1) What is a cardiac catheterization or coronary angiogram?
Cardiac catheterization and coronary angiography are terms that are often used interchangeably. They both refer to a diagnostic test that involves the insertion of a long thin plastic tube, the catheter, through an artery. We usually use the femoral artery which is located near the right or left groin crease. Occasionally an arm or wrist artery can be used. Local anesthetic (Xylocaine) is injected under the skin so that the any pain during the remainder of the procedure is minimized. The procedure is often performed with the patient awake but if preferred, can also be done under conscious sedation. This means that the patient is arousable but can be sleeping or be in a 'twilight state."

The catheter is then inserted into the femoral artery and then gently advanced up into the aorta reaching the coronary artery. The coronary arteries provide blood flow to the heart muscle. Dye is then injected through the catheter and into the coronary artery. All the while, X-Ray pictures are taken of the injection, which is called an angiogram. These pictures tell us whether there are any blockages in the artery and how severe they are. Another part of the procedure involves injecting dye into the left ventricle itself, which is the main pumping chamber of the heart, to see how well it pumps.

At the conclusion of the procedure and when all the information is obtained, the catheter is removed and pressure is applied to the groin (or arm) until there is no bleeding from the site. Another option we often use is a closure device or "plug" to seal the artery.

2) When does someone need cardiac catheterization?
The two most common reasons are to evaluate the coronary arteries and to evaluate the heart valves.

For coronary artery indications, the patient may be having unstable symptoms such as during a heart attack or they may have new or worsening symptoms of angina. Alternatively, there may be evidence of an important blockage based on a stress test result.
For heart valve indications, the aortic or mitral valve may be narrowed or incompetent leading to symptoms or endangering the heart muscle.

3) How long does a catheterization take?
The actually catheterization usually takes a half hour. Sometimes it may take longer if there is unusual anatomy or extra twists and turns in the femoral artery or aorta. In addition, the cath lab staff will sterilize the groin (or arm) area and prepare the room and equipment. This may take another half hour. So from the time the patient gets wheeled into the cath lab, it may take an hour or more. This is important to keep in mind and not to worry if the procedure seems to be taking extra time.
4) How dangerous is a catheterization and what are the risks?

A catheterization is an invasive procedure and does carry potentially serious risks. Fortunately, the most serious risks are rare. These include death, heart attack and stroke which each carry a 1/1000 risk. Vascular injury, usually in the form of bleeding under the skin or hematoma may occur in 2 -3% of cases but can usually be managed with extra compression and only very rarely leads to impairing blood supply to the limb or infection.

The dye itself, which contains iodine and is also used in CT scans and IVPs (intravenous pyelograms) is associated with two key risks. The first is allergy. If you have had any allergic reaction to dye (also called: contrast, IVP dye, CAT scan dye and angiogram dye) please let your doctor know so that we can pre-treat you with anti-allergy medication. Allergic reactions to dye are also sometimes correlated with allergies to seafood and iodine. In such circumstances, we often will also pre-treat with anti-allergy medication.

The second risk is to the kidneys. Patients with pre-existing kidney disease are at risk for making the kidney disease worse with the dye. We routinely draw a kidney blood test prior to the catheterization to check the function. Depending on the degree of kidney disease, we may use kidney protective strategies to minimize the risk.

One final risk: Very rarely, during a catheterization, the coronary artery itself can get damaged. In such circumstances, stenting can often take care of the problem. If not, then emergency coronary bypass surgery may be necessary.

5) What do I need to do before the catheterization?
The night before, you will be called by the hospital to tell you what time to come in. There is no food or drink after midnight the night before. The only exception to this is medicines. You should go ahead and take all medicines, including aspirin, Plavix, blood pressure and cholesterol medicines, etc. the morning of the test.
The only medicines you should not take are
1) Diabetes medicines (since you will not be eating) and
2) Coumadin or warfarin (which you should not have been taking for at least several days.)
If there are any questions regarding diabetes medications prior to the catheterization, please call your cardiologist.

6) Where is the catheterization or angiogram performed?
We perform these procedures at Robert Wood Johnson University Hospital in New Brunswick and at CentraState Medical Center in Freehold. Both hospitals have state-of-the-art facilities and superb staff to make the procedure as comfortable and as safe as possible.

7) What if a blockage is found?
If a blockage is found it may or may not need to be fixed. Depending on the coronary artery anatomy as well as the clinical situation such as symptoms and stress test results three options are considered. The first is medical therapy, which involves prescribing medications to minimize or eliminate symptoms as well as decrease the likelihood of future heart disease. The second option is angioplasty often combined with stenting. The third option is coronary bypass surgery.

8) What is coronary angioplasty or stenting?
This procedure opens up blockages in the coronary arteries. Through a catheter (the thin tube used for cardiac catheterization) a wire is advanced across the blockage. A balloon is then advanced and inflated squeezing the blockage up against the walls of the artery. The balloon is then deflated and taken out. This results in a larger channel for blood to flow down the artery. Occasionally, that's all that is necessary. Usually, however, a stent is then passed down the artery and with the help of another balloon, the stent is inflated to create an even bigger channel.

