Continuous advancements in medical technology now make it possible for angiography interventions to be executed even from narrow veins. Angiographic interventions, which were for many years conducted from the groin (inguinal) area, can now be applied from the wrist as well. This makes it possible for the patient to get an angiography in the morning and return to the office or home in the afternoon. Receiving an angiographic intervention from the wrist area makes it so much quicker to resume important daily activities. Stating that the use of radial veins in coronary interventions significantly reduces the occurrence of undesired and troublesome complications, Anadolu Medical Centre Cardiology Specialist Associate Prof. Dr. Ertan Ökmen answers our questions.
How is the decision for an angiography taken?
Not everyone needs to get an angiography. Certain criteria exist to determine the necessity. We accumulate all medical information of patients experiencing chest pain accompanied by irregular effort tests results and a problematic echocardiography. The decision for an angiography is given after the careful assessment of this information. We later provide the patient with information about available and suitable methods. Since we now use wrist angiography as a standard method we do not mention alternatives; we only explain the method itself. In response, patients not only feel happy to have heard of a new method they are relived after hearing the significant advantages.
Do patients hesitate in the process of determining the suitable angiography method?
Actually patients have no hesitation about determining the method, they are more concerned about having an angiography or not. Although in less than one thousand, angiography is a life threatening intervention. The potential risks, on the other hand, are usually concentrated around the angiography entry point.
What advantages do wrist angiographies have to offer?
In contrast to inguinal veins, radial veins are located very close to the surface of the skin, which make them very easy to locate and enter even with overweight patients. Close proximity to the skin and the skeletal tissue located right underneath make it much easier to apply compression in order to close the entry point. Similarly, controlling the bleeding is much simpler too. We have to use high doses of anticoagulants in all stent interventions from inguinal veins. This is why it is impossible to remove the sleeve allowing entrance to the vein. At least 4 to 6 hours is required for the anticoagulant drugs to wear off before the sleeve can be removed. The patients have to lie in bed throughout this duration and must not move their leg. 4 to 6 hours later the sleeve is removed. This is followed by compression of 15 to 20 minutes and then another 4 to 6 hours of sand bag compression in an attempt to stop the bleeding completely. This is why patients undergoing diagnostic coronary angiography via inguinal vein have to lie down straight without moving their legs for about 6 hours. This duration doubles to 12 hours for treatment oriented interventions such as with a balloon or stent. During this period patients cannot stand up or go to the toilet. Meanwhile, with radial vein interventions the sleeve is removed immediately after the process is complete regardless of high doses of anticoagulants. The patient has a wristband resembling apparatus, which is kept over the entry point for 2 hours. The wristband is removed prior to being discharged and replaced with a bandage. Patients can remove the bandage by themselves the next day. Naturally the patient can stand up, sit down, use the toilet and even eat using the operated hand immediately after the intervention. Instead of 6 hours in the hospital, the patient can be discharged in 2.5 to 3 hours following a diagnostic coronary operation.
How long is the recovery period following a wrist angiography? Lets say when can they can get back to work?
Well this is the great thing. If patients want to, they can get back to their jobs the same day. Naturally the angiography results are the main determinant. If the angiography results indicate conditions requiring treatment the patient is handled differently. They might be hospitalized if necessary.
How is the operation realised?
The area under the skin is anaesthetised using local anaesthetics. The patient does not feel any pain since the incision is extremely small. No problems occur in the phase to follow.
Is there a risk of complications?
The rate of point of entry complications for wrist angiography is recorded at less than one in a thousand. In other words the risk is close to zero. The important issue after the operation is the compression of point of entry. The actual operation is the closure of the 3 mm wide incision opened for the catheter to enter the vein. Problems arising from point of entry are mostly related to the failed healing of this incision. The vein used for inguinal angiography is a wide vein. The skeletal tissue is considerably further away (deeper) with muscle and fat tissue in between. Effective compression is sometimes not possible especially with overweight female patients. Stopping the bleeding with wrist angiography on the other hand is much quicker and easier due to the skeletal structure located right underneath the vein thanks to the specially designed wristband. This also contributes to the quick closure of the incision. Considering the gains of valuable information provided by angiography, the risks involved in the procedure remain quite insignificant.
