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Oxford Specialist Handbooks
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Cardiac
Catheterization
and Coronary
Intervention
SECOND EDITION

Andrew Mitchell
Consultant Cardiologist, Jersey General Hospital,
Saint Helier, Jersey; and Honorary Consultant Cardiologist,
John Radcliffe Hospital, Oxford, UK

Giovanni Luigi De Maria

Consultant Cardiologist, John Radcliffe Hospital,
Oxford, UK

Adrian Banning
Professor of Cardiology and Consultant Cardiologist,
John Radcliffe Hospital, Oxford, UK

1
1
Great Clarendon Street, Oxford, OX2 6DP,
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First Edition published in 2008
Second Edition published in 2020
Impression: 1
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  v

Foreword

‘The only good is knowledge and the only evil is ignorance’

Socrates (469 BC–399 BC)

‘An investment in knowledge always pays the best interest’

Benjamin Franklin (1706–1790)

Can the history and techniques of cardiac catheterization really be encom-

passed in a pocket-sized handbook? Clearly the answer is ‘yes’.
This handbook succinctly summarizes the historical advances in d­ iagnostic
and therapeutic coronary angiography from its origins in 1929 when Werner
Forsmann performed right heart catheterization on himself, through the
advent of percutaneous intervention with the first balloon angioplasty by
Andreas Gruentzig in 1977, up to the current drug-eluting stent era.
The main focus however is the practical applications and techniques
of current practice in the catheterization laboratory, including radiation
­protection, vascular access, view selection for diagnostic angiography, and a
detailed summary of current interventional techniques and devices.
The chapter on complications, including a summary of when such
issues are likely to occur and details of how to manage each predicament,
­deserves particular attention.
This manual will prove to be a valuable guide to anyone wishing to learn
the indications and practical techniques of cardiac catheterization, from
­cardiology trainees and other catheter laboratory personnel as well as
serving as a useful quick reference guide for more experienced cardiologists.

Professor Patrick W. Serruys, MD

Thorax Centre
University Hospital
Rotterdam, The Netherlands
  vii

Preface

This latest edition of Cardiac Catheterization and Coronary Intervention ex-

pands on the practical success of the original edition but without losing the
main purpose of the book. The text is written to offer a practical guide
to coronary angiography and cardiac intervention, incorporating tricks and
tips, hints and suggestions for the cardiology trainee learning cardiac cath-
eterization, the nurse, or the technician assisting the case, or the senior
cardiologist needing a reminder about certain conditions.
Coronary angiography and cardiac catheterization remain a key com-
ponent of modern cardiac care. Since the first edition of this book, the
development of complementary cardiac imaging techniques such as car-
diac computed tomography has resulting in more focused and selected
patient care allowing targeted revascularization strategies using coronary
intervention. The assessment of flow haemodynamics, changes in inter-
ventional techniques and stent delivery, as well as revised indications for
revascularization mean that the world of interventional cardiology remains
a rapidly evolving field. New sections in this edition are included on these
topics as well as the role of the heart team, trends in vascular access, and on
the use of pressure wire assessment and associated interventional imaging
techniques. The challenges faced during primary angioplasty and its clinical
and practical difficulties are explored.
The book will act as an easily accessible reference for all members of the
team in times of need. Using hints and tips from experts in the field, the
familiar Oxford Handbook style, and with clear diagrams and illustrations,
we expect this guide will remain the standard text for guiding cardiac cath-
eterization and coronary angiography.
ARJM
GLDM
AB
November 2019
  ix

Acknowledgements

We are grateful for all of the help, support, advice, tips, and tricks from the
many wonderful catheter laboratory teams and staff that we have had the
honour and pleasure to work with, many of whom will have indirectly con-
tributed to the quality and content of this book.
ARJM: dedicated to Claire, Oliver, and Imogen for their continued love and
support.
GDM: dedicated to Michela and Milena.
AB: dedicated to Anne, Amy, and Eve.
  xi

Contents

Symbols and abbreviations xiii

Contributors xvii
References xix

1 Introduction 1
2 The team 25
3 Vascular access 43
4 Cardiac catheterization 71
5 Specific conditions 107
6 Coronary angiography 129
7 Coronary artery bypass graft angiography 165
8 Percutaneous coronary intervention 183
9 Additional procedures 253
10 Complications 277
11 Post procedure 315

Index 323
  xiii

Symbols and abbreviations

% cross-​reference
M website
ACC American College of Cardiology
ACT activated clotting time
AHA American Heart Association
AL Amplatz left
ALARA as low as reasonably achievable
ALARP as low as reasonably practicable
Ao aorta
AP anteroposterior
AR Amplatz right
ASD atrial septal defect
BMS bare-​metal stent
BRS bioresorbable scaffold
CABG coronary artery bypass surgery
CAD coronary artery disease
CathLab catheterization laboratory
CHIP complex high-​risk indicated patients
CPR cardiopulmonary resuscitation
CTO chronic total occlusion
Cx circumflex
DC direct current
DES drug-​eluting stent
DOAC direct oral anticoagulant
EAPCI European Association of Percutaneous Cardiovascular
Interventions
ECMO extracorporeal membrane oxygenation
EDV end-​diastolic volume
ESV end-​systolic volume
FFR fractional flow reserve
fps frames per second
GPI glycoprotein IIb/​IIIa inhibitor
GTN glyceryl trinitrate
Gy gray
IABP intra-​aortic balloon pump
iFR instantaneous wave-​free ratio
xiv S YMBOLS AND ABBREVIATIONS

INR international normalized ratio

IR(ME)R Ionising Radiation (Medical Exposure) Regulations
IRA infarct-​related artery
IV intravenous
JL Judkins left
JR Judkins right
kV kilovolt
LA left atrium
LAD left anterior descending
LAO left anterior oblique
LE lead equivalent
LIMA left internal mammary artery
LMS left main stem
LV left ventricular
LVEDP left ventricular end-​diastolic pressure
mA milliampere
MACE major adverse cardiac events
MCS mechanical circulatory support
MI myocardial infarction
MINOCA myocardial infarction with non-​obstructive coronary
arteries
MR mitral regurgitation
OTW over the wire
PA pulmonary artery or posteroanterior
PCI percutaneous coronary intervention
PCWP pulmonary capillary wedge pressure
PES paclitaxel-​eluting stent
PET positron emission tomography
POBA plain old balloon angioplasty
PPE personal protective equipment
PTCA percutaneous transluminal coronary angioplasty
PVC premature ventricular complex
PVR pulmonary vascular resistance
RA right atrium
RAO right anterior oblique
RIMA right internal mammary artery
RV right ventricular
SCAI Society for Cardiovascular Angiography and Interventions
SPECT single-​photon emission computed tomography
STEMI ST-​segment elevation myocardial infarction
Sv sievert
 S YMBOLS AND ABBREVIATIONS  xv

SVG saphenous vein graft

SVR systemic vascular resistance
SVT supraventricular tachycardia
TAVI transcatheter aortic valve intervention
TLR target lesion revascularization
VF ventricular fibrillation
VSD ventricular septal defect
VT ventricular tachycardia
WHO World Health Organization
  xvii

Contributors

Dr Angie Ghattas
Interventional Cardiologist, University Hospital of Coventry and
Warwickshire, Coventry, UK
Professor Paul Leeson
Professor of Cardiovascular Medicine, University of Oxford,
and Consultant Cardiologist, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
Professor Nick West
Consultant Cardiologist and Clinical Lead for Coronary Intervention,
Papworth Hospital, Royal Papworth NHS Foundation Trust,
Cambridge, UK
  xix

