Minimally invasive Coronary Angiography -Angioplasty, Radial approach, no risk for bleeding, along with quick mobility and discharge in a few hours

Dr. George Papaioannou, MD MPHDirector of the Hemodynamic Lab of the Athens Medical Center.

The coronary artery disease is a heart arteries disease and is the main reason of morbidity and mortality to men and women of the western hemisphere. This means that blood vessels (coronary arteries), which provide blood and oxygen to the heart, develop some type of stenosis or blockage, leading either to angina or myocardial infarction (necrosis), even to sudden death. The final diagnostic exam for the verification or not of the diagnosis is coronary angiography, while in many cases, treating the disease includes further invasive techniques (angioplasty – stent placement), if deemed necessary.

Coronary angiography method

Invasive cardiology uses the human circulatory system (arteries) as a «route» for the passing of small catheters (little tubes, shaped like macaroni) of 2 mm diameter or even smaller, which are lead painless to the area of the heart. Those little tubes allow the administration of radiopaque liquid inside the coronary arteries, by which the artery network of the heart is depicted. The insertion of the catheter to the artery is usually done via leg puncture (femoral artery). The puncture could also be done to the arm βραχίονα (humeral artery) or to the wrist (radial arteryαρτηρία). The last one is the ideal approach for the minimally invasive coronary angiography.

Leg puncture

Leg puncture is the most frequently used technique for the creation of a route to the circulatory system and the insertion of catheters up to the heart in order to display coronary arteries. This technique, invented back in 1960, is the most widely used, but has some limitations. The femoral artery could have some disease (e.g. a patient with peripheral artery disease), something that does not allow a catheter’s insertion. In other cases, the patient is overweight and the femoral artery is located deeply inside subcutaneous tissue, making the approach quite difficult and also its compression after the end of the surgery even more difficult in order to stop hemorrhaging. Rarely, a potential hemorrhage by the artery after the end of the exam is not visible to the naked eye and could happen to the back of the artery, creating from a simple discoloration to a crucial hematoma. Finally, with the femoral artery puncture there is a small possibility of damaging the femoral nerve, due to the fact that it is located to close proximity. All previous complications, despite the fact of their low number, are the limitations of the femoral approach for coronary angiography.

Most limitations related to the approach by the femoral artery do not exist to the radial approach.

Radial approach

Despite the fact that the radial artery is much smaller in diameter in comparison with the femoral artery, each diameter is sufficient to allow most catheters to pass through it and to reach the coronary arteries. Further improvements of the materials have lead to the creation of special sheaths (the small tubes initially placed initially inside the artery), which are autramatic, as well as special catheters of a smaller diameter for the conduction of the diagnostic coronary angiography as well as of the surgery to the coronary vessels (angioplasty and/or stent placement).

Advantages of the radial approach

Most limitations related to the approach by the femoral artery do not exist to the radial approach. Even for overweight patients, radial approach is close to the skin, making the initial puncture much simpler. For the same reason, when diagnostic coronary angiography has finished, a short compression of the radial artery is sufficient to stop bleeding, even in patients receiving anti-clotting medication, such as after the execution of angioplasty. Finally, the radial artery is not proximal to any large nerve. Thus the possibility of damaging a nerve during surgery is not existent.

Radial approach does not present the risk of bleeding. Thus, the patients do not need the painful pressing of the femoral artery after the end of the exam or to lie down for many hours in order to avoid potential hemorrhage from the femoral artery. After the end to the diagnostic exam they can get up and walk right away. Also, due to the simpler process of healing of the artery wound on the wrist, most patients are able to leave to leave the hospital in a few hours without the need to spend the night.

Are all patients eligible for radial approach?

There are some requirements for a patient to be perfect candidate for the minimally invasive coronary angiography. The first one is to certify that there is a «double» supply of blood in the hand. The radial artery creates a loop in the hand and is united with the ulnar artery. Both arteries supply blood to the hand and fingers (Image 3). This double blood supply of the hand makes the radial approach completely safe. Even if the radial artery for some reason is “blocked” (a very rare complication), the clinical result is not important due to the fact that the hand is still supplied by the ulnar artery. The first step of the invasive cardiologist is to test the normal operation of both radial and ulnar artery. A simple test, which is done by pressing the arteries of the hand, is able to show the double provision of blood to the hand. If the test fails then the femoral approach is the preferred choice. Also, the femoral artery is preferred, when we know in advance the need to use catheters of larger diameter, the presence of bypass grafts and/or the coiling of blood vessels in the neck, which could inhibit the passage of the catheter from the hand to the coronary arteries. In total a high percentage of patients (70%-80%) are eligible for radial approach.