What is the rate of success?
Since 2007, we have successfully executed coronary angiography and stent interventions on approximately 5000 domestic and international patients using this method. This method has now become standard procedure in many countries including France, Japan, China, Belgium, Germany and The Netherlands.
How long does it take to get the angiography results?
We get the results instantaneously. This is because we can see the coronary condition during the procedure. We can observe venous narrowing on the screen whilst the recording is in progress. We are able to decide on the next move there and then.
Are there special groups of patients unsuitable for wrist angiography?
There are patient groups to whom we prefer not to apply this procedure. One group is dialysis patients for example. Movement in the arm veins with these patients can be problematic. Another group is patients with chronic kidney deficiency. Arm veins with these patients are important so we do not prefer to apply this method. People who have experienced arm traumas due to accidents or injury constitute another group we cannot apply wrist angiography.
Is it possible to conduct such an operation on slim individuals with fine vein structure?
No, another group unsuitable for this method is very slim individuals. Compared to fine veined people those with a heavy build have wider veins. We check the veins of slim people with our hands; we take an ultrasound if necessary and then decide if vein width is suitable for the procedure. The catheters we use are extremely fine. This is why the rate of individuals unsuitable for this procedure due to fineness of their veins remains at a mere one percent.
Is there a difference between males and females in regards to the procedure and the outcome?
There is no gender difference in terms of the applied procedure. The only difference is the fact that female veins are finer than males. However this does not present any difficulty for the application. On the other hand privacy concerns result in the tendency for females to prefer wrist angiography.
Do scars remain on the wrist following the procedure?
Wrist angiography is executed from a very small incision only 3-4 mm wide. Hence, the remaining scar is no larger than three to four pinheads.
Can a person undergo wrist angiography more than once?
Of course, this is possible. In such instances we chose a spot a few centimetres above the previous point of entry. Using the other wrist is another option we have. We have had patients receiving more than one angiography who have later had balloon stent implants.
What happens if emboli (blockades) are identified during angiography requiring stent implant? Do you act straight away?
This is how we usually approach such cases: If the emboli is causing a critical narrowing that cannot wait and the condition is suitable for opening with balloon and stent we do the treatment right away. For instance we apply a stent for patients that have experienced heart attacks, people presenting clinical indications of a previous heart attack or cases who haven’t had a heart attack but angiography results indicate high risk. The procedure can be executed similar to the angiography method using the same route, the same day, the same session. In all other cases we prefer to make necessary preparations and implant the stent in a few days. One must remember that we need time to discuss treatment alternatives with the patient as well.
How does your patient adapt back to daily life following the angiography?
Following the wrist angiography patients can return home by themselves without the need for any assistance. They are able to resume their daily routine as long as they don’t strain their arm. However we do recommend the patients to shower without removing the special bandage. We don’t have a specific diet to adhere to in relation to angiography. Nevertheless there are actions to be taken according to the angiography result. If we identify embolism in the veins the patient must start on what we call hart protective diet that involves consuming low cholesterol, low salt and low fat foods. This translates as eating a fruit and vegetable based regime. If results come normal and cholesterol values are low we do not necessarily recommend a special diet. However there is something valid for all angiographies – the patient must drink plenty of water. This helps the body flush out the marker fluid administered during the procedure. We try and make patients drink at least two litres of water before they leave the hospital and we ask them to drink plenty of water after they arrive home as well.
Are there specific exercises recommended in this process?
We don’t want patients to exert themselves too much. They can use their arm, eat their food or have a drink. The crucial thing is to refrain from lifting heavy objects. Although the incision is very small we want the wound to close in the shortest possible time. Till now we haven’t had a single patient coming to us for bleeding. Sometimes tight bandages over the incision cause slight bruising if the patient unconsciously sleeps on that arm. However the bruising recedes once patients correct their position.
