Version May 2024
INTRODUCTION — Cardiac catheterization is an invasive procedure that is used for diagnostic and therapeutic purposes. This topic will discuss our approach to minimizing the risks of the procedure, increasing the likelihood of the procedure's goal(s), and optimizing the patient's experience. The content of this topic applies most specifically to patients for whom diagnostic coronary angiography and possible percutaneous coronary intervention are planned. Some content also applies to other cardiac procedures such as transcatheter valve replacement or cardiac electrophysiology.
Related general topics include:
●(See "Complications of diagnostic cardiac catheterization".)
●(See "Periprocedural complications of percutaneous coronary intervention".)
●(See "Percutaneous coronary intervention with intracoronary stents: Overview".)
PREPROCEDURE VISIT — Once a decision has been made between the patient and the healthcare provider to proceed with cardiac catheterization, the procedure details should be discussed by the proceduralist or their representative. Patient confidence and compliance with practitioner instructions are strengthened when the procedure is explained adequately, including the benefits and risks, and in such a way as to give the patient sufficient time to ask questions or comment. During that discussion, the following potential patient concerns should be covered:
●Why is the procedure being recommended?
●Are there reasonable alternatives to the procedure?
●What is the practitioner's best guess as to the findings?
●What will happen immediately before, during, and after the procedure?
●Will the patient experience any pain?
●Who will be in the room with the patient?
●Will trainees be present?
●What is the likely time of discharge?
●When can the patient return to usual activity?
History and physical examination — The following historical items should be carefully evaluated and well documented prior to the procedure:
●History of bleeding
●History of contrast allergy
●History of other drug allergies or adverse reactions (ie, sedation, anesthesia)
●History of stroke, transient ischemic attack
●History of symptoms of claudication or peripheral vascular interventions
●History of prior cardiac catheterization, including adverse events and findings
●History of obstructive sleep apnea or difficult intubation
The physical examination should focus on the following to determine a baseline:
●Examination of the lungs.
●Examination of the heart.
●Examination of arterial circulation, including the strength of the pulse at all locations and the absence or presence of bruits.
Informed consent — Informed consent is necessary for patient protection and legal purposes. The procedure consent should be obtained well before elective procedures and as timely as possible in urgent procedures, such that patients have sufficient time to weigh the risks and benefits, understand alternative options, and discuss with family or other providers. It is important to discuss every procedure that may be performed. In general, these include diagnostic cardiac catheterization, coronary angiography, and possible percutaneous coronary intervention (PCI). In general, the consent document is usually signed just prior to the procedure.
If PCI will be performed immediately following diagnostic catheterization, consent for PCI must be obtained prior to sedation and preferably at the time of consent for cardiac catheterization. If the anatomy is high risk, where the superiority of PCI as compared with other revascularization procedures (eg, coronary artery bypass graft surgery) is unclear or the risks are higher than an average PCI procedure, the precatheterization discussion may be insufficient [1]. In these cases, it would be ideal to defer PCI procedure until after additional consultations and discussions. Emergency procedures such as ST-elevation myocardial infarction need prompt treatment, making true informed consent difficult [2]. Every attempt must be made to discuss risks and benefits of the procedure and available alternate therapies with patients and family, and must balance the benefits of a good discussion with those of rapid intervention in these situations [3].
Patients with do-not-resuscitate status must be willing to revoke this status for at least 24 hours for the procedure [4-8]. Possible exceptions include pericardiocentesis for end-stage malignancy or right-heart catheterization for end-stage heart failure.
Assess risks for bleeding — All patients undergoing angiography and PCI procedures should be evaluated for risk of periprocedural bleeding since this is a risk factor for mortality due to the bleeding itself or cessation of antiplatelet or anticoagulant medications leading to ischemic events [9]. (See "Periprocedural bleeding in patients undergoing percutaneous coronary intervention".)
Measures to mitigate risk include using radial rather than femoral access, ultrasound-guided access, and using smaller-diameter sheaths.
Baseline laboratory tests — Whenever feasible, laboratory tests for outpatient procedures may be done within 30 days of the procedure to look for any potential issues that require attention. Laboratory work may also be done on the morning of the procedure for patients who have had normal labs in the past.
Laboratory tests should include hemoglobin/hematocrit, white blood cell count, platelet count, electrolytes (including sodium and potassium), blood urea nitrogen/creatinine, and an international normalized ratio for patients taking warfarin. Any test that is outside the normal range should be fully considered before the patient is asked to come to the hospital.