9) What are the risks of coronary angioplasty and stenting?
The risks are similar to those associated with diagnostic cardiac catheterization. Because we are also fixing the coronary artery, the risk of damaging the artery does rise to half of one percent of requiring emergency coronary bypass surgery.

10) What are stents made of?
Stents are thin, delicate wire mesh tubes and are usually made of surgical stainless steel. There is no problem with getting MRIs in the future since there is very little magnetic material in the stent. Also, the stent is fairly well positioned within the artery so it is not going to move.

11) Are all stents the same?
No. The two categories are drug coated stents and bare metal stents (non-drug-coated.) The first stents to be used in the mid 1990s were bare metal stents. While they reduced the re-narrowing rate from 30% to 15%, cardiologists wanted even better and more durable results. In 2003, the first drug-coated stents were approved. These reduced the re-narrowing rate to 6%. These statistics are approximate and can be higher or lower depending on a variety of factors, which can be addressed in the discussion you have with your cardiologist. With both types of stents the patient must take aspirin and Plavix (or Effient) for a period of time after the stent is deployed. These medications prevent blood clots from forming within the stent. Such blood clots can result in an occlusion of the artery and a heart attack and even death. So never stop aspirin or Plavix (or Effient) without discussing this with your cardiologist.

In bare metal stents it is necessary to use these two medications for only one to two months. For drug-coated stents, one or more years are necessary. The key message here is for a patient to benefit safely from getting a drug-coated stent, he or she must be able to afford and take aspirin and Plavix (or Effient) for a year or more. If surgery or procedures like epidural injections, prostate biopsy, colon polyp removal are planned within the next couple of months, it may be better to opt for a bare metal stent or balloon angioplasty alone so that the aspirin and Plavix may be safely stopped prior to the procedure. Also, if there is a significant bleeding tendency, which may make taking aspirin or Plavix difficult or harmful, this also needs to be discussed. This decision on which stent or whether to use stents at all needs to be discussed with your cardiologist.

12) How durable and safe are stents?
While stents are generally durable, there is a potential for re-narrowing, or what cardiologists refer to as restenosis. The process of restenosis is related to the healing process, which occurs within an artery that has had a stent deployed within it. Just as some people have excessive scar formation after surgery, some arteries tend to have excessive regrowth of tissue in the area of the stent. This excess tissue can crowd out the space within the artery and cause a limitation of blood flow. The likelihood of restenosis after a bare metal stent has been deployed is 15%.

Drug-coated stents are designed to prevent the regrowth of tissue and therefore decrease the likelihood of restenosis. The likelihood of restenosis in drug-coated stents is 6%.

These statistics are approximate and can be higher or lower depending on a variety of factors, which can be addressed in the discussion you have with your cardiologist.

When restenosis occurs after a stent is deployed, it does so after several months and usually within the first year. Occasionally it can occur later. We can detect restenosis if patients report recurrent symptoms or if a stress test shows decreased blood flow into an area of the heart.

One final note: occasionally, a stent can clot off and occlude or block off blood flow entirely causing a heart attack. This occurs less than 1% of the time. It is associated with a number of factors including skipping aspirin and/or Plavix (or Effient) prematurely.

That is why it's vitally important to take these two medicines as instructed and not to stop without discussing it with your cardiologist. Even if another doctor or dentist instructs you to stop it we need to know so we can evaluate the best course of treatment.

13) What about coronary bypass surgery?
There are situations when we refer patients to coronary bypass surgery. Cardiologists don't perform the surgery. Rather, specially trained surgeons do. At Robert Wood Johnson University Hospital, we have some of the best-trained cardiac surgeons in the region with an excellent safety record. If your cardiologist feels that surgery is the best option, you will have the opportunity to discuss and ask questions with the surgeon so that you can make best-informed choice.

14) What happens after the procedure?
For diagnostic catheterization, patients typically leave on the same day after several hours of rest and observation. If angioplasty and/or stenting is performed, an overnight stay is more typical. We usually advise no driving for 48 -72 hours to avoid excessive bending and straining which may lead to bleeding at the site where the catheterization was performed. There should be no heavy lifting or vigorous exercise until the patient comes to the office for a follow-up visit and the groin can be examined for adequate healing.

If a plug or closure device is used, then no prolonged contact with water such as in baths, hot tubs and swimming pools is not permitted for one week to avoid unsterile water from penetrating under the skin and contacting the plug and potentially causing infection. Showering is OK 48 hours after the catheterization but a hand-held shower is preferable to minimize water soaking the area of the plug/closure device.

  • Main Office:

    Heart Specialists of Central Jersey
    901 West Main Street, Suite 205
    CN 5050
    Freehold, NJ 07728
    Phone No:
    (732) 866-0800
    Fax:(732) 866-0018