What is an angiogram?

“Angio” is an abbreviation of the term “angiography.” In medical terminology, angiography refers to the “imaging of blood vessels.” An angiogram can be performed on any blood vessel in the body. In this section, when I say “angio,” I am referring specifically to the imaging of the heart’s blood vessels.

Coronary Angiography

Who is eligible for an angiogram?

Angiography is performed to determine whether there is stenosis or occlusion in the heart vessels. The patient groups suspected of this condition are as follows:

  • Those with typical chest pain or similar complaints (For example, those who feel pain, burning, or pressure in the chest while walking or climbing uphill)
  • Those whose preliminary test results (ECG, ECHO, stress test, or scintigraphy) are abnormal
  • Those with serious problems detected on virtual angiography (CT angio) or those for whom a decision cannot be made due to unclear images
  • Those having a heart attack
  • Those with heart failure
  • Certain patients with detected heart rhythm disorders

Who should not undergo angiography?

Normally, some patients who need an angiography may have special circumstances or accompanying diseases that may make performing the procedure risky or futile. Examples include:

  • Withholding consent after informed disclosure (Refusal of permission by first-degree relatives of patients who are not mentally competent)
  • Active infection
  • Active bleeding (Menstrual bleeding is not an obstacle)
  • Severe kidney failure
  • Severe anemia
  • Severe hypertension that cannot be controlled with medications

What are the risks of an angiogram?

As with any procedure, there are some risks associated with angiography. Each of the serious complications occurs in 2 out of every 1000 people. Risk, in fact, varies from person to person. For example, emergency angiographies performed for heart attack treatment and angiographies performed on patients with serious diseases in other organs are riskier. However, not performing an angiography—that is, not starting the treatment process for problems in the heart vessels—can be much riskier. Therefore, the decision to perform an angiography is made based on the risk-benefit balance. Possible complications of angiography include:

  • Leg or wrist artery injury: Serious bleeding or occlusion may develop in the leg (groin) or wrist artery. Consequently, blood transfusion or emergency vascular surgery may rarely be required.
  • Heart rhythm disorder (Arrhythmia): Short-term arrhythmias that resolve spontaneously are common during angiography but are not significant. Rarely, emergency situations may develop that impair consciousness and require medication or electroshock.
  • Kidney failure: The dye, called contrast medium, which allows us to obtain images during angiography, impairs the kidneys in 5 out of every 100 patients. The risk is even higher in those who already have kidney problems. For example, the risk is five times higher in advanced-stage kidney failure. Although kidney impairment may develop, it usually resolves completely with intravenous fluid support. Sometimes, temporary dialysis may be required. The need for permanent dialysis is extremely rare.
  • Allergy: Rarely, an allergy may develop due to the contrast medium. Itchy rashes may occur on the skin; this is a temporary condition. Very rarely, allergic reactions are severe enough to obstruct breathing. All necessary equipment for such emergencies is available in the angiography suite.
  • Heart attack: If the patient’s heart vessels are very delicate, the catheter may damage these vessels. This can lead to the occlusion of the heart vessels, meaning it can cause a heart attack. In this case, a stent must be placed immediately to open the vessel. Very rarely, emergency heart surgery (bypass) may be required.
  • Heart vessel tearing (dissection) or perforation (rupture): These problems occur rarely. In most cases, the problem is resolved with emergency interventions performed during the procedure. Very rarely, emergency heart surgery (bypass) may be required.
  • Stroke: Small fats or clots that break off when the catheter touches the delicate areas of the vessels allowing us to reach the heart can rarely escape to the brain vessels. This can cause a temporary or permanent stroke.

Is there a risk of death during an angiogram?

In the event of a complication, the problem is usually resolved with emergency interventions. Very rarely, interventions may fail, and the patient may die. This risk is also related to the physician’s experience. Death occurs in approximately 1 out of every 1,000 angiograms.

