A Trip to the Angiographic ("Angio") Suite

Joseph McNabb had been active most of his life. In high school he was an all-state high school athlete and, following college, he served a four-year tour in Vietnam as a paratrooper. To cope with the many stressful scenarios he saw in his twenties during combat, he began to smoke approximately two packs of cigarette per day. At the age of 35, he began to experience pain and tightness in both hips and thighs when he walked at a brisk pace, which were relieved within five minutes of rest. His primary care physician convinced him his pain was due to recurring trauma to his back and hips, which had occurred during his many parachute missions throughout the years. When X-rays of his hips and back turned up nothing, he was told to "learn to live with the pain and decrease his activities." Having been very active throughout his adult life, he felt this explanation was inadequate.

As luck would have it, he related his story to a friend in his late sixties with similar complaints. His friend had told him that he had been diagnosed with peripheral arterial disease (PAD), and had undergone a balloon angioplasty and stent procedure a few years prior. Following his trip to the "angio suite;" he was now able to walk any distance without any pain whatsoever. Joseph was convinced to seek a second opinion. He found a vascular medicine specialist who determined with a noninvasive ultrasound test that he had severe blockages in both iliac arteries in his abdomen and pelvic region. His leg pain was known as intermittent claudication and was due to PAD.

The doctor recommended that he undergo a diagnostic angiogram because of Joseph's lifestyle-limiting intermittent claudication, and possibly an endovascular procedure. The plan was to perform balloon angioplasty and place stents to relieve the obstructions, if technically possible.

Joseph wanted to know what an angiogram was and what to expect during his visit to the angio suite. His doctor explained that an angiogram is a procedure used to diagnose and confirm the location of the blocked arteries, to assess the severity of the blocked arteries, and to decide the best treatment to open the arteries. The possible treatment options are either a catheter-based procedure such as an angioplasty and/or stenting, or surgery (bypass graft). After weighing his options, Joseph decided to take the doctor's advice and proceed with the procedure.

The angiogram procedure is performed in an area of the hospital called the "angiography suite" or sometimes referred to as the "catheterization laboratory." Using X-ray dye (contrast) and special equipment, the doctor threads a catheter through an artery, usually in the groin (rarely the arm), and takes pictures of the arteries in the abdomen, pelvis, and/or the legs. Once the doctor decides there is a need for a vascular procedure, preparation begins at home. As a patient, you should: Write down all of the questions you have about the procedure, mention any dye or medication allergies, and list all of your medications, including prescribed blood thinners (Coumadin® or warfarin). Make sure you know whether you should take your routine medications such as diuretics, insulin, or oral diabetic pills on the day of the scheduled procedure. If you are taking aspirin and/or Plavix®, make sure that taking those medicines and others that morning is okay with your physician.

You will probably be asked to not eat or drink anything the evening and night prior to the test. On the day of the procedure, plan to arrive at least one hour before the scheduled time, accompanied by a relative or friend, to meet the staff and go through a complete checklist of what to expect; you will also have a final opportunity to ask questions. An intravenous (IV) line will be started by a nurse and medications will be given for sedation.

Upon entry into the angiographic suite, you will be moved onto a specialized X-ray table. A nurse and a radiology technician will prepare you for the procedure by applying various devices to monitor your vital signs, electrodes for an EKG, blood pressure cuffs, and a finger-clip to ensure that adequate levels of oxygen are maintained. They will clean the area of the body where the catheter will be inserted into the blood vessel (artery or vein) and will apply a sterile sheet over you.

The doctor will begin the procedure by applying a local anesthetic into the area over the puncture site, which will serve to numb the area and avoid any subsequent pain during the procedure. It is important to communicate to the staff any pain experienced, which may then require further sedation/ analgesia or be suggestive of a possible complication. Once the catheter has entered safely into the artery, X-ray dye (contrast) is administered to see whether the material called plaque has narrowed or completely blocked any of the arteries involving the peripheral circulation, which may explain your symptoms. In addition, based on the findings, your doctor may perform additional procedures, such as balloon angioplasty or stenting of the clogged arteries, to open them up and restore flow into the region not getting enough blood and causing the symptoms of PAD. Depending upon the type of intervention, the length of time in general for the procedure will vary between 30 minutes to two hours.

Following the angiographic procedure, the staff will bring you to a post-procedure or recovery area. At that point, it is important to keep the leg (or arm) straight, particularly while you are transferred from the table to a stretcher. The catheters will be taken out either in the recovery area or back in your hospital room, and pressure will be applied over the incision site for about 20-30 minutes to make sure there is no bleeding.

Bed rest (usually four to six hours) is essential to let the puncture site heal. You will be able to eat while you remain in bed after the procedure. In most cases, you will be instructed to drink extra fluids to help the kidneys get rid of the X-ray dye. The following morning, you may resume light activity. It is common to experience minor tenderness or bruising in the area where the catheters were inserted into the artery, which usually respond favorably to over-the-counter pain medications. Depending upon the procedure, your doctor will advise you on your restrictions and when it is safe to resume normal activities such as driving a car.

In Joseph McNabb's case, he had two stents placed, one in each iliac artery because both were severely narrowed. He was discharged to his home the following morning. To his delight, he resumed jogging, cycling, and playing 18 holes of golf without a cart–without any pain in either leg. Motivated to take charge of his "rejuvenated" lifestyle, he quit smoking and lost 20 pounds; he takes an aspirin and a cholesterol-lowering drug (statin) every day. "I feel like I am a kid back in high-school starring on the football team. I am forever grateful to my vascular physician and my 'trip to the angio suite,' which gave me a new lease on life."

About the Author: Robert M. Schainfeld, DO, is a Vascular Interventionalist and the Associate Director of Vascular Medicine in the Division of Cardiology at Massachusetts General Hospital (MGH) in Boston. He is also a Lecturer of Medicine for MGH.