References

Reference textbooks
Grossman W (2013). Grossman and Baim’s Cardiac Catheterization,
Angiography, and Intervention, 8th edition. Wolters Kluwer.
Samady H, Fearon WF, Yeung AC, et al. (2018). Interventional Cardiology,
2nd edition. McGraw-​Hill Professional.
Sorajja P, Lim MJ, Kern MJ (2019). Kern’s Cardiac Catheterization Handbook,
7th edition. Elsevier.
Websites
Abbott Vascular: M https://​www.cardiovascular.abbott/​us/​en/​home.
html
American College of Cardiology: M http://​www.acc.org/​
American Heart Association: M http://​www.americanheart.org/​
Boston Scientific: M http://​www.bostonscientific.com/​
British Cardiovascular Intervention Society: M http://​www.bcis.org.uk/​
Cordis: M http://​www.cordis.com/​
European Society of Cardiology: M http://​www.escardio.org/​
Guidant: M http://​www.guidant.com/​
Medtronic: M http://​www.medtronic.com/​
St. Jude Medical: M http://​www.sjm.com/​
Transcatheter Cardiovascular Therapeutics: M http://​www.tctmd.com/​
 1
Chapter 

Introduction
Background 2
Definitions 2
History of cardiac catheterization 3
Indications for cardiac catheterization 4
Indications for coronary angiography 6
Cardiac CT or invasive angiography? 8
Radiology equipment 10
Fluoroscopy and acquisition 12
Radiation safety 14
Dose excess 18
Patient preparation 20
Catheter laboratory preparation 22
2 Chapter  Introduction

Background
In the last couple of decades, there has been a progressive increase in
the provision of invasive cardiology techniques and access to coronary
revascularization, particularly percutaneous coronary intervention (PCI).
These techniques are largely learnt by apprenticeship with the training
guided by the skills and beliefs of the trainer. For the training cardiologist
(and also for the fully trained), it is important to have an independent ref-
erence guide for performing and interpreting cardiac catheterization and
coronary angiography studies. This handbook has been written to provide
key points, hints, and tips to the reader in an easily accessible style.

Definitions
• Cardiac catheterization is the passage of a catheter into the left and/​
or right heart to provide diagnostic information about the heart and/​or
blood vessels.
• Coronary angiography is a procedure where contrast material is injected
into the coronary arteries under X-​ray guidance in order to define the
coronary anatomy and determine the degree of luminal obstruction. It
remains the standard investigation for patients with known or suspected
coronary artery disease (CAD).
 History of cardiac catheterization 3

History of cardiac catheterization

The first human heart catheterization studies were performed using a modi-
fied urinary catheter that was inserted via the internal jugular vein into the
right atrium. This work was initially performed on cadavers but, by per-
forming the procedure on himself using fluoroscopic control and a mirror,
Werner Forssmann was able to take a chest X-​ray and document the first
right heart catheterization study in 1929. The work was taken up by André
Cournand in 1941, who catheterized the right ventricle and performed
more detailed right heart studies. In 1947, Zimmerman performed the
first simultaneous left and right heart catheterization study. A few years
later in 1953, Sven-​Ivar Seldinger developed his eponymous technique for
percutaneous vascular access (% p.44). Forssmann, Cournand, and co-​
worker Dickinson Richards were awarded the Nobel Prize in Physiology
or Medicine for their contributions in 1956. Mason Sones, working at the
Cleveland Clinic, determined a new technique for selective coronary angi-
ography in 1959. In 1977, Andreas Grüntzig performed the first coronary
angioplasty in Zurich on a severe proximal left anterior descending cor-
onary artery lesion in a 38-​year-​old man (% p.184). The first coronary ar-
tery stents were implanted in 1986. Since the early 1990s, there has been
a rapid and successful development of percutaneous coronary intervention
(PCI) procedures and devices.
Further reading
Cournand A. Catheterization of the right auricle in man. Proc Soc Exp Biol Med 1941; 46: 462–​66.
Forssmann W. The probing of the right heart. Clin Wkly J 1929; 8: 2085–​87.
Gruntzig AR. Transluminal dilatation of coronary artery stenosis. Lancet 1978; 1: 263.
Sones FM. Cine coronary arteriography. Mod Concepts Cardiovasc Dis 1962; 31: 735–​38.
4 Chapter  Introduction

Indications for cardiac catheterization

Cardiac catheterization is usually indicated to identify the degree and extent
of CAD and to complement data obtained from non-​invasive imaging mo-
dalities. This includes the evaluation of left ventricular function, the assess-
ment of valvular heart disease, pericardial disease, congenital heart disease,
and cardiomyopathies.
In general terms, the only absolute contraindication to cardiac catheter-
ization is refusal of patient consent; however, there are a number of relative
contraindications.
Relative contraindications
• Acute kidney injury.
• Pulmonary oedema.
• Known radiographic contrast allergy.
• Uncontrolled hypertension.
• Active gastrointestinal haemorrhage.
• Acute stroke.
• Untreated coagulopathy.
• Untreated (or unexplained) febrile illness.
Indications for cardiac catheterization 5
6 Chapter  Introduction

Indications for coronary angiography

Coronary angiography is primarily used to determine the coronary
anatomy and to identify any luminal stenoses. It provides some infor-
mation on the nature of the stenosis, such as the extent of coronary
­atherosclerosis (% p.154), the presence of thrombus (% p.202), coronary
spasm (% p.152), myocardial bridging (% p.163), and coronary dissection
(% p.300). Coronary angiography remains the standard investigation for
determining coronary anatomy but the technique is limited by its inability
to see beyond the coronary lumen. Coronary angiography is therefore a
procedure of ‘lumenography’ or ‘lumenology’.
Class 1 indications
The current American College of Cardiology (ACC)/​American Heart
Association (AHA) class 1 indications for coronary angiography include the
following:
• In patients with known or suspected coronary heart disease who have
stable angina with:
• Canadian Cardiac Society class 3 or 4 angina on medical treatment.
• High-​risk criteria on non-​invasive testing.
• Patients who have been resuscitated from sudden cardiac death or
who have sustained ventricular tachycardia (VT) or non-​sustained
polymorphic VT.
• In patients with unstable coronary syndromes with:
• High or intermediate risk for adverse outcome with unstable angina
refractory to initial adequate medical therapy or recurrent symptoms
after initial stabilization.
• High risk for adverse outcome in patients with unstable angina.
• High-​or intermediate-​risk unstable angina that stabilizes after initial
treatment.
• Initially low short-​term-​risk unstable angina that is subsequently high
risk on non-​invasive testing.
• In patients with acute ST myocardial infarction:
• As a prelude to primary PCI within 12 hours of the onset of
symptoms.
• As a prelude to revascularization in patients with cardiogenic shock
within 18 hours of onset of shock.
• In patients with recurrent (stuttering) episodes of symptomatic
ischaemia.
• In patients recovering from myocardial infarction who have ischaemia
at a low level of workload with electrocardiogram (ECG) changes
(≥1 mm of ST depression).
Coronary angiography during valve assessment
• Diagnosing coronary artery stenoses can be difficult using non-​invasive
techniques in patients with significant valvular pathology.
• It remains routine practice therefore to consider diagnostic coronary
angiography in symptomatic patients who are undergoing assessment
for valve surgery.
 Indications for coronary angiography 7

• The small risks of the additional procedure are believed to be

outweighed by the potential consequences of missing severe coronary
disease.
• The information obtained should also be considered an important part
of overall surgical risk assessment.
• For example, the addition of coronary artery bypass surgery (CABG)
to aortic valve replacement in elderly patients significantly increases the
operative risk.
• In patients with mitral valve disease, undiagnosed coronary disease may
be the mechanism responsible for mitral regurgitation.
• Practice varies according to institution but a useful guide would be
to perform coronary angiography in all patients over the age of
40 years with one or more cardiac risk factors (e.g. diabetes mellitus,
hypertension, family history), in asymptomatic patients with suspected
myocardial ischaemia, and in patients with left ventricular systolic
dysfunction.
• In patients with endocarditis, coronary angiography is only
recommended before surgery in those with multiple cardiac risk factors
or in those with evidence of coronary embolization.
Other indications
There are other groups of patients who may benefit from cardiac catheter-
ization and/​or coronary angiography. These include:
• Patients with typical angina in spite of antianginal medication.
• Those with atypical chest pain and recurrent hospitalization.
• Patients who are unsuitable for non-​invasive testing.
• Patients with heart failure of unknown aetiology.
• Pilots and bus drivers with borderline investigations.
• Patients presenting with chest pain soon after coronary
revascularization.