You may be justified in feeling concerned about all these risks mentioned above; but remember: these complications are rare. What matters is whether the angiography is truly necessary. If the decision to perform an angiography has been made in accordance with current scientific data and guidelines, avoiding the procedure actually means exposing yourself to much greater risks, such as heart attack and death.

What should you keep in mind before an angiogram?

  • Ask your doctor which medications you should take and which ones you should avoid on the day of the angiography. You may be asked to stop taking certain blood thinners a few days before the procedure, or sometimes to continue them. The same applies to diabetes (blood sugar) medications.
  • Be sure to tell your doctor if you have any known allergic tendencies (to medications, iodine, contrast media, latex products such as rubber gloves, etc.).
  • Depending on the angiography results, your doctor may state that you need to stay in the hospital for a few more days. In other words, you may not be able to go home that same day. Therefore, we recommend bringing your personal items (slippers, toothbrush, etc.) with you to make your hospital stay more comfortable. Also, plan for a relative to drive you home upon discharge. A

How is an angiogram performed?

Before the angiography, you will be placed on your back on a stretcher-like table. Here, the arm of the X-ray machine will move around your head and chest to film your heart vessels from many angles. Either before arriving at the angiography suite or while inside, an intravenous line (IV cannula) will be inserted into the back of your hand or arm to administer fluids or medication when necessary. Electrodes will be attached to your chest so that we can monitor your heart rhythm. A device (oximeter) will also be placed on your finger or toe to monitor your blood oxygen level. If the groin or wrist area is very hairy, it will be shaved with a clipper and then disinfected. Then, the entry site will be numbed with medication from a fine-needle syringe so that you do not feel pain, and a plastic sheath will be placed at the entry point. A long wire will first be sent through this sheath, followed by a long and flexible tube (catheter) to your heart. Once the catheter is positioned at the opening of your heart vessels, a dye will be injected. This dye may cause a short-term sensation of warmth; do not be alarmed. Thanks to the dye, it will be possible to determine whether there is any narrowing or blockage in the vessels, which have now become visible.

Coronary Angiography

How long does an angiogram take?

An angiogram typically takes 10 to 15 minutes. However, in some cases, the anatomical characteristics of the access site, the blood vessels leading from the access site to the heart, or the coronary arteries may be complex. In such cases, the procedure takes longer.

Is there any pain during an angiogram?

During the angiogram, only the site where the catheter is inserted will be numbed. You will remain awake throughout the procedure. However, you may be given sedatives to help you relax. These medications may make you drowsy; this is normal.

Is a wrist angiogram better, or a groin angiogram?

Most patients can undergo angiography via either the wrist or the leg (groin). The details are as follows:

  • The most common complication in angiography is bleeding at the vascular entry site. This occurs less frequently at the wrist entry site compared to the groin and is less likely to be serious. Even if it occurs, it can be easily controlled by manual pressure.
  • The wrist route is more comfortable for the patient than the leg. The groin route, however, is more comfortable for the doctor.
  • In the wrist route, there is no requirement to lie flat on the back for 4-6 hours after angiography. Actually, if the groin entry site is closed with special closure devices rather than manual pressure, there is no need to lie flat for a long time in the groin route either; the patient can stand up, walk after 1 hour, and be discharged earlier.
  • Since the radial (wrist) artery has a small diameter, the probability of occlusion is much higher than that of the femoral (groin) artery; occlusion develops in 1 out of every 10 patients. However, since there is an additional (collateral) artery in the wrist, no problem develops even if the radial artery is blocked by a clot; or rather, it is extremely rare. The probability of groin artery occlusion is lower, but since it is the only artery supplying the leg, if it becomes blocked, emergency stenting or surgery may be required.
  • The wrist artery is more prone to catheter-induced spasm (contraction). Contraction can cause the artery to squeeze the catheter, which may lead to difficulty in removing the catheter in some patients and severe pain during this process.
  • The probability of infection at the wrist entry site is much lower than in the groin. If an infection develops in the groin, it can sometimes lead to very serious consequences.
  • Not every procedure and every patient is technically suitable for the wrist route. Both the wrist anatomy must be appropriate and the doctor must be experienced in wrist procedures.
  • In some patients, it may be necessary to use the groin route or the wrist route due to clinical and anatomical reasons.
  • Whether it is the groin route or the wrist route, the images obtained during angiography are the same.
In conclusion, the wrist should be preferred if possible. The most important reason for the recommendation to prefer the wrist is that bleeding—the most common complication—is less frequent and severe compared to the groin route. However, due to the details mentioned above, it is best to leave the final decision to the physician who will perform the angiography. Personally, my (Prof. Dr. Şükrü Akyüz) first choice when performing angiography is the wrist route. I use the groin route for angiography if the wrist anatomy is not suitable (tortuous, thin, or prone to spasm). If I have performed angiography through the groin, I routinely prefer to use a special closure device.