The first step of the invasive cardiologist is to test the normal operation of both radial and ulnar artery.

What are the reasons for the limited use of the radial approach in Greece?

The most common reason that patients are not informed for the radial approach is that that there is a very small number of invasive cardiologists that prefer this technique. Many places in Europe and/or Japan and also the United States of America and Canada have centers that are using either exclusively or mostly the radial approach as the main approach for the conduction of diagnostic coronary angiographies and angioplasties. Other reasons for the low use of radial approach for the conduction of coronary angiography is the lack of financial motive from the part of insurance companies and also hospitals but mainly due to the existing structure of the insurance system, the lack of information by patients and also the reluctance of invasive cardiologists to promote this technique. However this situation changes dynamically. More and more centers and invasive cardiologists begin to see the advantages of radial approach characterized by low implications, increased satisfaction on behalf of the patients, but also lower cost (reduced hospitalization time and low percentage of complications). At the Medical Center of Athens, the radial approach is for the last two the main personal diagnostic approach of patients submitted to coronary exams.

The femoral approach for the conduction of coronary angiography exists and will exist as a main technique for many years. The radial approach, offering a minimally invasive coronary angiography with almost zero percentage of complications and excellent satisfaction on behalf of the patients, requires specialized medical and nurse staff and greater skills. But its advantages are such that will make it the main approach for diagnostic and treatment purposes to the coronary vessels for the next years. 

By Georgios Ι. PapaioannouMD, MPH, FACC, FSCAI Invasive Cardiologist, of the Hemodynamic Lab of the Athens Medical Center.

Cardiac failure – The disease with the gradually increased hospitalization

Congestive Cardiac Failure (CCF) is a disease during which the heart is not able to supply tissues with a sufficient blood quantity, in order to satisfy the needs of the organs. The CCF clinical syndrome is the final manifestation of many cardiac conditions.

CCF was known since the antiquity. The father of medicine Hippocrates believed that: «A flesh oedema is caused mainly when someone, following a long-term disease remains without catharsis for some time. The flesh deteriorates and melts and becomes viscous. The abdomen is filled with water, tibias and legs are getting swollen. If the treatment starts from scratch before the concentration of water becomes extensive, one should administer cathartic medicine (diuretics) which will expel water or phlegm».

Nowadays almost 6 million Americans in the USA and 1% of the United Kingdom population suffer from CCF. The occurrence of the diseases is 10 persons /1000 in ages over 65. CCF is either acute, when symptoms are recent or chronic when there is a gradual evolution. Symptoms are dyspnea (effort or calm), weakness, fatigue, lower limbs oedema, tachycardia or arrhythmia, reduced ability for exercise, stubborn cough or whistling with white or red sputum, ascitic concentration, body weight increase (due to liquids retention), anorexia or nausea, difficulty to concentrate or reduced reflexes.

The risk factors for CCF are multiple.

The existence of one factor is sufficient to induce CCF but the combination of multiple factor is sure to increase the risk for the occurrence of the disease.

The main risk factors are: high blood pressure due to which the cardiac workload is increased, coronary disease during which narrowed arteries could not supply the heart with sufficient quantity of oxygen and lead to weakening of myocardial tissue as well as acute ischemic stroke which causes an extended myocardial damage ο and could lead to the reduction of the performance of the pumping ability of the heart. Arrhythmias many times cause an increase of the cardiac workload and weakening of the cardiac muscle. Also, diabetes could lead to CCF because it increases the risk for coronary disease as well as of high blood pressure. Also guilty for CCF occurrence are some anti-diabetic pills. Apnea during sleep is also an additional burdening factor, because it leads to the reduction of oxygen levels of the blood as well as to arrhythmias –which are both weakening factors of the cardiac muscle. Viruses, extensive alcohol consumption and renal diseases could lead to CCF. A small percentage of CCF patients are born with structural cardiac problems. Finally, neglected valve diseases could also cause CCF.

The Complications are multiple. CCF could lead to renal insufficiency (mainly for neglected cases) due to reduced blood supply to the kidneys. Also the operation of heart valves and the liver could worsen by the increased liquids retention. The flow through the heart pump is reduced, a fact contributing to the potential clot development and occurrence of cardiac and/or cerebral strokes. Nowadays the timely treatment could significantly improve the symptoms and life quality of patients. Despite that CCF keeps being a life threatening disease because it might lead to sudden death.