It is extremely unusual for asymptomatic patients with no evidence of

cardiac ischaemia to undergo coronary angiography.
8 Chapter  Introduction

Cardiac CT or invasive angiography?

Two main factors have contributed to make invasive coronary angiography
the technique of choice for assessment of coronary anatomy so far:
• Good spatial resolution (allowing accurate imaging of small structures,
such as coronary vessels).
• Good time resolution (allowing accurate imaging of moving structures,
again such as coronary vessels).
Initially, no non-​invasive technique could match these standards. However,
this has changed with cardiac computed tomography (CT) allowing image
acquisition of up to 320 slices in one rotation, covering the complete
volume of the heart in one short breath-​hold. These features account for
significant improvement in both spatial and time resolution.
At the time this book was written, both European and American guidelines
recommended functional non-​invasive tests (cardiac magnetic resonance,
stress echocardiography, single-​photon emission computed tomography
(SPECT), or positron emission tomography (PET)) as a first-​line strategy
to assess ischaemia in patients with suspected CAD and to guide decisions
about revascularization. It should, however, be acknowledged that new evi-
dence about coronary CT-​derived fractional flow reserve and perfusion CT
is likely to evolve this.
The evidence collected so far has confirmed a consistent high sensitivity
and high negative predictive value of cardiac CT (which can go up to 100%).
The specificity and consequently positive predictive value, however, are sig-
nificantly lower (<50% in some studies) and strongly influenced by technical
and patient-​related factors.
When compared to invasive angiography, the diagnostic accuracy of car-
diac CT has been showed to be influenced by:
• Type of scanner (a 64-​detector row scanner is the minimum standard).
• Pretest CAD probability.
• High coronary artery calcium score.
• High heart rate.
• High body mass index.

For this reason and because of the strong negative predictive value, car-
diac CT is currently indicated mainly to rule out CAD.

Currently, these are the main indications for cardiac CT

• Ruling out CAD in patients without established CAD who present
with typical or atypical angina or with non-​anginal chest pain plus an
abnormal resting ECG.
• Ruling out stable CAD in patients with low to intermediate pretest
probability or after an inconclusive functional test.
• Ruling out coronary lesions in patients admitted with suspected acute
coronary syndrome and inconclusive ECG and cardiac-​injury markers.
• Assessing patency of saphenous vein grafts (they are less mobile than
native vessels, are larger in size, and tend to not develop calcified
atherosclerosis and for this reason are well assessed by cardiac CT).
 Cardiac CT or invasive angiography? 9

• Clarifying coronary anatomy, distal landing zone, and proximal cap

for optimal planning of revascularization in coronary chronic total
occlusions.
• Defining anomalous coronary origin and/​or anatomy, including
arteriovenous fistula.
Cardiac CT should NOT usually be considered in
• Patients with high pretest probability of coronary disease.
• High coronary artery calcium score (>1000).
• Large body mass index.
• Previous coronary stenting (CT accuracy for instent restenosis
decreases with stent size <3 mm diameter and thick-​strut stents—​first
generation).
Cardiac CT in transcatheter aortic valve intervention
Cardiac CT is a key step in the decision-​ making and planning of
transcatheter aortic valve intervention (TAVI) for aortic stenosis, by pro-
viding details about:
• Size, tortuosity, and disease of femoral and axillary arteries in guiding
vascular access selection.
• Aortic annulus sizing (diameter, area, and perimeter) for selection of
TAVI valve size and type.
• Aortic root and sinotubular junction sizing (relevant for self-​expandable
TAVI valve).
• Whole aorta anatomy definition with special regard for tortuosity,
atherosclerosis, and complex lesions (thrombus stratifications,
ulcerations).
• Degree of calcification of the aortic valve.
• Height of coronary artery ostia from the aortic annulus plane.
• Identification of angles for ideal angiographic working view.
10 Chapter  Introduction

Radiology equipment
The standard equipment to produce X-​ray-​based images in the catheter-
ization laboratory (CathLab) is based on the C-​arm fluoroscopic system. It
consists of an X-​ray generator and detector:
X-​ray generator
(X-​ray tube located on the lower part of the C-​arm, thus under the patient.)
The X-​ray generator or X-​ray tube consists of:
• Cathode (negative charge).
• Anode (positive charge).
• Evacuated glass insert.
• Tube housing.
• Collimators.
The cathode usually consists of a coil of tungsten wire which emits electrons
when heated by the passage of electric current. The electrons are acceler-
ated towards the anode by a high potential difference (measured in kilo-
volts (kV)). The anode is a rotating saucer-​shaped tungsten disc. When the
electrons emitted by the cathode interact with the anode, X-​rays (photons)
are produced (plus heat). The anode rotates to dissipate the heat produced
and the whirring noise usually heard coming from the tube is actually pro-
duced by the rotating anode.
All these reactions take place within an evacuated glass insert containing
both the cathode and the anode. The glass insert itself is contained within a
tube housing with internal lead walls. This lead lining presents a small radio-
lucent window allowing the beam of X-​ray to pass through. The housing
tube also presents collimators which are lead panels that can be moved in
by the radiographer to restrict the size of the X-​ray beam, thus limiting ra-
diation exposure to the field of interest only.
The energy of the X-​ray beam can be influenced by the operator/​radi-
ographer acting on:
• Voltage (kV) applied between the anode and the cathode.
• Current (milliampere (mA)) flowing from the cathode to the anode.
• Filtration (aluminium or copper filter at the exit of the X-​ray beam).
Increasing photon energy reduces radiation absorption (and thus radiation
dose) because photons are more ‘penetrating’. This, however, is associ-
ated with lower-​quality images since, due to less absorption, more photons
reach the X-​ray detector leading to lower image contrast. See Table 1.1.
Modern systems have an integrated dose rate control, aiming to modu-
late mA and kV in order to maintain a constant dose of radiation reaching
the detector, thus keeping the image quality steady when other settings (e.g.
projection angles) change.
 Radiology equipment 11

Table 1.1 Effects of changing kV

Effect on number of Effect on photon

photons
Energy
Increase kV + +
Increase mA + =
Increase filtration − +

X-​ray detector
(Located on the upper part of the C-​arm, thus above the patient.)
The X-​ray beam, generated by the X-​ray generator, passes through the
patient’s body structures, interacting with them mainly by the phenomena
of absorption and scattering. The resulting X-​ray beam, exiting from the
patient’s body, reaches the X-​ray detector where the image is generated.
There are two types of X-​ray detectors:
Image intensifier (old-​generation X-​ray detector)
Received X-​rays are converted into light by an input phosphor and light is
then converted into electrodes by a photocathode. The electrons are then
focused and intensified to interact with an output phosphor which recon-
verts electrons back into light which is then picked by a camera.
Flat-​panel detector (new-​generation X-​ray detector)
A phosphor screen converts X-​rays into light, which is then converted into
electrons. These electrons form the digital image.
12 Chapter  Introduction

