Diagnostic procedure of dsa and management of its

DSA detail common procedure and complications

1. Diagnostic procedure of DSA and management of its complications Dr bhavin j patel Sr neurology Gmc kota

2. Introductio n Egas moniz was first to perform cerebral angiography in 1927. Cerebral angiography is a procedure by which the intracranial and extracranial head and neck circulation is evaluated.

3. Indications

4. Vascular anatomy

5. Checklist

6. Checklist

7. Checklist

8. Material requires in DSA Femoral sheath & Needle Cathaters :- Diagnostic Guiding Microcathater Guide wire Contrast

9. DSA Procedure Arterial puncture and sheath access Aortic placement and selective catheterization of supraaortic arteries Catheter flushing Projections for image acquisition Contrast injection Hemostasis

10. Arterial puncture and sheath access R outes available:- Femoral----- most commonly used Radial Brachial Carotid Local anesthetic injection should be give before puncture. Immediately after sheath insertion mixture of heparin( 5000 IU/ml), lidocaine (2%, 1 ml) and nitroglycerin (0.1 mg) is infused to prevent or relieve vasospasm.

11. Arterial puncture and sheath access Femoral artery access:- 18-19 G needle is used 4-8 fr femoral sheath with 20 cm length. 40 or 80 cm femoral sheaths are used for tortuous artery. Advantage of sheath:- Makes manipulation easier Reduce incidence of bledding

12. Femoral artery access:- Access site determination methods:- Manual method Fluoroscopy guided Ultrasound guided

13. Arterial puncture and sheath access Radial artery access:- Indication:- difficult femoral artery access due to occlusive disease To visualize right subclavian artery in difficult access to it Before considering radial art access patency of palmer arch should be confirmed. Landmark:- 2 cm cephaled to radial styloid process 21 G needle should be used.

14. Aortic placement and selective catheterization of supraaortic arteries Guidewire is advanced into abdominal aorta, thoracic aorta and arch of aorta. Diagnostic catheter then advanced over guide wire till arch of aorta. Guidewire is then withdrawn and catheter is manipulated in such a way that it allows engagement of origin of supra aortic vessels.

15. Aortic placement and selective catheterization of supraaortic arteries Once origin is engaged then guidewire is advanced in distal common carotid or subclavian artery. Again then diagnostic catheter is advanced over guidewire into desired position and the guidewire is withdrawn. Road mapping technique allow adequate positioning of guidewire and diagnostic catheters.

16. Aortic placement and selective catheterization of supraaortic arteries

17. Aortic placement and selective catheterization of supraaortic arteries

18. Aortic placement and selective catheterization of supraaortic arteries Types of catheter and its use:- Pigtail :- aortogram Davis catheter:- normally used catheter for cerebral angiogram Simmons 2:- used in older patient with tortuous artery Simmons 1:- used when angio performed through radial route Headhunter:- greater stiffness and used for difficult right subclavian artery.

19. Catheter flushing I t is very important to prevent clotting of blood in catheter. To prevent thromboembolic complications For ease of contrast injection or catheter manipulation. Two methods :- Continuous irrigation system Intermittently double flushing the catheter with syringes every 90 seconds

20. Continuous irrigation system

21. Projections for image acquisition Optimal positioning, magnification, and filming rates are necessary to provide sufficient information regarding the disease and vascular territory. Frame rate :- 2 / sec for arterial and 1/ sec for venous phase Aortic arch study:- 20-25 degree LAO Carotid bifurcation and vertebral:- AP and lateral view

22. Projections for image acquisition Posterior circulation:- townes view Ant communicating and MCA art:- Caldwell’s view / submento vertex/ tilt lateral view PICA and vertebrobasilar Junction:- Townes angle biplane oblique Three dimensional rotational angiography has recently substitute need of the multiple image acquisition.

