Coronary Angiography in 100 Cases of Ischemic Heart Disease

As late as the end of 1940 available contrast media for cardiovascular examinations were relatively toxic. Selective angiocardiography and thoracic aortography had therefore usually to be performed under general anesthesia. In order to avoid motion blur due to respiration, the lungs were inflated and kept in an inspiratory position during the film exposures. A striking improvement of the quality of the exposed films could be observed when the examination had been performed with a moderate inflation of the lungs. In 1955, Boerema and Blickman (2), in experiments on dogs, obtained better angiocardiographic films when the intrabronchial pressure was elevated. Due to the obstruction of inflow to the right side of the heart, a decreased flow of blood was induced, with a consequent reduction in dilution of the medium. Other effects in cardioangiography may also be obtained by elevation of the intrabronchial pressure, as demonstrated in animal and man by one of us (10). With sufficient deceleration of the blood stream, for example, layering of the contrast medium is produced which can be utilized to direct it into different vascular regions of the arterial system, as well as in the venous system. These observations were later verified by others (4). Before we decided to utilize the principle of layering of the contrast material in coronary angiography, however, we compared three different ways of producing adequate retardation of the blood stream. With temporary occlusion of the inferior vena cava, a sufficient reduction of flow in the aorta can be obtained so that the contrast material can be layered into the coronaries when injection is made in the ascending aorta. Temporary cardiac arrest by injection of acetylcholine after the method of Arnulf (1) was also a possible technic for producing deceleration of the circulation. For various reasons, however, we chose to reduce the flow in the aorta by utilizing an elevation of the intrabronchial pressure to 40 cm. of water. We have now used this procedure in more than 100 cases of coronary arterial disease with good results. Method By Seldinger's method of percutaneous catheter insertion, one catheter is introduced into the femoral artery and guided up into the aorta, where it is placed with its tip immediately above the aortic valves. Two centimeters distal to the first catheter a very thin polythene catheter is inserted, also percutaneously in the femoral artery, for continuous recording of the blood pressure. In cooperative patients the examination is then performed in a sitting position with the left anterior part of the chest wall close to the film changer (Fig. 1). If the patient is capable of reducing the systolic arterial pressure by voluntary expiration against the closed glottis (Valsalva maneuver) to 80–100 mm. Hg, the injection of the contrast medium is performed without general anesthesia.