Fluoroscopy and acquisition

Optimization is the process of ‘getting an adequate diagnostic picture with
the lowest practicable dose’. There are multiples strategies to address
image optimization and they can be grouped as follows:
Equipment-​based strategies:
• Dose rate control.
• Projection angles (shallow angles reduce exposure, since less patient
thickness and surface are exposed).
• kV and mA settings.
• Fluoroscopy (pulsed).
• Acquisition.
Technique-​based strategies:
• Patient position.
• As distant as possible from the X-​ray generator.
• As close as possible to the X-​ray detector.
• Collimation.
Broadly, fluoroscopy is defined as the technique used to obtain real-​time im-
ages of a body structure. During a CathLab procedure, two main modalities
are used to obtain images:
Fluoroscopy (or pulse fluoroscopy)
This provides real-​time imaging. It offers the benefit of lower radiation ex-
posure for the patient and the CathLab team. This is achieved through auto-
mated switching on and off of the X-​ray beam throughout the exposure.
In this way, a predefined number of images (frame) will be produced in a
time unit (second). The frame rate in pulse fluoroscopy is typically set at
7.5 frames per second (fps). Because of these settings, pulsed fluoroscopy
offers a lower image quality and it is ideal for scouting shots, wiring, and
balloon and stent delivery. Modern systems now allow storing of a few
seconds of fluoroscopy, eliminating the need to use acquisition purely to
store images.
The acquisition or ‘cine’ mode
This has a higher radiation dose and higher frame rate (usually from 12.5 to
30 fps (7.5 fps at the Oxford Heart Centre)). It is used to obtain a series
of high-​resolution images with reduced image noise. These images have
higher resolution and contrast and are saved for recording/​diagnosis pur-
poses. The number and length of acquisition or cine ‘runs’ is usually the
main source of patient radiation exposure in interventional cardiology pro-
cedures. This is why acquisition/​cine mode should be used sparingly.
Fluoroscopy and acquisition 13
14 Chapter  Introduction

Radiation safety
All staff performing cardiac catheterization and coronary angiography must
be familiar with local radiation protection procedures. There will be a des-
ignated Radiation Protection Supervisor who will check some basic paper-
work and issue dose meters so that radiation exposure can be monitored.
An interventional cardiologist will receive an appreciable amount of radi-
ation that may span several decades. It is important that this is accurately
monitored. Appropriate protective devices (% p.15) should be worn and
all exposures must be ‘as low as reasonably achievable’ (ALARA) (% p.15).
Basic dosimetric quantities
• Most background radiation is received from natural sources (87%),
particularly from radon gas and from gamma rays.
• Medical sources account for at least 10% of ionizing radiation.
• The absorbed dose is the energy absorbed per unit mass and is
measured in grays (Gy; 1 Gy = 1 joule (J)/​kg).
• The equivalent dose is the absorbed dose weighted by a radiation
quality factor and is measured in sieverts (Sv).
• The effective dose is that dose that would give the same level of risk if it
had been received uniformly over the whole body.
• Annual dose limits for an exposed worker aged over 18 years should be
less than 20 mSv (averaged over a 5-​year period).
• Typical annual whole body doses for an interventional cardiologist are
up to 5 mSv and for a radiologist 0.5–​1 mSv.
Biological effects
When ionizing radiation passes through tissue matter it undergoes inter-
actions and loses energy. The biological effects depend not only on the
total energy but also the type of radiation and how the energy is distrib-
uted. Some radiation is transmitted through the tissue and is attenuated
by the film to produce an image. Some radiation is scattered away from
the direction of the primary beam (scattered radiation). Some of the radi-
ation undergoes interactions within the tissue volume with the production
of ionized molecules and free radicals and with direct or indirect damage
to proteins, enzymes, and DNA. If enough cells in a tissue are killed or un-
able to function normally, there will be a loss of function of that tissue or
organ depending on the number of affected cells. These effects are called
deterministic effects and include cataracts, impaired fetal development, and
neurological and gut damage. In the cardiac CathLab, prolonged radiation
to a small area of skin may result in deterministic effects ranging from mild
erythema to skin ulceration. Damage to chromosomal DNA may lead to a
modified cell that can still reproduce, resulting in cancer. These effects are
called stochastic effects.
 Radiation safety 15

Ionising Radiation (Medical Exposure) Regulations 2017

In the United Kingdom, the use of ionizing radiation is governed by
the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) 2017.
Hospitals must define and hold a register of referrers (those entitled
to request procedures—​usually clinicians), practitioners (those respon-
sible for accepting requests (usually radiologists)), and operators (usually
radiographers). During cardiac catheterization, the cardiologist is often
the referrer, practitioner, and the operator. A clinical evaluation must be
recorded for all exposures, including fluoroscopy, and doses should be
audited. Hospitals are to be investigated regularly. If a radiation dose is
delivered that is greater than expected, the local radiation protection ad-
visor must be contacted. In cases of overexposure, plaintiffs could bring
an action under criminal (not civil) law.

Radiation protection
Most cardiac CathLabs will have viewing areas protected from the radiation
source by lead glass shields. There will also often be mobile shields for staff
and the operator. Lead gowns are usually one-​piece aprons or a separate
top and skirt. The latter may be better suited to those with back problems.
The amount of protection given by lead gowns is described as lead equiva-
lent (LE) and is measured in mm LE. Most gowns are 0.25–​0.35 mm LE.
The higher the LE, the heavier the gown. The amount of protection is also
dependent on the output of the radiation source. Lead rubber 0.35 mm LE
thyroid shields should be worn to protect the thyroid gland and lead glasses
to protect the eyes.

The inverse square law

The intensity of the radiation varies inversely to the square of the dis-
tance from the source, that is, stepping back from 1 m to 2 m away from
the source will reduce the radiation exposure by a factor of four.

ALARA
‘As low as reasonably achievable.’
There are two main modes of imaging in the cardiac CathLab: screening
and acquisition. X-​rays pass through the patient from the X-​ray source be-
neath the patient to the image intensifier. Screening uses low-​energy X-​ray
pulses to display a real-​time image on the screen. Screening is generally used
for catheter and wire positioning and manipulation. Image acquisition uses
a higher X-​ray dose and stores the images digitally to a hard disc (and often
to another medium such as a CD).
There are a number of ways in which the radiation dose can be minim-
ized and ALARA:
• Always think about radiation dose when putting your foot on the
screening pedal. Is screening absolutely necessary at this point?
• Ensure that the image intensifier has finished moving before screening.
16 Chapter  Introduction

• Keep the image intensifier as close as possible to the patient.

• Having the X-​ray source (beneath the patient) further away from the
patient reduces the dose to the skin.
• Low frame-​rate acquisitions may reduce dose at the expense of reduced
image quality—​uses may include screening for long interventional
procedures or during pregnancy.
• Use of magnification increases the dose rate to the patient’s skin.
Risk estimates to the patient
An assessment of the probability of inducing a fatal cancer can be made
using data from the survivors of nuclear bombs and from nuclear workers.
The normal lifetime risk of developing cancer (about one in three) must be
taken into consideration with these figures. See Table 1.2.