23. Contrast injection Visualization of an artery angiogram requires that injected contrast be the equivalent of approximately 30% of the volume of flowing blood Recommended injection volume and rate:- Internal carotid and vertebral art:- 8 ml at 6 ml/s External carotid artery:- 6 ml at 4 ml/s Common carotid and subclavian :- 10-12 ml at 8 ml/s Aortogram :- 40 ml at 15 ml/s

24. Hemostasis After removal of catheter and sheath manual pressure is applied at the site of puncture. Two methods:- Manual compression Vascular closure device Trials have shows mixed result regarding use of closure devices.

25. Post procedure Bed rest for 4- 6 hours Give IV fluid atleast 4-6 ml/kg/ hr for initial 6-12 hrs. Neurological and vascular examination Repeat renal function test and APTT

26. Neurological Complication Ischemic stroke / TIA (Most common Neurological complication ) Thrombosis within the catheter with subsequent embolization . Mechanical disruption of aortic or supra-aortic vessel plaque . Dissection of the catheterized vessel with subsequent thrombosis and embolization secondary to wire or catheter manipulation . Air embolism

27. Neurological Complication Transient Global Amnesia and Cortical Blindness Aneurysmal Rupture During Angiography

28. Risk Factors Patients older than age 70. Patients whose angiograms require a higher volume of contrast. Patients whose angiograms last more than 60 to 90 minutes or require multiple catheters. Patients whose angiogram was performed by a fellow alone.

29. Risk Factors Patients with systemic hypertension or renal impairment. Patients referred for subarachnoid haemorrhage or who are immediately postoperative.

30. Disease Related Complication In analysis of three prospective studies Permanent and transient complications was significantly lower in patients with SAH compared to TIA or stroke (1.8% versus 3.7%). Aneurysm/AVM without SAH compared with TIA or stroke (0.3% versus 3.7%).

31. Microemboli and Microbubbles Emboli may represent dislodged Atheromatous material Thrombus from the catheter Air bubbles. Transcranial Doppler (TCD) - reveal much about cerebrovascular physiology and intraprocedural events.

32. Ct SCAN OF A CHILD WITH AIR EMBOLISM

33. Treatment If large enough to be detected fluoroscopically, and the vessel is easily accessible, aspirate using microcatheter and flush the vessel with heparinized saline to break up the remaining bubbles. Quick and readily available (though unproven) methods Use of transcranial Doppler (to agitate and break up bubbles), Heparinization (to prevent clot from forming in vessels stagnating from the air) Administration of oxygen and induction of hypertension

34. Treatment If available, hyperbaric oxygen chambers have shown good outcomes. Started within 6 hours / After 6 hours - Outcome 67% / 35%. When in doubt, a variety of methods can be used simultaneously, including hyperbaric oxygen plus induction of barbiturate coma to attempt to protect the brain. The most important thing is to recognize that air emboli have occurred and then use whatever treatment modalities that are available.

35. Catheter related thrombosis Treatment Arterial pressure should be raised. Visible thrombus may be treated by mechanical lysis using a guide wire. Thrombolytic agent – tPA . Recanalisation rate-44%. Antiplatelets before procedure.

36. Catheter related vasospasm Prevents adequate positioning of catheter. Also cause vasospasm induced cerebral hypoperfusion . Rx – intraarterial 2% lidocaine (20mg diluted in 10 ml saline) Nicardipine (1 mg in 10 ml saline)

37. Transient Global Amnesia and Cortical Blindness Transient global amnesia after cerebral angiography – reported rare but not so rare. Some of these appear to be idiosyncratic to the patient, for instance, direct toxicity in the setting of compromise of the blood–brain barrier resulting in clinical onset of cortical blindness, hemiballismus , or bilateral cochlear deafness.

38. Transient Global Amnesia and Cortical Blindness Usually occurs in the absence of other neurologic signs. Patients invariably recover without specific intervention within 24 to 72 hours. Effect on the posterior circulation with particular reference to the medial temporal lobes.

39. Aneurysmal Rupture During Angiography Most severe neurologic event - rebleeding of a freshly ruptured aneurysm, with a mortality upto 79%. Rebleeding was considered coincidental. Power injections of standard rates accompanied by an increase in intravascular pressure.