Electrocardiogram — A baseline electrocardiogram (ECG) should be performed within 30 days of cardiac catheterization. This ECG will help operators delineate any new changes from ischemia or arrhythmia during or after the procedure.
Patient medications — It is important to review the patient's current medications. The following medications may need to be discontinued, have a dose alteration, or have a schedule change.
●Anticoagulants – The approach to the management of long-term anticoagulant therapy is discussed in detail elsewhere. (See "Periprocedural management of antithrombotic therapy in patients receiving long-term oral anticoagulation and undergoing percutaneous coronary intervention" and "Anticoagulation for prosthetic heart valves: Management of bleeding and invasive procedures" and "Perioperative management of patients receiving anticoagulants", section on 'Timing of anticoagulant interruption'.)
●Metformin – Metformin should be held for 48 hours before and after the procedure, particularly in patients with depressed left ventricular ejection fraction or chronic kidney disease.
●Insulin dosing – Insulin dosing should be tailored to accommodate the patient's nil per os status.
●Beta blockers – Beta blockers may be continued without interruption.
●Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics – Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics may be continued up to the day of the procedure, held on the morning of the procedure, and resumed immediately postprocedure.
●Aspirin and P2Y12 inhibitors – Aspirin and P2Y12 inhibitors may be continued without interruption.
●Sodium-glucose cotransporter-2 (SGLT2) inhibitors – Based on the risk of euglycemic diabetic ketoacidosis with SGLT2 inhibitors, they should be held 24 to 48 hours before major surgery, including cardiac catheterization procedures. These medications can generally be resumed once the patient is eating [10,11].
Transportation and diet — All patients should be driven to and from the facility in which the procedure will be performed, as they will not be able to drive themselves.
Patients should be instructed to fast prior to a procedure for at least two hours after ingestion of clear liquids or at least six hours after ingestion of a meal, although some institutions require overnight nil per os status [12].
Prevention of contrast-related adverse outcomes — Possible contrast-induced acute kidney injury and allergic reactions to contrast need to be considered in the preparation of all patients. All patients should be asked about a history of contrast allergy, and a preprocedural assessment of kidney function should be performed. These issues are discussed in detail elsewhere. (See "Prevention of contrast-associated acute kidney injury related to angiography", section on 'Prevention' and "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography", section on 'Patients with past reactions to contrast'.)
Will trainees be involved? — Cardiac catheterization procedures performed at universities and other teaching hospitals involve participation of trainees. The actual work performed by trainees may vary depending on their level of training, but supervision is mandatory.
PROCEDURAL CONSIDERATIONS
Sedation — A thorough assessment of whether the patient can tolerate sedation/anesthesia must be performed before the procedure. A patient's American Society of Anesthesiologists class and Mallampati Scale, which predict difficulty in intubation, should be documented.
Moderate sedation and mild analgesia coupled with local anesthesia are crucial to minimize anxiety and sympathetic tone. A typical sedation protocol for the procedure might be a combination of 0.5 to 2 mg of midazolam and 25 to 50 mcg of fentanyl, both by the intravenous (IV) route [12]. Dosing must be carefully based on age, body weight, creatinine clearance, and comorbidities. Caution must be employed in elderly patients with history of respiratory insufficiency. All patients must receive local anesthesia with 1% lidocaine with no more than 0.5 to 1 mL at the site of puncture to avoid vasospasm from pain. Most patients can be managed successfully with midazolam and fentanyl. Intubated patients may require propofol. (See "Procedural sedation in adults in the emergency department: Medication selection, dosing, and discharge criteria", section on 'Medications'.)
Staffing requirements — The cardiac catheterization laboratory team consists of a credentialed physician (primary operator), possibly a physician trainee or physician assistant, a certified cardiovascular technologist, and a registered nurse (RN). The staffing requirements for a particular procedure depend on the type of case performed such as interventional versus diagnostic, elective versus emergency, and state and local hospital regulations. Typically, the cardiovascular technologists or physician assistant are at the tableside and are trained in sterile techniques, radiation safety, setting up equipment such as manifolds and injectors, and preparing catheters and wires for the procedure. The RN is involved with administering medications, continuous monitoring, and recording the patient's vital signs. All staff must have up-to-date advanced cardiac and basic life support certifications.