Table 1.2 Risk estimates to the patient by examination

Examination Typical effective Equivalent Additional lifetime

dose (mSv) background risk of fatal cancer
radiation
Chest X-​ray 0.02 3 days 1 in 1,000,000
Abdomen X-​ray 0.7 4 months 1 in 30,000
Lumbar spine 1.3 7 months 1 in 15,000
CT head 2.3 1 year 1 in 10,000
Coronary angiogram 6 2.7 years 1 in 3500
Radionuclide cardiac 6 2.7 years 1 in 3500
study (Tc-​99m)
Barium enema 7 3.2 years 1 in 3000
CT chest 8 3.6 years 1 in 2500
CT abdomen 10 4.5 years 1 in 2000
CT coronary angiogram 10 4.5 years 1 in 2000
Radiation safety 17
18 Chapter  Introduction

Dose excess
According to the IR(ME)R definition, an incident occurs when a patient re-
ceives an unintended radiation exposure or receives a radiation exposure
greater than intended.
• Near miss: an event which could have led to unintended exposure or
overexposure, which was promptly noted to allow preventative actions
to be put in place.
• Incident not requiring notification.
• Incident requiring notification.
In interventional cardiology, an overexposure is typically considered when
the total exposure is at least ten times greater than the intended dose. As
a general rule, the radiographer must warn the operator when 1 Gy of ra-
diation exposure has been reached. In these circumstances, the operator
is asked to record the degree of radiation exposure in the report and to
communicate it appropriately to the patient.
Radioprotection applies to CathLab staff and not only to patients.
Recommended limits of radiation exposure for CathLab staff are shown
in Table 1.3.

Table 1.3 Recommended limits of radiation exposure for CathLab staff

Effective dose Skin and Eye

extremities
Employee (mSv/​year) 20 500 20
Trainee (<18 years old) 6 150 15
(mSv/​year)
Dose limit for women of reproductive capacity is 13 mSv to the abdomen for any consecutive
3-​month period.
Dose excess 19
20 Chapter  Introduction

Patient preparation
History
• Prior to any invasive cardiac procedure it is vital to have clear
documentation of the indication for the procedure and the cardiologist
responsible.
• It is also important to record if any medical events have happened or
symptoms have changed since that decision was made.
• Prior interventional procedures should be reviewed, paying attention to
vascular access sites, choice of catheters, complications, and outcomes.
• If the patient has had coronary artery bypass graft (CABG) surgery then
the operation note should be made available (% p.166).
• Echocardiography results should be noted.
• The patient’s drug history should be reviewed and allergies (or lack of )
recorded.
• Often this information is performed at a pre-​admission clinic but can be
obtained on the morning of admission.
• The patient’s fasting status should be confirmed.
• After appropriate discussion of risks (% p.278) and benefits, consent for
the procedure should be obtained and documented according to local
guidelines.
• Both groins should be shaved if femoral cannulation is planned.
Investigations
• A brief physical examination should be performed, noting in particular:
• Pulse and blood pressure.
• The presence or absence of peripheral pulses.
• Any evidence of pulmonary congestion (i JVP, basal crackles).
• Results of recent blood tests should be available. As a minimum, this
should include a blood count, assessment of electrolytes, renal function,
and glucose.
• Lipid status should be documented.
• Anticoagulation status should be obtained in patients who have been
taking warfarin.
• A 12-​lead ECG should be performed prior to cardiac catheterization (to
act as a baseline).
• Patients should have a venous cannula inserted for the administration of
sedation, intravenous (IV) fluids, and emergency drugs (preferably in the
left arm).
Special considerations
Antiplatelet therapy
Most patients undergoing coronary angiography will have suspected CAD
and will already be on antiplatelet therapy (with aspirin and/​or clopidogrel).
Patients who are due or expected to undergo PCI are usually preloaded
with clopidogrel 300–​600 mg according to local policy (% p.218).
Anticoagulation therapy
(% p.64.)
 Patient preparation 21

Warfarin is typically withheld for 3–​5 days prior to the procedure. Most
operators would be comfortable with an international normalized ratio
(INR) of less than 2. In patients who require continuous anticoagulation
(e.g. mechanical mitral valves), IV unfractionated heparin is recommended
and stopped 2 hours before the procedure. Patients on subcutaneous low-​
molecular-​weight heparin can have the dose omitted on the morning of
the procedure.
Impaired renal function
See % p.312 for detailed management. Patients with known renal impair-
ment (particularly patients with diabetes mellitus) should be well hydrated
prior to cardiac catheterization. Some cardiac centres also recommend
giving N-​acetylcysteine. Contrast load should be minimized and consider-
ation made for non-​ionic, hypo-​or iso-​osmolar contrast agents (% p.79).
Biplane imaging may reduce the number of contrast injections required.
Diabetes mellitus
Patients requiring insulin or oral hypoglycaemics should be placed early
on the procedure list. The morning dose of insulin and short-​acting oral
hypoglycaemics can be withheld on the morning of the procedure. Close
monitoring of the capillary blood sugar level should be performed. The pa-
tient should be encouraged to eat and drink once recovered and return to
their usual medication regimen. Patients on metformin have a very low risk
of lactic acidosis if renal function is normal; however, it is recommended to
withhold metformin for the day prior to the procedure and for 2 days after.
22 Chapter  Introduction

Catheter laboratory preparation

Personnel
The cardiac CathLab personnel usually consist of a specialist nurse, a car-
diac physiologist, a radiographer, and a cardiologist. Each will have defined
roles in preparing the patient for cardiac catheterization. It is important that
the team understand these routines before commencing a case (e.g. who
would defibrillate in the event of ventricular fibrillation (VF)?). It is good
practice to observe a number of procedures in a cardiac CathLab when
changing hospital as routines vary from place to place. It is also important
to have an understanding of the local resuscitation guidelines in addition
to knowing the whereabouts of resuscitation equipment and emergency
drugs. Most centres would teach this as part of the induction process.
Patient
• The patient will need to be checked in by a member of the team and
correctly identified.
• The consent form should be checked and the signature confirmed with
the patient.
• Female patients of child-​bearing age would need to confirm that they
are not pregnant.
• Before commencing the procedure, review the notes to ensure that the
investigation is still clinically indicated.
• Introduce yourself in a confident, professional manner and remember
the patient’s name.
Equipment
Once the patient is positioned on the table:
• Wear protective equipment (masks/​hats) according to local policy.
• Ensure venous access has been obtained.
• Ensure a good-​quality continuous ECG recording.
• Check the pulse oximetry trace and confirm adequate oxygenation
(SaO2 >96% on room air).
• Give supplemental oxygen to high-​risk patients or those receiving high
doses of sedation (see ‘Pre-​medication’).
• Wear lead protection (% p.15) and a sterile scrub suit.
• Prepare and drape the vascular access site using an aseptic technique.
Check with the nursing staff about local procedure.
• Check the pressure manifold has been adequately flushed (% p.76) and
that contrast has been run through (% p.76) without air bubbles.
• Ensure that the pressure transducer has been calibrated.
• Check the sterile trolley, ensuring that all necessary equipment is
present (% p.76 and p.77).
 Catheter laboratory preparation 23

