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Diagnostics Cases



In a Western European hospital one operator found good pressure trace and the amount of first contrast injection was as if he was taking a diagnostic shot. This artery was the only patent vessel that the patient had, and it was supplying collaterals to other areas. The contrast hung in the vessel and the patient did not survive this diagnostic shot. It also created serious problems in the intervention cardiology career of the operator.

First injection should always be very gentle and small in amount and be sure that contrast clears away. In this way you can avoid such disasters.



If you have inserted an arterial or venous sheath and you want to change it to a different sheath, Be careful.

In a South Asian hospital an operator was not able to locate the wire straightner and pushed the guide wire into the sheath, to be exchanged, over the dilator. Dilator had accidentally gone beyond the tip of the sheath. Note that it has a sharp edge and when the next wire was being inserted the wire also went into the vessel wall. The next sheath went in the vessel wall causing major dissection in the femoral artery.

So when you are changing the sheath, arterial or venous, please push the guide wire using the straightner and do not use the dilator as a straightner. The straightner will not enter deep into the sheath. and will not guide the wire into the vessel wall and the wire will stay in the lumen of the vessel and as result the next sheath will also stay in the lumen of the vessel.

Always use a guide wire with a “J” tip.

In above patient the dissection was fortunately against the blood flow and it sealed itself in one week.



In a Western European hospital the operator was unable to engage the left coronary system with a Judkins catheter and he opted for an Amplatz-left. There was a marked pressure drop with the canulation and injection. The catheter was disengaged, and engaged again for the next shot. After the fourth diagnostic shot patient collapsed and could not be resuscitated. After first injection operator should not have used the amplatz again(decision with hindsight).

If there is pressure drop or ventricularisation, it warns about the left main ostial stenosis. Operator should aim to finish the diagnostic shots with minimum possible injections. He can leave the sheath in situ and retake further shots if not satisfied.

The injection should not be forceful as it can lift a plaque in the left main.

Avoid multiple canulations of left main when the pressure is dropping and you disengage the catheter after injections

Failure to easily engage the left main is not always wrong curve of diagnostic catheter or abnormal origin. Be careful as it can also be left main ostial stenosis. Do not rush for an amplatz, as it enters the ostium with support of its curve and the push of curve can lift the atheroma.

A sinus shot will help you to exclude left main ostial disease and increase the choice of catheters.



In many countries the diagnostic and the PTCA hardware is used several times. The pig tail catheter is especially used several times. It can cause following problems

  • Clot in distal segment
  • In a South Asian hospital an overused pig-tail catheter caught in aortic root and developed an angle. When pulled back it fractured at the angle. With a snare the distal segment was caught and pulled back. It did not enter the femoral sheath and required arteriotomy to be removed.

Keep a count of reuse by marking the catheter every time, it is used. Using a mark on the catheter solves this problem.



A. With pig-tail in aortic root take an aortogram (required anyway for aortic regurge). In this the aortic opening will be visible. In same view use a left amplatz catheter and point the straight wire towards the opening.

B. Take aortogram as above. Place a sones B catheter in root curving at the opening now gently rotate the Sones catheter in clockwise direction and withdraw it, it will tend to enter the valve so gently advance the wire.

In a South-Asian hospital in a middle aged female patient, a straight wire was used to enter aortic valve. Note that these wires have a relatively stiff tip. It went through the LV and the pig tail also went in the pericardium. With the proximal holes, it showed the LV pressures. Operator directly went for high pressure cine without the test shot. She developed severe pain with marked ST elevation(chemical pericarditis). She developed fever and pericardial effusion. She was given Ibuprofen and cephalosporin for 5 days. She totally recovered. This case teaches two lessons.

  • Always have a test injection before high pressure injection.
  • Use a soft wire to enter LV such as turmo or wholly wire. It will not lift anything from the valve to embolise and it will not go through the LV in pericardium

Above lady had an echocardiogram after 12 months, it did not reveal pericardial thickening.



Use a soft wire. The advantage is that it will not pierce the aortic wall or a collateral



In a south Asian hospital an operator was using a 7f left amplatz diagnostic catheter. It dissected the left main and the patient had to sent for an emergency surgery.

When using amplatz be gentle.

If diagnostic catheter is tending to go into the circumflex and not very easily going in the LAD take a smaller size judkins and it will tend to go in LAD. If catheter is tending to go selectively in Cx then a larger size catheter will tend to go in Cx.

In another case, the guiding catheter was tending to go into the circumflex, the operator after extremely anticlockwise managed to bring it in the LAD but since it had a relatively larger curve, it entered upto the mid-LAD and caused severe spasm of the vessel.



In a Western European hospital an operator connected the pig-tail to high pressure injector.  He did not check with flush injection and tried a cine run directly. A large amount of air was injected (as there was no contrast in the injector) with dire consequences.


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