When can I be discharged after an angiogram?

If the angiography is performed via the wrist, most patients are discharged after 2 hours. If performed via the groin, the hospital stay is 2 hours if a special groin closure device is used, and 4–6 hours if it is not.

What precautions should be taken after an angiogram?

After the angiography, your nurse will regularly check your catheter entry site (your groin or wrist). One of the most important issues to monitor after angiography is bleeding. To prevent bleeding, the following steps are taken:

  • If the angiography was performed through the wrist, a bracelet-like, compressive closure device (with a screw or air-filled) is placed on your wrist. After 2-3 hours, your nurse will remove it and wrap your wrist with a sterile dressing.
  • If the procedure was performed through the groin, the vascular entry site can be closed immediately with special groin closure devices. This allows you to stand up and walk after 1 hour. However, if these devices cannot be used due to economic or supply issues, the entry catheter will be removed by hand, and manual pressure will be applied for approximately 15-20 minutes to ensure bleeding control (this stage can be slightly painful). Once it is confirmed that there is no bleeding, you must lie flat for 4-6 hours. During this period, some doctors request that a heavy sandbag be placed over the patient’s groin area to prevent bleeding. Although it is thought that this reduces bleeding by applying pressure, the main mechanism is not this; it is to ensure the restriction of leg movement. Personally, I (Prof. Dr. Şükrü Akyüz) prefer not to use a sandbag if I am sure the patient understands they must not move their leg. In fact, current medical recommendations are now in this direction. This is because if bleeding occurs from the groin artery, the bleeding area may be missed as it remains under the sandbag, and the necessary intervention may be delayed. This can have serious consequences, including life-threatening risks. Additionally, the sandbag significantly disturbs the patient’s comfort and causes a poor experience.
  • Despite the above measures, bleeding can still occur rarely. In this case, you will either see the bleeding directly or feel a sensation of warmth in your groin. It is very important to apply manual pressure to the bleeding site without losing time and then inform your nurse.

You should tell your nurse if your fingers or toes tingle or become numb. Also, you should drink plenty of water after angiography (except for patients with heart failure). This will reduce the likelihood of your kidneys being impaired due to the contrast medium. After discharge, there is no harm in walking and returning to your usual daily activities as of the following day. However, you should avoid heavy work and lifting heavy loads (>5 kg) for a few days. Additionally, you should inform your doctor if the following occur at the catheter entry site (groin or wrist):

  • Bleeding (In this case, you should apply pressure to the site with your hand and call 112)
  • A growing swelling (Swelling that does not exceed the size of a hazelnut is normal)
  • Increasing redness (Slight redness, swelling, bruising, or tenderness is normal)
  • Inflammatory discharge (Occasional small amounts of clear discharge are normal)
  • Excessive pain (It is normal if your pain decreases over time)
  • Persistent numbness in the leg or wrist
  • Fever

References

1. Vrints C, Andreotti F, Koskinas KC, et al. ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024 Sep 29;45(36):3415-3537.