Pre-​medication
Some patients are understandably anxious before cardiac catheteriza-
tion. Short-​acting benzodiazepines are useful to alleviate anxiety (and the
associated hypertension) in the CathLab. Diazepam (given as Diazemuls
2–​10 mg IV) or midazolam (0.5–​2.5 mg IV) can be given as the patient
arrives on the table. Care should be taken in the elderly, in patients with
advanced airways disease, in patients with significant co-​morbidity, and
in the obese. Additional sedation can be given with small aliquots of a
short-​acting opioid (e.g. fentanyl 25–​50 mcg).
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pulling them to me, I tied four of ihem fest together at both ends, as
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pieces of plank upon them, crosswise, I found I could walk upon it
very well, but that it was not able to bear a y great weight, the j
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saw I cut a spare topmast into three lengths, •ad added them to my
raft, with a great deal of labor and pains. But the hope of furnishing
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five pieces of dried goat's flesh (which we lived much upon), and a
little remainder of European com, which kad been laid by for some
fowls which we had brought to sea with OB, but the fowls were
killed. There had been some barley and wheat together, but, to my
great disappointment, I found afterward diat the rats had eaten or
spoiled it alL As for liquors, I found sev* •ral cases of bottles
belonging to our skipper, in which were some 5«rdial waters ; and,
in all, about five or six gallons of rack. These J stowed by
themselves, there being no need to put them into the ftheets, nor
any room for them. While I was doing this, I found the Mde began
to flow, though very eahn ; and I had the mortification to i^*e my
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belonging to the boat, and besides the tools which were in the
chest, I found two saws, an axe, and a hammer ; and with this
cargo I put to sea. For a mile, or thereabouts, my raft went very
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upon a shoal, and not being aground at the other end, it wanted but
a little that all my cargo had slipped off toward that end that was
afloat, and so fallen into the water. I did my utmost by setting my
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sides, and a strong current or tide running up. I looked on both sides
for a proper place to get to shore, for I was not willing to be driven
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guided my raft, and at kst got 60 near, as that reaching ground with
my oar, I could thrust her ' directly in ; but here I had like to have
dipped all my cargo Into the SM agtun ; lor that shore lying pretty
steep, that is to eay, sloping, there was no place to land but where
one end of my float, if it ran on shore, would lie so high, and the
other sink lower, as before, that it Would endanger my cargo again.
All that I could do was to wait till tiie tide was at the highest,
keeping the raft with my oar like an anchor to hold the side of it fast
to the shore, near a flat piece of ground which I expected the water
would flow orer , and so it did. A.B soon as X found water enough,
for my raft drew about a foot of water, I thrust her upon that flat
piece of ground, and there fastened or moored her, by sticking my
two broken oars into the ground, one on one Bide, near one end,
and one on the other side, near the other end | thus I lay till the
water ebbed away, and left my raft and all my cargo safe on shore.
My next work was to view vlte country, and seek a proper place foj
toy habitation, and where to stow my goods, to secure them from
what* ever might happen. Where I was I yet knew not — whether
on the con* tinent or on an island — whether inhabited, or not
inhabited— whethet in danger of wild beasts, or not. There was a
hill, not above a mil» from me, which rose up very steep and high,
and which seemed to over lop some other hills, which lay as in a
lidge from it, northward. I took out one of the fowling pieces and
one of the pistols, and a horn of powder, and, thus armed, I
travelled for discovery up to the top of that hill ; where, after I had,
with great labor and difBoulty, got up to the top, I saw my fate, to
my great affliction, viz. : that I was on an island, environed every
way with the sea, no land to be seen, except Bome rocks, which lay
a great way off, and two small islands, less thi this, which lay about
three leagues to the west. I found also that the island I was in was
barren, and, as I saw good] teason to believe, uninhabited, except
Ijy wild beasts, of whom, how-, ever, I saw none ; yet I saw
abundance of fowls, but knew not their' linds ; neither, when I killed
them, could I tell what was fit for food, Mtd what not. At my coming
back, I shot at a g'-'^^t bird which I eaw Bitting upon a tree, on the
side of a great wood I believe it was the flrst gun that had been fired
there since the creation of the world. I had no sooner fired, but from
all parts of the wood there arose on isinumerabl* number of fowls,
of many sorts, making a confused Bcixamlng, and crying, every one
according to his usual note but not
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one or tnsai of aay kincl that I knew." As for ila& creatuM I

kiUad, 1 *
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I vna 'Qc.dey soma approheiKion lest, during my a1cniou%

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Bnt 4bi»« irhieh comforted me still more was, that, last of

all, aftet tbad made five or six Ruch Toyages as these, aud though I
had nothing more to expect from the ship that was worth my
meddling with, 1 say, after all this, I found a great hogshead of
bread, and three largt ranlets of rum or spirits, and a box of sugar,
and a barrel of fine fiour; this was surprising to me, because I had
given over expecting; any more provisions, except what was spoiled
by the water. X aoon smptied the the hogshead o^that bread, and
wrapped it up, i-aroel by parcel, in pieces of the aaili, •srbieh I cut
ont — and, in a word. I got all ibis safe on shore also. The next day
I made /mother voyage, and now having plundered the ship of what
was portcbla and fit to hand out, I began with th« cables, and
cutting the great cable into pieces sueh as I could move, I got two
cables and a hawsei on shore, with all the iron work I could get, and
having cut down the spritsail yard, and the mizen-yard, and
OMerything that I could, to make a large raft, I loaded it with all
those heavy goods, and came away ; but my good luck began now
to leavo me, for this raft was so unwieldy, and so overladen, that
after I was entered the little cove, where I had landed itie rest of my
goods, not being able to guide it so handily as I did the other, it
overset, and throw me and all my cargo into the water ; as for
myself it was no great harm, for I was near the shore ; but as to my
cargo, it was a great part of it lost, especially the iron, which I
expected would hav« been of great use to me ; however, when the
tide was out, I got most of the pieces of cable ashore, and some of
the iron, though with infinite labor, for I was fain to dip for it into the
water, a wo* . whicli fatigu' d me very much. After this I went every
day on boar:3, and broug'-.t away what I could get. I lad now been
thirteen days ashore, and had been eleven times on board the ship ;
in which tima I had brought away all that one pair of bands could
well be supposed capable to bring : though I verily believe had the
calm weather held, I should have brought away the whole ship,
piece by piece, but preparing the twelfth time to go on board, I
found the wind began to rise. However, at low water, I went on
board ; and though I thnught I had rummaged the cabin so
eftectually as that nothing could be found, yet I discovered a locker
with drawers in it, in one of which I found two or three razors, and
one pair of large scissors, with some ten or a dozen of good knives
and forks ; in another I found about thirty-six pounds in uioney,
soma European coin, '•""ua Brazil, some pieces of eight, som9 gold,
tind eoiuft wlver.
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6S ' ^ACvHirTcrBEs of i iasfldd tQ layaalf at the sight of tlik

money. " O drt^," J «»• olaimed, " what art thou good for ? Thou art
not worth t& m«, no, not th« taking oif the groimd ; one of those
knives is -worth all thia heap. I have no manner of use for thee ;
e'en remain where thoa arti and go to the bottom, as a creature
whose life is not -worth saving." Eowever, upon second thoughts, I
tooli it away ; and wrapping all tki« in a piece of canvas, I began to
think of makingTmothor raft ; but while I was preparing this, I found
the sky overcast, and the wind began to rise, amd in a quarter of an
hour it blew a fresh gala from the shore. It presently occurred to
me, that it was in vain to pretend to make a raft with the wind off
shore ; and that it was my business to be gone before the tide or
flood began, c* otherwise I might not be able to reach the shore at
all Accordingly I let myself dowa intf» the water, and swam across
the channel which lay between the ship and the sands, and even
that with difficulty enough, partly with the weight of the things I had
about me, and partly the roughness of tho water ; for the wind rose
very hastily and before it was quite high water it blew a storm. But I
was got home to my little tent, where I lay, with all my wealth about
me very secure. It blew very hard all that night, and in tho morning,
when I looked out, behold no more ship was to be aaeo. 1 I was a
little surprised, but recovered myself with this satisfactory reflection,
viz., that I had lost no time, or abated no dil« igence, to get
everything out of her, that would be useful to me, and that, indeed,
there was little left in her that I was able to bring awa> if I had
more time. I now gave over any more thoughts of the ship, or of
anything out of ker, except what might drive on shoye from her
wreck ; as indeed, divers pieces of her afterward did ; but those
things were of small use to me. My thoughts were now wholly
eaxiployeA about securing myself against either savages, if any
should appear, or wild beasts, if any were in the island ; and I'had
many thoughts of the method how to do this, and what kind of
dwelling to make ; whether I should make a cave in the earth, or a
tent upon the earth ; and, in short, I resolved ©B both ; the manner
and description of which, it may not be im« proper to give an
account of. I soon found the place I was in was not for my
settlement, particu. larly because it was upon a low, moorish grouad,
near the sea, and I belirved it would not Lo wholesome ; and more
particularly because there was no fresh water near It ; so I resolved
lo find a move haalthy and more convenient spot of groimd.
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BDBtNSON (HSUSOtf ^ f o«H9«>^j^ sereral tftfogs m mj