Diagnosing CCF is based to taking the patients’ history, clinically examine him/her, αbut also a series of exams including blood tests including NT - pro-BNP which is a reliable prognostic index, chest x-ray, electrocardiogram and fatigue test or the dobutamine stress echo. Clearly the most important role to the evaluation of cardiac function for this disease is the echocardiogram. During this exam one could calculate the fraction of expulsion which is an objective index of evaluation for the severity of the disease. In some cases, information for the causes of the disease and also its severity might be given by Heart MRI. The results of clinical and other exams help each cardiologist to classify the severity of the case and to define treatment.

The classification according to the New York Heart Association (NYHA) is international in order to classify patients based in symptoms. Class Ι (NYHA) patients do not have any symptoms. For Class ΙΙ (NYHA) no symptoms to ordinary activities but patients feel fatigue after extensive exercise. For Class ΙΙΙ (NYHA) symptoms now appear to ordinary activities and finally for Class IV (NYHA) which is the most severe, the patient has acute dyspnea even when calm. A second classification is that of the American Cardiology College using a grading for the disease from το Α to D depending on aggravating factors of the patients, symptoms and the dynamic evolution of the disease. For example the patients of Stage Α present some aggravating factors for CCF without occurrence of the disease. Patients of Stage D are in the final stage of the disease and could be treated only in a hospital. The abovementioned classification helps to the documentation of risk factors and the start of timely and aggressive treatment, in order to prevent or to slow down the progress of the disease.

Nowadays for its treatment are used many categories of medicine such as β- inhibitors, inhibitors of the receptors of angiotensin ΙΙ, digitalis therapy, diuretics, spironolactone or epleronone. Also many times is deemed necessary based on the indications, by-pass or valves replacement. In case of recording dangerous (threatening) arrhythmias there is the option to plant a defibrillator which in various ways replaces the normal heart rate.

Evolution in the level of research contributed to the identification of the notion of bisynchronism presented by some CCF patients and caused by damage to the electric system of the heart. In specific patients the implant of a biventricular pacemaker and the equilibration of the synchronization of parts of the heart lead to impressive results. For the last years patients with final stage CCF are implanted with Left Ventricular Assist Devices (LVADs) to the abdominal or precordial area. The initial design of those devices has been made as a «bridge» for transplant, because in some cases the transplant is not plausible or finding a heart takes a lot of time. However recent studies showed that in many cases LVADs could improve cardiac function and substitute the transplant. However these findings are still in development. Patients that do not react to any of mentioned therapies are lead to transplant. Unfortunately many times the waiting could be many months or years.

It must be noted that important modification of the daily life could prevent the aggravation of the disease. Initially giving up smoking protects coronary blood vessels, reduces blood pressure and cardiac workload. Also the regulation of body weight (BW) as well as the daily limitation of saturated fatty acids and cholesterol reception  - as aggravating CCF factors ­ reduces the potential for CCF occurrence. It must be also made clear that it highly recommended to reduce alcohol consumption for CCF cases, since on one part its use interacts with the medicine taken, on the other it weakens the cardiac muscle and also increases the risk for arrhythmias. Without doubt in severe CCF cases it is recommended to limit the consumption of salt and liquids, since it leads to water retention. The recommended salt reception for CCF patients should not be over 2 mg. If there is also high blood pressure or the patient is older than 50 the quantity is 1.5 mg. Aerobic exercise helps essentially for the reduction of the myocardial muscle needs. A special work-out program for CCF patients must be organized. The avoidance of intense emotional burden and stressing factors essentially leads to the reduction of cardiac workload and as a result to the stabilization and improvement of the disease. Finally in cases of apneas during sleep a relevant sleep study must be made and directions should be given.

In the USA each year are recorded 500 thousand new cases. It is calculated that in the next years, CCF would be the most common diagnosis and will be «responsible» for most admissions to hospitals. This happens because with new techniques and medicine, many patients survive and are lead long-term to heart failure.

With the currently applied drastic treatment we achieve not only slowing down the disease but also the improvement of the function of the left ventricle dye to reversal of each reformation. As a result the quality of life of patients is improved (since they are relieved of their symptoms) the main target of CCF treatment. The prevention of the CCF is everything so all risk factors should be checked and eliminated by modifying diet, way of life and taking, where necessary the required medication. 

