Chest X-ray Before Cath—Is There a Point?

Morton Kern, MD, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in cardiology.

Morton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.

Kern:

A query came my way I thought was interesting:

A patient has angina-like pain at rest/with exertion and undergoes catheterization, then was found to have unobstructive mild CAD. On review, a chest mass was both found on fluoroscopy after the cath and present on chest X-ray (CXR) taken before the procedure but not reviewed by the cath lab team. Later it was reported by radiology and action was taken.

Questions:

1. Do you review every CXR/CT/CT angiogram before a cath?

2. What is our liability for missing a finding in the chest that would have been seen by CXR or fluoroscopy?

My thought is that we, the fellow and I, try to review every CXR before each case. There’s a lot of helpful information both positively and negatively, and it’s useful to exclude obvious contraindications to the procedure.

However, we do not always have a timely CXR available and will proceed to cath for ACS without CXR review. It’s not ideal, but it’s real.

Should we wait for the CXR/CT before going to cath in such settings? What’s your practice?

---

Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY):

We don’t get CXR’s prior to cath (and don’t systematically review them in advance).

---

Mauricio Cohen, MD (Cleveland Clinic Florida, Weston):

Agree. No systematic chest X-rays before cath. I don’t usually review.

---

Neal Kleiman, MD (Houston Methodist Hospital, TX):

No, although if a patient has had a CT angiogram, we review it.

---

Jeffrey M. Schussler, MD (Baylor Scott & White – The Heart Hospital, Dallas, TX):

CXR - not so much. 

CT - A large minority of my cath patients now come to me because they had a CT angiogram. I find it helpful to review them prior to cath, not only because of the lesion information, but as it pertains to access. I’m predominantly a right radial approach person, and it’s super helpful to see what the right subclavian anatomy is. I find that this is also helpful in patients who have had a chest CT as you sometimes find potential access issues, and coronary ostia location issues based on a non-gated chest CT. 

I don’t want to ever get stuck (again) doing a right radial cath in a patient with arteria lusoria (retro esophageal subclavian path) when they had a prior CT done—happened to me once. 

---

James Blankenship, MD (University of New Mexico, Albuquerque):

At my prior institution, we stopped getting routine CXRs before cath about 30 years ago. We don’t routinely review prior CXRs before cath. The index case provides a good rationale for doing so, but the yield of actionable findings would be quite small. Regarding CTs, I agree with Jeff that knowing subclavian/innominate artery anatomy from CT before cath is useful. We have been fortunate with arteria lusoria—Dr. Tanawan Riangwiwat in our lab identified four arteria lusoria patients (out of 13,000 PCIs) where the aberrant origin was identified after cath; all were successfully completed with right radial access.

---

Mitchell Krukoff, MD (Duke University Medical Center, Durham, NC):

My answer is similar to Mike’s—no CXR for cath per se, but it’s often a good idea as part of chest pain and dyspnea evaluations.

---

Bonnie Weiner, MD (Saint Vincent Hospital, Worcester, MA):

Can’t remember the last time there was a “routine” chest X-ray before cath. May have been in the pre-Jurassic period. We may see more CTs, as coronary CT angiography prior to cath becomes more frequent.

---

Timothy Henry, MD (The Christ Hospital, Cincinnati, OH):

Agree with that. I think the last time was when I was a medical resident.

---

Malcolm Bell, MD (Mayo Clinic, Rochester, MN):

There is much useful information to be gleaned from a CT angiogram or even noncardiac CT, if they have been performed, that can be helpful in terms of access, anatomy, patency/position of grafts, etc, that I find myself searching for these prior to almost every case in my current practice.

We do not routinely order CXR before cath unless there were concerning symptoms as part of the presentation (eg, cough or pulmonary congestion). If recent imaging was ordered by other practitioners, we try to review it as part of precath review.

---

Dmitriy Feldman, MD (NewYork-Presbyterian/Weill Cornell Medicine, New York, NY):

As per the Society for Cardiovascular Angiography and Interventions’ 2021 expert consensus on best practices in the cath lab:

“Chest X-rays are not routinely needed before catheterization laboratory procedures but are appropriate if the preprocedural evaluation suggests pulmonary congestion or new lung pathology. When available, angiograms from prior procedures should be reviewed along with prior catheterization or CT chest reports to identify problems with vascular access or coronary cannulation and how they were resolved.”

---

Jesse W. Currier, MD (UCLA Health, Los Angeles, CA):

We used to pick up a couple of lung cancers a year in our VA population by preprocedure CXR. But the vast majority of our patients get rubidium PET myocardial perfusion imaging before cath, which has a low-dose CT for attenuation correction. That’s good enough to exclude lung cancer. Good enough to see anomalous coronary origins. I do review any CTA precath; coincidentally, I have a patient tomorrow with arteria lusoria. With regards to the liability of missing a lung cancer during a coronary angiogram, I doubt most lawyers are smart enough to figure out that it could be a concern. But I would assume, just as in coronary CTA, you would be liable. Yet another reason to collimate. 

---

The Bottom Line From Mort Kern

The review of the CXR is no longer routine and rarely will trigger an investigation to defer the cath procedure. If a CXR/CT is available, we should review it for the both the educational value as well as the potential clinical contribution to our thinking about the procedure in front of us.