siluatfon wlloli I foimd ifOaM ba j^per f0F me ; first, air and fresh
water, I jaat novr mentioned ] ssooadlj, shelter from ths heafc of the
sun ; thirdly, security from raTonotla oreattires, "whether men or
beasts ; fourthly, & view to ths MA, that if God Bent any ship in
sight, I might not lose any ad« -vantage for my deliverance, of which
I was not willing to banish all Bay expectations yet. la search of a
place propwr for this, I found a little plain on t^Q riA« of a rising hill,
whose front toward til&R little plain was as steep u a house-side, so
^hat nothing could •ome down \ipon me from tha top. On the side
of this rook, there waa a hollow place, worn a littlt ruij in, like the
entrance or doo>- of a oare ; but there was not really axkj care, or
way into the rook at all. On the flat of the green, just before this
hollow place I resolved to ^tch my tent. This plain was not above a
hundred yards broad, and about twice as long, and lay like a green
before my door ; and, &t the end of it, dsBcended irregularly every
way down Into the lo^* ground by the sea-sida It was oa the N. N.
W. side of the hill ; so that It was sheltered frona the he£bt every
day, till jit came to a W, tad by S. bub, or thereabouts, which, la
those countries, is near the tetting. Before I Bet up my tent, I drew
|b half-circle before l6e hoUov plaee, whioh took in about ten yards
in its semi-diameter from tha reck, and twenty yards in its diameter
from its beginning a&A ending. In Biis half-cirole I pitched *wo rows
of strong stakes, drivtfig &em into the ground till they stood vary*
firm like pileai, the bigg.esft oftd being out of the ground, aboi^ ive
feet and a half, and sharpened Ml the top. Tlks ft^re rows 4&d aot
stand above sis inches from oaa w&other. Then I took the pieces t f
cable #hich I cut in the ship, and laid (ham in rows, one upon an
another, within the circle, between thesa two rows of stakes, np t»
the to^ placing other stakes in the inside, leaning against them,
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llmif^i ttom «n th« world, and eo»^,»qQentl7 slept taotvf

in ^ night wbieb otherwise t could not bav« done ; though, as it
appeared after Provlslenst etc.. into IU» Ealritttloa— SrdcriaMa Sf
SoUtutlw Consolatorj ti«fiactloiiiNTO this fence, or fortress, with
infinite ia'bor, I carried a]9 my riebes, all my proTlsions, ammonition,
and Btores oi which you have the account above ; and I made a
larga ten^ which, to preserre me from the rains, that in one part of
tht year are very violent there, I made double, viz : one Bmaller tent
within, and one larger tent aoove it, and covered the uppermost with
• large tarpaulin, which I hud saved among tha iMils. And now I lay
no more for awhile in the beoi which I had bronghl •o ehore, but in
a hammock, which waa indeed a very good one, and fc«longed to
the mate of the ship. Into this tent I brought all my provisions M«d
everything that would •poll by the wot, and having thus enclosed alii
my goods I made up the entrance, which till now I had left open,
and bo passed and repuKsed, fw I said, by a short ladder. When I
had done this, I began to work my way into th* rrvjk, and Vringing
all ttie earth and atones that I dug down o«i tbtough my im-U 1 laid
them up within my fence in the nature of a terrace, 89 that it raised
the ground «nthLn about a foot and a half, and thus 1 made me a
eeve just lK>nind my tent, which served mre I must go back to
■oxaie oi::di- things which took up some of my thoughts. At the
same time it happened, after I had laid my scheme for the setting
up my Itent, and making the cave, that a storm of rain falling from a
thick, oark cloud, a sudden flash of lightning happened, and after
that a groat clap of thunder, as is naturally the effeitt of it. I was not
so much surprised with the lightning as I was with a thought, which
darted into my mind as swift aa the lightning Uself— 0, my powder!
My very heart sank within me when I thought that, at one blast, alj
•aj powder might be dasboyed t On whioh, aet my def anot wUj, hvt
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BOfimsoM oBusoa^ 71 > Ibe pr6yid!iBg m« food, as I

thoaght, entirely dep«nded. I wai aotking near so anxious about my
own danger, though, had the powder taken fire, I should never have
known what had hurt me. Such impression did this make upon me,
that after the storm wa* over I laid aside all my works, my building
and fortifying, and appU> ed myself to make bags and boxes, to
separate the powder, and to keep it a little and a little in a parcel, in
hope that whatever might oome it might not all take fire at onoe,
and to keep it so apart that it should not be posi'ible to make one
part fire another. I finished this work is about a fortnight, and I think
my powder, which in all was about two hundred and forty pounds
weight, waa divided into not lesa than » hundred parcels. As to the
barrel that had been wet, I did not apprehend any danger from that,
so I placed it in my new cave, which in my fancy I called my kitchen,
and the rest I hid up and down in holoi among the rocks, so that no
wet micrht oome to it, marking very ear** fully where I laid it. In
the interval of time while ti^iB waa doing, I went out at leas6 onoe
every day with my gun, as well to divert myself as to see if I Gould
kill anything fit for food, and as near as I could, to acquaint mjisclf
with what the island produced. The first time I went out, I presently
discovered that there were goats upon the island, which was a great
satisfaction to me ; but then it was attended with this misfortune to
me, viz., that they were so shy, so subtle, and so swift of foot, that it
was the most difficult thing in the world to oome at them ; but I was
not discouraged at this, not doubting but I might now and then
shoot one, as it soon happened, for after I had found their haunts a
little, I laid wait in this manner for them : I ebservedf if they saw me
in the valleys, though they were upon the rocks they would run
away as in a terrible fright ; but if they were feeding in the valleys,
and I was upon the rooks, they took no notice of me, from whence I
concluded that, by the position of their optics, their sight ▼as 60
directed downward that they did not readily see objects that were
above them, so afterward I took this method I always climbed the
rocks first, 4o get above them, and then had frequently a fair mark.
The first shot I made among these creatures I killed a aha goat,
which had a little kid by her, which she gave suck to, which grieved
me heartily ; but when the old one fell the kid stood stock still by her
till I oame and took her up ; and not only so, but when X carried the
old one with me, upon my shoulders, the kid follvwed me quite to
my enclosure ; upon which I laid doirn the dam and took the Jdd in
mj arms and carried it over my pale, in hopes to hare bred U
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up tafi^e, btti it would not eat, so I was fotced to kill it •nd