Vascular access — The specifics of the performance of arterial access is beyond the scope of this topic. A few comments are made here. (See "Percutaneous arterial access techniques for diagnostic or interventional procedures".)
For diagnostic coronary angiography and percutaneous coronary intervention (PCI), the radial and femoral arteries are the two most commonly chosen. The choice between the two is determined by the patient's anatomy, comorbid conditions, anticipated PCI technique, and physician practice. As access-site complications are the most common cause of procedure-related morbidity, it is of paramount importance to review prior cardiac catheterization reports when available to help understand the difficulties encountered to avoid potential complications. In addition, it is mandatory to check and document distal pulses in all four extremities immediately prior to the procedure.
Femoral access was traditionally the preferred approach in the United States because of the large-bore diameter and ease of access. The transradial approach, however, has evolved as an alternative technique for both diagnostic- and interventional-related cardiac catheterizations [13,14]. For urgent procedures, radial access is preferred given a lower risk of bleeding. If femoral access is absolutely necessary, then it is important to obtain access under fluoroscopic and ultrasound guidance.
Femoral access — Although there is no absolute contraindication for femoral artery puncture, caution must be exercised in the following situations where use of the contralateral femoral artery, a radial artery, or an ultrasound-guided approach to the femoral artery must be considered: patients with absent or weak femoral artery pulse, femoral bruits, or iliofemoral bypass graft; prior vascular complications including pseudoaneurysm, femoral dissection, arteriovenous fistula, or ischemic limb; active groin infection; and history of iliofemoral or aortoiliac aneurysm [15]. In addition, patients with calcified common femoral artery (seen on fluoroscopy), scarred groins from multiple prior procedures, and previous endovascular stents/grafts are at risk of vascular-closure device failure and would require manual compression to achieve hemostasis [16]. Hence, it is of paramount importance to perform a femoral angiography to define the vascular system and identify the sheath location. Other scenarios in which femoral access should be avoided, if possible, include post-thrombolytic therapy, therapeutic oral anticoagulant, and bleeding diathesis.
Common complications associated with femoral artery puncture include groin hematoma, retroperitoneal hematoma, arteriovenous fistulas, femoral pseudoaneurysm, and groin infection. (See "Complications of diagnostic cardiac catheterization", section on 'Local vascular complications' and "Access-related complications of percutaneous access for diagnostic or interventional procedures".)
Large femoral hematomas and retroperitoneal bleeding are the most common causes of major bleeding with a reported incidence of 2.8 and 0.3 percent, respectively [15]. Major risk factors include age >75 years, severe renal impairment, female sex, postprocedure use of heparin, use of glycoprotein IIb/IIIa, and longer procedure time [15].
Femoral artery pseudoaneurysm is a common complication associated with low femoral arterial puncture. Manual compression with Doppler ultrasound guidance with or without thrombin injection are the accepted treatment strategies [15].
In patients with prior femoral arterial access closed using a vascular closure device, the femoral artery cannot be reaccessed within 90 days if a collagen plug-based closure device is used, although reaccess 1 cm proximal to the prior access site can be considered. There are no restrictions to access groins closed using suture-based or nitinol-clip-based closure device [15,17].
Radial access — Prior to obtaining radial artery puncture, the Allen or Barbeau tests are conventionally used to assess dual circulation in the palmar arch. Despite no correlation, these tests are employed to potentially identify patients who may be at risk of hand ischemia in cases of radial artery occlusion:
●With the Allen test, the radial and the ulnar arteries are occluded by simultaneous manual compression until the palm blanches. Release of the ulnar artery should result in return of a pink hand within 8 to 10 seconds in a normal test. (See "Patient evaluation prior to placement of hemodialysis arteriovenous access", section on 'Allen test'.)
●The Barbeau test is a more objective assessment of the ulnar flow and is performed using pulse oximetry. A baseline arterial waveform is obtained when both arteries are open. The radial artery is manually occluded for two minutes and four responses (A, B, C, or D) are observed.
•A: No change in arterial waveform.
•B: Some dampening of the arterial waveform.
•C: Loss of arterial waveform but returns within two minutes.
•D: Loss of waveform but takes longer than two minutes to return. Type D response is typically a contraindication for the procedure.
In general, transradial access is avoided in the following scenarios:
●Absolute contraindication:
•Absence of bilateral radial artery pulses.
