium level

• Creatinine+estimated glomerular filtration rate (GFR) (limit contrast to ≤3.7× GFR for patients at increased risk for contrast nephropathy, such as patients with chronic kidney disease, Section 28.3 )

• Pregnancy test (for women of childbearing potential).

Prior imaging :

• Review prior coronary angiograms and PCIs.

• Review noninvasive testing results (echocardiography, magnetic resonance imaging [MRI], stress testing).

• In patients with recent diagnostic angiography or coronary computed tomography angiography (CTA), the target lesion(s) can be determined prior to the procedure.

1.2

Monitoring

• Assess baseline ECG and heart rate.

• Assess patient’s baseline vital signs and pulse oximetry.

1.3

Pharmacology

• Allergies?

• Has patient received aspirin?

• For patients with a well-documented aspirin allergy: have they been desensitized?

• For patients allergic to contrast: have they been premedicated ( Section 3.3 )?

• For planned PCI or for patients with ST-segment elevation acute myocardial infarction (STEMI): have they received a P2Y ₁₂ inhibitor?

• On metformin: in patients with chronic kidney disease hold metformin the day of the procedure and do not restart until at least 48 hours after the procedure. In patients without chronic kidney disease metformin does not necessarily need to be discontinued; instead renal function can be checked after the procedure and metformin withheld if renal function deteriorates.

• On insulin: reduce insulin to adjust for fasting status before the procedure.

• On warfarin: discontinue 5 days prior to elective procedures and check the INR on the day of the procedure. Radial access is preferred in anticoagulated patients.

• On direct oral anticoagulants (DOAC): discontinue prior to elective procedures, as outlined in Table 1.2 .

  Table 1.2

  How long to stop a DOAC before a cardiac catheterization procedure.

  Direct factor Xa inhibitors	Days to hold
  Apixaban (Eliquis)	2 days
  Edoxaban (Savaysa)
  Creatinine clearance 50–95 mL/min	2 days
  Creatinine clearance 15–49 mL/min	3 days
  Rivaroxaban (Xarelto)
  Creatinine clearance≥50 mL/min	2 days
  Creatinine clearance 15–49 mL/min	3 days

  Direct thrombin factor IIa inhibitor	Days to hold
  Dabigatran (Pradaxa)
  Creatinine clearance>80 mL/min	2 days
  Creatinine clearance 50–79 mL/min	3 days
  Creatinine clearance 30–49 mL/min	4 days
  Creatinine clearance 15–29 mL/min	5 days

  Creatinine clearance calculator: http://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation/ .

1.4

Access

History :

• Prior radial artery harvesting for CABG?

• Arteriovenous (AV) fistula for dialysis? Avoid using this arm for cardiac catheterization.

• Access site(s) used for any prior procedures? Has a closure device been used? Consider using contralateral femoral or radial access if an Angioseal was used within 90 days.

• Prior access site complications? If yes, what was the complication and how was it managed? If yes, avoid using the same access site.

• History of PAD? Access through severely diseased or occluded iliofemoral or subclavian arteries should be avoided.

• Clinical presentation: radial access is especially favored in STEMI patients.

• On warfarin or DOAC: radial access is preferred.

• High risk of bleeding: radial access is preferred.

• Patient preference (patients who work extensively with their hands/arms or use them for support may prefer femoral approach).

Physical examination :

• Good distal pulses?

• Morbid obesity? (Favors radial access)

Labs : high INR and low platelet count favor radial access.

Prior imaging :

• Review prior cardiac and/or peripheral catheterization films: disease or tortuosity in aortoiliac and upper extremity vessels?

• Computed tomography (CT) of the chest:

  • Anomalous aortic arch anatomy?

  • Size of iliac/subclavian vessels and presence of disease.

  • Arteria lusoria? (Anomalous origin of right subclavian from the aortic arch.) Arteria lusoria favors use of left radial or femoral access.

• CT of the abdomen/pelvis: location of common femoral artery bifurcation and disease in iliofemoral vessels.

• Ultrasound of peripheral arteries.

Desired outcome: Decide on access site and size/length of the sheath.

1.5