«at it is&i^ self. These two supplied me Tdth flesh a great vhile, for
I eat sporo iagly, and preserved my provisions (my bread especially)
as mtieh as I possibly could. Having now fixed my habitation, I
found it absolutely neo«(Bsary to provide a place to make a fire in,
and fuel to bum ; and what I did for that, as also how I enlarged my
cave and what conveniences I made, I shall give account of in its
proper place, but I must first give som-J little account of myself, and
of my thoughts about living, which it DMiy well be supposed were
not few. I had a dismal prospect of my condition, for as I was not
cast away upon that island without being driven, as is said, by a
yiole&t storm, quite out of the course of our intended voyage, and a
great wt^y, viz., some hundreds of leagues out of the ordinary
course of the trade of mankind, I had great reason to consider it as
a determination of Heaven that in this desolate place, and in this
desolate manner, I fihould end my life. The tears would run
plentifully down my face when I made these reflections ; and
sometimes I would expostulate ■orith myself why Providence should
thus completely ruin its creatures, and render them so absolutely
miserable, so abandoned without help, BO entirely depressed, that it
could hardly be rational to be thankful for such a life. But something
always returned swift upon me to eheek these thoughts and to
reprove me ; and particularly one day, walking with my gun in my
hand by the sea side, I was very pensive upon the subject of my
present condition, when reason, as it were, expostulated with me
the other way, thus : "Well, you are in a deaolatd condition, U is
true, but pray remember, where are the rest of you? Did not you
come, eleven of you, into the boat? Where are the ten ? Why wer«
thoy not saved and you lost ? Why were you singled out? Is it
better.to be here or there? " And then I pointed to the sea. All evilf
axe to be considered with the good that is in them, and with what
wena attends them. Then it occurred to me again, how well I was
furnished for nay snbnstence, and what would have been my case if
it had not happened (which was a hundred thousand to one) that
the ship floated fn>a the place where she first struck, and was
driven so near to the shore that I had time to get all these things
out of her ? What would bare been xty case if I had been to have
lived in the condition in which I at first eame on shore, without
necessftiies of life, or neoeaaaries to supply and procure them?
Particularly, said I aloud (thou^^ to n^s«lf>» what
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jaoBmsoN CRUSOE. 78 Bbould I hav* 4on« without a gun,

without ammuiiition, wlthons aay tools to mak« anything, or to work
\nth, without elothee, bedding, a tent, or any manner of, covering ?
and that now I had all tb(»o to a Bufflcient quantity, and was in a
fair way to provide myself in suoh a manner as to live without nay
gun when my ammunition was spent, so tJaat I had a tolerable view
of subsisting without any want, as long aa I lived ; for I oonsidered,
from the beginning, how I would pi^jvide for the aooidents that
might happen, and for the time that was to come, not only after my
ammunition should be spent, but even after my health or strength
should decay. I confess I had not entertained any notion of my
ammunition being destroyed at one blast — I mean my powder
being blown up by Ii|[hining — and this made the thoughts of it so
surprising to me when it lightened and thundered, as I observed just
now. And now being to enter into a melancholy relation of a scene
of silent life, such perhaps as was never heard of in the world
before, I shall take it from its beginning and continue it in its order.
It was by my account, the 30th of September, when, in the manner
as above said, I first set foot upon this horrid island ; when the sun,
being to us in its autumnal equinox, was almost just over my head ;
fov I reckoned myself, by observation, to be in the latitude of nine
degrees twenty^ two minutes north ot the line. €l^^ttx Bthn.
BebinNc'i siodt tf Beoko&iaS Time— Difioulti&s ejlaizg from Want
FTBE I had been there about ten or twelve days. It eaoaa into my
thoughts that I should lose my reckoning of time for want of books
and pen and ink, and should even forget the Sabbath days from the
working days ; but to prevent this I mxi it with my knife upon a large
post in capital letters and making it into a great cross, I set it upon
the shore where I first landed, via : " I oame on shore here on the
30th of September, 1669. " Upon the sides of this square post I cut
every day a notch Yrith my knife, and every seventh notch was as
long again as the rest; and e/7«rj first day of the month as long
again as that long one ; and thus I kept my calendar, or weekly,
monthly, and yearly reckoning cf time.
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T4 iaBTKNTtrBES o» Bnt it bnpi>«D«4, tbfti anong the

many things -which I toought out ©f the ship, in tha Beveral
voyages which, as above mentioced, I mftde to ii, I got »ev«ral
things of less value, but uot all less usefnl to me, which I found
some time after, in rummiiging the chests ; aa in particulflx, pens,
ink, and paper ; several pai-cels in the captain's mate's, gunner's
and oarpanter's keeping ; three or four compasste, some
mathematical instruments, dials, perspective charts, and bookfl of
navigation : all of which I huddled together, whether I might want
them or no ; also I found three very good Bibles, which came to me
in my cargo from England, and which I had packed up among my
things ; some Portuguese books also, and among them, two or three
popish ~rayer books, and several other books, all which I carojfnlly
secured. And I must not forget that we had in the ship a doj and
two oats, of whose eminent history I may have occasion to say
something in its place ; for I carried both of the oats with me ; and
as for the dog he jumped out of the ship himself, and swam on
shore to zne the day after I went on shore with my first cargo, and
was a trusty servant to me for many years ; I wanted nothing that
he could fetch me, nor any company that he could make up to me, I
only wanted to have him talk to me, but that would not do. As I
observed before 1 found pens, ink, and paper, and I husbanded
them to the utmost; and I shall show that while my ink lasted, I kept
things very exact, but after all that was gone, I could not ; fo* I
conid not make any ink by any means that I could devise. And this
put me in mind that I wasted many things notwithstandifig all that I
had amassed together ; and of these, this of ink was one ; M also a
spade, pickaxe, and shovel to dig or or remove the earth ; needles,
pins, and thread ; as for linen, I soon learned to want that without
much difficulty. This want of tools made every work I did go on
heavily ; and it was feaar a whole year before I had entirely finished
my little pale, or furrounded my habitation. The piles or stakes,
which were as heavy M I oould well lift, were a long time in cutting
and preparing in tha woods, and more, by far in bringing home ; so
that I spent sometimes two days in cutting and bringing home one
of those posts, and a third day in driving it into the ground ; for
which purpose, I got a heavy pieoe of wood, at fijst, but at last
bethought myself of one of the iron erowB, which, however, though
I found it answer, made driving thaa* posts or piles very laborious
and tedious work. But what need I have b0«n oonoemed at the
tediousness of ooything I had to d* ; HMfaxg X had tLne eaoxigh to
do it ki ; not had I any other «mpl0jr<
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BOBtNSOir CBTTSOB. TS H that bad bd«a over, at least that

I could foresee, MCMpt th^ tuBging the island to seek for food ;
\rhioh I did, more er less, every day. I now began to consider,
serioosly, my condition, and the oironm^ stances I \vag reduced to ;
and I drew up the state of my af&irs in rriting, not bo much to leave
them to any that were to oome after m« ifor I was like to have but
few heirs'), as to deliver my thoughts from 4aily poring upon them
and afflicting my mind ; and as my reaaoa fcagan to master my
desponaency, I began to comfort myself as well as I could, and to
set the good against the evil, that I might hav« ■omething to
distinguish my case from worse ; and I stated very im< partially, like
debtor and creditor, the comforts I enjoyed against tht saiaeries I
suffered, thus : I am oast upon a horrible desolate island, void of all
hope of recovery. I am singled out and separated, as it were, from
all the world, to be miserable. GOOD. '£nt I am alive ; and not
drown* ed, as all my ship's oompan/ were. But I am singled out too
fron» &11 the ship's crew, to be spared from death ; and He, that
miracu^ lously saved me from death, cai| deliver me from this
condition. I am divided from mankind, a But I am not starved and
per•olitaire ; one banished from hu- isliing in a barren place,
affording man society. no sustenance. I have no clothes to cover me.
But I am in a hot climate, where if I had clothes, I could hardly wear
them. T am without any defence er But I am cast on an island
means to resist any violence of where I see no wild beasts to hurt
man or beast. me, as I saw on the coast of Africa ; and what if I had
been ship*, wrecked there ? I have no sonl te epeak to or But God
wonderfully sent the ship in near enough to the shore, that I have
got out so many ndoa»Bary things, as will either supply aa^ wants,
er enable me t« supply pi^elf, even as leog as I liv^
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