•Patients receiving hemodialysis via arteriovenous fistula on the same side of the access site.
●Relative contraindications:
•Radial artery being considered for use in coronary artery bypass graft (CABG) surgery.
•Known upper extremity vascular disease including vascular anomalies, severe tortuosity, and vasospastic diseases.
•Presence of right and left internal mammary artery graft may be less accessible.
•Interventions requiring large-bore access.
Complications
Contrast-related complications — Contrast-induced acute kidney injury is an important complication. Contrast media is excreted by the kidneys 30 to 60 minutes post-administration and a deterioration in kidney function can be detected as soon as few hours after the procedure. For patients with a baseline elevation of creatinine, we repeat the test within 12 to 48 hours.
There is no absolutely safe limit of contrast dose, but a predictive value of contrast volume to creatinine clearance ratio >3.7 was significantly associated with an early abnormal increase in serum creatinine after PCI [18]. We recommend rechecking creatinine before discharge in patients with abnormal baseline values or when the dose of contrast used during the procedure exceeds the calculated maximum dose. Measures to minimize contrast volume during the procedure include:
●Review of prior coronary angiograms and chest computer tomography if available, especially among patients with complex coronary disease or CABG.
●Avoiding left ventriculography and aortography (if possible) by obtaining echocardiography prior to the procedure.
●Use automated injectors using in-line devices in the contrast tubing manifold compared with manual injection [19].
●Reduce the number, volume, and frequency of contrast injections by making use of other anatomical radiopaque markers such as graft clips, calcification, and implantable cardiac devices.
●Use biplane angiography, especially in patients with chronic kidney disease [20].
●Use of fractional flow reserve and intracoronary imaging can potentially reduce the amount of contrast injection by accurate lesion measurement [21,22].
Prevention of contrast-related allergy is discussed above (see 'Prevention of contrast-related adverse outcomes' above).
Patients in the catheterization laboratory who develop circulatory collapse due to an anaphylactic reaction from contrast can be urgently treated with intravenous (IV) epinephrine (bolus followed by infusion) and IV fluids. The approach used to manage perioperative anaphylaxis is appropriate (table 1) [12]. The management of anaphylaxis is discussed in detail elsewhere. (See "Anaphylaxis: Emergency treatment", section on 'Pharmacologic treatments'.)
Catheter-induced coronary artery dissection — Coronary artery dissection with a guide catheter during a diagnostic study is rare, with a reported incidence of 0.03 to 0.46 percent [15]. The mechanism of the proximal dissection is due to mechanical trauma from catheter wedged into the intimal layer of the vessel and exacerbated by a jet of contrast from the abnormally located catheter. Catheter-induced dissection is more likely to occur with the right coronary artery when compared with the left coronary artery due to relative difference in the size of the ostia and the natural alignment of the catheter.
Coronary dissection occurs more commonly with intervention during balloon dilation and can be classified into six types (type A: luminal haziness; type B: linear dissection; type C: extraluminal contrast staining; type D: spiral dissection; type E: dissection with reduced flow; type F: dissection with total occlusion). The reported incidence of dissection PCI is 30 to 50 percent [15]. Stenting of the dissected vessel is the standard of care.
Stroke — The risk of periprocedural stroke varies between 0.05 to 0.1 percent of diagnostic cardiac catheterizations and 0.18 to 0.44 percent of patients treated with PCI [23]. Risk factors for periprocedural stroke include administration of thrombolytics prior to PCI, renal failure, urgent/emergent PCI, unplanned intraaortic balloon counterpulsation, advanced age, hypertension, and diabetes [15,24]. Both in-hospital and one-year mortality among patients who suffer from cerebrovascular accident is high (up to 25 percent) [24]. Stroke in the perioperative period warrants urgent brain imaging and neurologic consultation for consideration of intraarterial thrombolysis or mechanical thrombectomy. (See "Stroke after cardiac catheterization".)
Allergic reactions to drugs — In addition to contrast (see 'Contrast-related complications' above), patients may have immediate reactions to aspirin, nickel, latex, lidocaine, and heparin in the catheterization laboratory. At times, it may not be immediately evident which of these is the culprit.
Aspirin — The approach to patients with a history of aspirin hypersensitivity is presented separately. (See "Introduction of aspirin to patients with aspirin hypersensitivity requiring cardiovascular interventions".)
