1. Evaluate and document the patient’s chief complaint, brief medical history, significant past medical history, allergies, previous surgical procedures, and
current medications (Fig. 1.1). Explain the procedure to the patient and perform a targeted physical examination including peripheral pulses. All prior imaging studies and physiologic tests (e.g., noninvasive vascular tests, magnetic resonance angiograms, computed tomograms, and radionuclide scans) should be available for review at the time of the study.

2. Obtain informed consent (see Chapter e-95).

3. Check laboratory results including estimated glomerular filtration rate (eGFR), hemoglobin, international normalized ratio (INR), partial thromboplastin time (PTT), and platelet count. Routine evaluation of coagulation parameters prior to transfemoral angiography may not be needed in everyone, and limiting evaluation of the coagulation profile to patients who have clinical evidence of a bleeding disorder or liver disease and to those who are anticoagulated may avoid unnecessary testing and delay.

4. Preprocedure hospital fasting guidelines should be followed due to the possible need to administer conscious sedation (e.g., solids and nonclear liquids 6 to 8 hours, clear liquids 2 to 4 hours) (1). Oral medications may be taken with small quantities of water.

5. See Chapter 65 for a detailed approach to the hydration of a patient with underlying renal disease.

6. Patient must void urine before leaving for the angiography suite (unless the bladder is catheterized).

7. Considerations for patients with specific diseases or conditions: Consult with referring or managing clinician, or both, on all items listed below (for more specific details, see the appropriate cited chapters).

a. Heparinized patient: Stop heparin infusion 2 hours prior to the arterial puncture in order to normalize the coagulation status. A PTT of 1.2 times control is acceptable, in the absence of other bleeding abnormalities. Alternatively, activated clotting time (ACT) may be followed. Because this test can be performed at the bedside, the timing of catheter removal and reinstitution of heparin can be more accurately determined. Heparin may be restarted within 2 to 4 hours after removal of the catheter for manual puncture-site compression or sooner in selected cases (e.g., patients for whom an arterial puncture closure device was used or venous catheterizations). For patients getting therapeutic dose injections of low-molecular-weight heparin, the dose prior to the procedure is held (2).

b. Warfarinized patient: Stop warfarin (Coumadin) 3 to 5 days prior to arterial puncture if possible. For hospitalized patients with persistently elevated INR and nonurgent indications for angiography, vitamin K (2 to 10 mg) may be administered either orally 24 to 48 hours preprocedure or intravenously (IV) 12 to 24 hours preprocedure with serial monitoring of the INR for reversal (3). Patients who require procedures on an urgent or emergent basis should be treated with short-acting products to reverse anticoagulation, such as fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), recombinant factor VIIa, or activated PCC. The goal is to achieve an INR of 1.5 or less. For patients in whom discontinuation of anticoagulation is unacceptable (e.g., metal prosthetic heart valve), warfarin can be stopped and anticoagulation may be transitioned with low-molecular-weight heparin as an outpatient, or the patient may be admitted for transition with IV heparin.

c. Oral anticoagulants: Three newer oral anticoagulant medications include the direct thrombin inhibitor, dabigatran, and two direct factor Xa inhibitors, rivaroxaban and apixaban. These medicines have relatively short halflives (<14 hours). As such, discontinuation for 1 to 2 days prior to arterial puncture is usually sufficient (longer in patients with renal disease because these drugs are cleared by the kidneys) (4,5). Recently, a monoclonal antibody fragment, idarucizumab, has been approved by the U.S. Food and Drug Administration to neutralize the effects of dabigatran in the event of a bleeding emergency.

d. Antiplatelet agents: These include aspirin, clopidogrel, and glycoprotein (GP) IIb/IIIa inhibitors. Guidelines recommend discontinuation of the latter two until cleared (5 to 7 days for clopidogrel, 8 to 48 hours for GP IIb/IIIa inhibitors) or potential platelet transfusion for emergency cases (2,5).

e. Thrombocytopenic patient: For transfemoral or transaxillary punctures, the functional platelet count should be greater than 50,000 per µL (2).

f. Insulin-dependent diabetic patient: In consultation with the referring physician, cut the morning insulin dose by half and schedule the procedure for the morning if possible. A slow infusion of 5% dextrose may be started prior to the procedure, and volume expansion with IV fluids is indicated to prevent contrast-induced nephropathy. Blood glucose levels should be monitored during prolonged procedures; insulin dose may need to be titrated before
resumption of usual regimen. If a diabetic patient on neutral protamine Hagedorn (NPH) insulin receives heparin during the procedure, do not reverse the heparin with protamine sulfate because this may cause a fatal anaphylactic reaction (6). Restart normal insulin schedule after the procedure once the patient has resumed oral intake.

g. Renal dysfunction (see Chapter 65)

h. Prior documented reaction to iodinated contrast media: Use measures described in Chapters 64 and e-89. Alternatively, consider gadolinium-enhanced MRA for patients without severe renal insufficiency. Carbon dioxide arteriography, intra-arterial pressure measurements, and duplex scan (infrainguinal) arterial mapping may aid diagnosis in selected patients. (See appropriate chapters.)

i. Precautionary measures: The patient’s chart should list the precautions necessary to protect both the patient (especially if immunocompromised) and the personnel who may come in contact with a patient with an infectious disease (e.g., HIV, infectious hepatitis, drug-resistant bacteria, Clostridium difficile).

j. Lidocaine hypersensitivity (local infiltration) (see Chapter 62). Consider:

(1) Local skin test, and if negative, proceed with local infiltration, or

(2) Procaine hydrochloride (or an aminoester local anesthetic rather than an aminoamide)

8. Medication precautions (see Chapters 62, 63, and e-94)

a. Sedation and analgesia: Most angiography and interventional procedures can be completed safely and expeditiously with a judicious combination of midazolam and fentanyl, which provide adequate conscious sedation and analgesia (7).

b. Age: Reduce medication doses by 30% to 50% for elderly patients.

c. Severe coronary artery or cerebrovascular disease: Avoid drugs that cause excessive drop in blood pressure or cardiac output.

d. Seizures: Avoid drugs that lower seizure threshold (e.g., meperidine, phenothiazines).

e. Hepatic dysfunction: Avoid drugs such as barbiturates, which are metabolized by the liver. Reduce initial doses of sedatives and analgesics.

f. Renal dysfunction: Extreme caution should be used in administering meperidine. Accumulation of its metabolite in these patients may lead to central nervous system excitation and seizures.

g. Pheochromocytoma: Patients with labile blood pressure need α blockade (e.g., phenoxybenzamine) (8). Consider consulting an anesthesiologist for the procedure. Short-acting agents, such as sodium nitroprusside, should be available for treating potential hypertensive crisis. Avoid the use of glucagon in patients with suspected pheochromocytoma.

h. Multiple myeloma: As with patients with diabetic nephropathy, these patients should be well hydrated in order to prevent acute tubular necrosis.

i. Sickle cell anemia and polycythemia vera: Patients may suffer thromboembolic complications following angiography (9).

j. Neuroendocrine tumors: Carcinoid crisis can be stimulated by angiography on patients with neuroendocrine metastases to the liver. Consider pretreatment with intramuscular (IM) octreotide and have an octreotide drip available (10).