By Dr. Aggeliki Eleftheriou, Special Cardiologist, Direct of the Cardiology Department, Athens Medical Center.

Microsurgery Technique


Despite the fact that creation and use of vision magnification devices for the observation of the sky and see navigation has been achieved some thousand years now, the first application in medicine was realized by Anton van Leeuwenhoek (1632-1723), who created the first microscope for lab use. The first application for applied surgical reasons was realized by Swedish Otorhinolaryngologists and Neurosurgeons, Nylen, Holmgre and Hinselman, in the 1930s. The revolution took place in 1953, by the German engineer Karl Zeiss, with the creation of the first surgical microscope OPMI 1 (Operative Microscope 1).

The term Microsurgery was born in 1960 by J. Jacobson, D. Miller and E. Suarez, who achieved anastomosis of a vessel of 1 mm diameter and is explained as the execution of operations under the magnification of a surgical microscope. Thus, it is a technique and not a specialty as some people believe. A necessary condition for the use of this surgical practice is the use of micro – tools and micro – sutures. Micro tools are the evolution of the tools of clock-makers and jewelers, because their small size allows for their use under the microscope’s magnification. Micro – sutures of 8/0, 9/0, 10/0 and 11/0 dimensions usually are not visible by the naked eyes. Thus, the Microsurgery is the technique using the three «Μ»: Microscope – Micro-Tools –Micro – Sutures. By using all these modern technology tools it is possible to recognize and operate tissues invisible to the naked eye.

For Upper Limb surgery and generally for the restoration of the musculoskeletal system, microsurgery was used to operate on small vessels and nerves by Orthopedic and Plastic Surgeons. Its first application was the reattachment of amputated fingers. In 1965, Komatsu and Tamai in Japan, achieved the first reattachment of amputated finger in a patient aged 28 years and in 1967 Yang in China made the first successful leg to hand finger transfer.

For the surgery of peripheral nerves, the French Michon in 1964, applied microsurgery for the restoration of injured nerve tissue and the Austrian Millesi, in 1965, used nerve grafts for the bridging of nerve lesions. Another application of microsurgery to Orthopedics and Plastic Surgery is the free transfer of tissues, thus the reception of part of skin or muscle from one part of the body and its transfer to another one. A necessary condition for this transfer is the anastomosis of the blood vessels that secure the blood supply of transferred tissues. Harii in 1972 and Daniel and Taylor in 1973, published the first free tissue transfer. The latest achievement of micro-surgery is the hand transplant, applied for the first time in 1998, in Lyon France, by Dubernard and his colleagues, to evolve to the simultaneous transplant of two hands by Biemer and Hoehnke in Germany in 2008. In Greece, the father lf Microsurgery is considered to be the professor of Orthopedics Mr. Panayiotis Ν. Soukakos, who first applied the method during the '70s and achieved the first finger reattachment in 1979.

From this point microsurgery in Greece presented an important growth and today almost all microsurgical operation are able to be performed with high percentage of success, same with those of worldwide practice. The use of Surgical Microscope is applied by almost all specialties of surgery, such as ophthalmology, otorhinolaryngology, urology, neurosurgery and other, but in a an international level the term «Micro-Surgeon» is used for the Surgeon who handles surgically small vessels and nerves.

Your hands will only achieve what your eyes can see!

What Microsurgery can do today:

  • Amputated hand and finger reattachment.
  • Nerve transection restoration (Final –Final Suture or nerve graft).
  • Intraneural removal of symphysis (intraneural neurolysis).
  • Removal of intraneural tumors.
  • Restoration of bronchial plexus injuries.
  • Free transfer τμήματος of skin or muscle part for covering skin lesion.
  • Free transfer of bone for bridging bone lesion.
  • Free flap bone transfer for the improvement of blood supply in another bone suffering necrosis.
  • Muscle transfer to achieve missing hand function.
  • Transfer of fingers or joints from the leg to the hand, in case of injuries or congenital anomalies.
  • Hand transplant.

Training in Microsurgery is a difficult procedure, which requires calm, patience, self-control and...many hours of exercise! However the result justifies the effort, because the important solutions offered to the patient were not possible under traditional techniques. For daily use, the application of simple magnification, such as magnifying lenses (Loopes), ensures the best visibility, for the recognition and repair of the Upper Limb tissues.