Nickel — Nickel allergy is a common cause of contact dermatitis. Coronary stents are made using 316L stainless steel, platinum-chromium, or cobalt-chromium alloy platforms, which include nickel (10 to 35 percent), chromium (18 to 20 percent), and molybdenum (2 to 10 percent) in varying amounts [25].
In general, routine testing for nickel allergy and choosing the type of stent based on a history of nickel allergy are not recommended. Although early studies suggested an association between nickel allergy and restenosis in bare metal stents, prospective studies have not confirmed this. (See "Nickel hypersensitivity and coronary artery stents".)
Latex — The prevalence of latex allergy is estimated to be <1 percent of the general population and up to 17 percent of healthcare workers [26]. Direct contact with latex is not necessary, as latex can filter off the gloves and become an airborne pathogen in the closed environment of the cardiac catheterization laboratory. When a latex allergy is recognized, all procedures must be performed in a latex-free environment, which means no latex gloves or latex accessories should be in room. (See "Latex allergy: Epidemiology, clinical manifestations, and diagnosis" and "Latex allergy: Management".)
Lidocaine — Clinically significant allergy to local lidocaine is rare. In such cases, mepivacaine 1% or bupivacaine 0.25% should be used [27]. (See "Allergic reactions to local anesthetics", section on 'Types of allergic reactions to local anesthetics'.)
Heparin — The most common type of allergic reaction with heparin is a cell-mediated delayed type IV hypersensitivity reaction with clinical manifestations of skin necrosis, including pruritic erythematous plaques or maculae [28-30]. Immediate type I allergic reactions (IgE-mediated) are rare [29]. Due to its rarity, there are no standardized protocols to follow in the presence of any type of heparin allergy. Heparin-induced thrombocytopenia is discussed separately. (See "Management of heparin-induced thrombocytopenia".)
Radiation safety basics — All team members involved in the cardiac catheterization laboratory must receive training and education on radiation safety. Personal protective equipment includes lead aprons, shields, thyroid collars, caps, and lead glasses [12,31]. Individual radiation exposure monitoring is of paramount importance, and all team members must be encouraged to always wear a radiation badge on the collar during the procedure. (See "Radiation-related risks of imaging" and "Radiation dose and risk of malignancy from cardiovascular imaging".)
The use of angulated views substantially increases radiation exposure. Left anterior oblique views produce greater exposure compared with right anterior oblique views. Typically, the default frame rate is 15 frames per second and decreases to 7.5 frames per second, and greater use of low-dose acquisition has been shown to have a marked reduction in total air kerma and air kerma rates [32]. Furthermore, keeping the detector close to the patients, using lower-quality (lower frame-rate) fluoroscopy, and reducing the steepness of angulation are all measures to reduce operator radiation exposure [12].
POSTPROCEDURAL CONSIDERATIONS
Hydration — Adequate postprocedural hydration is the single most important measure to reduce contrast-induced kidney injury (see 'Contrast-related complications' above). Randomized controlled trials comparing isotonic bicarbonate with intravenous saline showed no differences in the rates of renal outcomes [33,34]. The POSEIDON trial was a randomized controlled trial including 396 patients that compared intensive pre- and postprocedural hydration using a strategy measurement of left ventricular end-diastolic pressure (LVEDP) versus usual care of normal saline 3 mL/kg for one hour before cardiac catheterization. The results demonstrated that contrast induced nephropathy occurred less frequently in the LVEDP group when compared with controls (6.7 versus 16.3 percent [relative risk 0.41, 95% CI 0.22-0.79]; p = 0.005) [35]. Further intensive management with IV crystalloid in combination with forced diuresis using a fluid balance system demonstrated that elevation of urine output to >150 mL/hour before and during the procedure reduced rates of contrast-induced kidney injury [36].
Time of discharge — Patients can be discharged home the same day after uncomplicated diagnostic coronary angiography without high-risk findings such as significant left main or multivessel coronary artery disease involving proximal segments of major coronary arteries, and after uncomplicated planned or ad hoc percutaneous coronary intervention (PCI). Since sedation is administered for these procedures, patients should not be allowed to drive for at least 24 hours, and hence they need someone to drive them home. Other important factors include absence of access-site complications and absence of symptoms post-procedure before discharge. Patients with access-site or procedure-related complications, complex anatomy, and lack of support at home should be monitored overnight. A same-day discharge (SDD) checklist post-PCI may be used to make sure patients meet the required criteria before discharge [37].
Historically, patients who received PCI were monitored overnight for any complications. SDD after PCI has gained popularity in several countries, including the United States [38-42]. The main advantages of SDD are improved patient satisfaction, shorter hospital length of stay, and reduced overall costs. Advances in stent implantation, vascular closure devices, and adjunctive pharmacotherapy are the primary reasons for greater adaptation of SDD programs. Given the widespread adaptation of the SDD programs, patient education with clear communication with the family about the potential risks after discharge is critical to ensure patient safety and prevention of legal liability.
In 2021, the American College of Cardiology published an expert consensus document that details the conditions under which it is safe to discharge patients on the same day after PCI [43]. We practice in a manner consistent with recommendations made in the document.
Post-procedure access site considerations
Femoral artery access — Manual compression, femoral compression systems, and vascular closure devices are the typical options in cases of femoral access. Although it is prudent to remove the femoral sheath as soon as possible, the timing of sheath removal is predominantly dictated by the patient's anticoagulation status. In patients who underwent a diagnostic study with minimal use of anticoagulation, sheaths can be removed immediately after the procedure. In patients who receive heparin, sheath removal can occur four to six hours after the infusion is stopped, when the activated clotting time (ACT) is approximately 150 to 180 seconds. For patients who receive bivalirudin, sheath removal can occur safely at two hours post-cessation of infusion in most patients. In patients receiving enoxaparin, sheath removal can be safely performed 8 to 12 hours after the last dose [12]. Checking ACT levels in patients who received bivalirudin or enoxaparin is not useful.
In general, ambulation can be recommended after one to eight hours post-procedure and is typically dictated by the sheath size and success of vascular closure device. Patients who received manual compression can be ambulated after four to six hours, while those who received a vascular closure device may do so in one to four hours [44-47]. Prior studies have demonstrated that vascular closure devices are associated with increased efficacy including reduced time to hemostasis, earlier ambulation, hospital discharge, and patient comfort. However, the safety of vascular closure devices has remained controversial, with studies showing a higher rate of vascular access site complications compared with manual compression [48-50]. Nonetheless, despite a steep learning curve, vascular closure devices are considered safe in patients undergoing cardiac catheterization.
Radial artery access — Hemostasis of the radial artery access site can be achieved by manual compression or mechanical wrist band compression device. All sheaths are removed at the end of the case. Given the superficial position and ease of compressibility, it is not necessary to check the ACT prior to sheath removal. A modified "reverse Allen's test" may be performed to check patency of the radial artery. A pulse oximetry test with arterial wave is seen after lowering the pressure in the compression device and simultaneous manual occlusion of the ulnar artery, hereby confirming patency of the radial artery [51]. In our laboratory, a radial hemostatic device is left in place for approximately 30 minutes for diagnostic cardiac catheterization and approximately 90 minutes for PCI to achieve adequate hemostasis. Approximately 3 mL of air is deflated every 15 minutes until the band is completely deflated. In the absence of adequate hemostasis and return of bleeding, the air is reinjected, and the clock starts again. Patients should be able to be discharged after sedation wears off, within two hours after removal of the compression band. There are no ambulation restrictions, but patients are encouraged to avoid lifting weights or exercising their wrist for the next 24 hours.
SUMMARY AND RECOMMENDATIONS
●Meticulous preparation and execution of various important steps are essential prior to, during, and after cardiac catheterization procedures to ensure these procedures are performed safely and that patients have the best results with minimal complications. (See 'Preprocedure visit' above.)
●Informed consent should be obtained prior to the procedure, and patients should be informed if trainees are going to be present in the procedure. Do-not-resuscitate status needs to be discussed and reversed for the procedure. (See 'Informed consent' above.)
●Preprocedural steps include obtaining laboratory tests, correction of any electrolyte abnormalities, and assessing bleeding risk for appropriate access site selection. (See 'Preprocedure visit' above.)
●The patient's medications must be reviewed, and clear instructions need to be provided regarding which medications should be held for the procedure. It is important to hold anticoagulation for a few days prior to the procedure to minimize the risk of bleeding. (See 'Patient medications' above.)
●The use of contrast material is associated with risks of allergy and acute kidney injury. (See 'Contrast-related complications' above.)
●Discharge timing must be determined based on a multitude of patient- and procedure-related factors, with the goal of getting patients home safely. (See 'Postprocedural considerations' above.)
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