40. Aneurysmal Rupture During Angiography Studies intracarotid contrast injection may cause a reflex bradycardia and mild hypotension, there is an initial 1- to 2-second period of elevated intracarotid pressure, which declines over approximately 2 to 10 seconds. Koenig et al. reported on 10 cases of aneurysmal rupture during angiography and reviewed the literature. They observed a 100% mortality rate in their patients. They advised that consideration be given to a reduction in contrast injection rates to about 4 mL/s in patients with recent subarachnoid haemorrhage.

41. Aneurysmal Rupture During Angiography Intraprocedural rupture may not always be seen on the angiographic images. Warning signals - vital signs, subjective complaints, and deterioration in neurologic status. . With a sudden increase in ICP , diminished runoff of contrast in the internal carotid artery may be seen Occluding embolus / sudden sustained elevation of ICP can cause similar stagnation and poor runoff of contrast .

42. Treatment Packing the defect with coils. Emergency craniotomy and clipping may be required Acute hydrocephalus due to SAH – ventricular drainage

43. Nonneurologic Complications of Cerebral Angiography Hematoma formation at the arterial puncture site. Reported as high as 10.7% for femoral puncture sites depending on sheath size and use of heparinization. Higher hematoma rates for carotid and brachial sites have been reported at 25.3% and 15.7%, respectively.

44. The pulse is more difficult to control in the brachial areas during compression. Dion et al. reported that patients older than age 70 had a hematoma rate of 18% after transfemoral cerebral angiography, of whom one third needed fluid replacement or surgical repair . Complication:- Pseudoaneyurysm , venous thrombosis, femoral neuropathy Rx - Compression. Protamine sulphate, surgical removal

45. Femoral artery pseudoaneurysms are rare – Incidence 0.05% to 0.55%. Rx :- conservative, open repair or thrombin injection Other nonneurologic complications with an incidence of less than 1% to 2%, which constitute serious problems, include MI, allergic reactions. Minor complications include nausea or vomiting, benign bradycardia or extrasystoles , fainting, or delayed hematoma formation after discharge. Nonneurologic Complications of Cerebral Angiography

46. Contrast-Induced Nephropathy Acute contrast-induced AKI is defined as a rise in serum creatinine of >25% above baseline or a rise of 0.5 mg/ dL within 48 hours of a contrast-based procedure. A marker for significantly increased in-hospital mortality - 22% compared with 1.5% in nonaffected patients Occurrence of contrast-induced dialysis is associated with an in-hospital mortality rate of 35%

47. Accounts for as much as 10% of hospital-acquired renal failure. In up to 40% of diabetic patients undergoing angiography. Even higher proportions in patients with established severe renal impairment. Usually transient and requires long-term dialysis in less that 1% of cases. Contrast-Induced Nephropathy

48. Diabetic patients, and particularly those with (GFR) <60 mL/min, will need to discontinue using metformin for at least 48 hours following a procedure. Adequate hydration in preparation for the procedure + use of a bicarbonate infusion protocol, discussed below. Premedication with N -acetylcysteine. Use of nonionic contrast agents, particularly iodixanol. Contrast-Induced Nephropathy

49. A meta-analysis of trials suggests that use of iodixanol can reduce the likelihood of AKI from 3.5% to 1.4% in an at-risk patient, or by even more in higher-risk groups.

50. Contrast reaction Hypersensitivity reaction:- minor 1-6% severe 0.01-0.02% Previous episode of anaphylactoid reaction to contrast - 17% - 35% risk Three types:- Vasomotor:- feeling of warmth, nausea, emesis Vagal :- hypotension, bradycardia Anaphylactoid :- minor or severe .

51. Contrast reaction Prednisone 50 mg every 6 hours for 3 doses( 13,7,1) ending 1 hour before the procedure and diphenhydramine 50 mg intramuscularly (IM) 1 hour before the procedure For emergency patients, hydrocortisone 200 mg IV stat and repeated every 4 hours during the procedure. MPS 32 mg PO during the 24 hours before an angiogram and repeated 2 hours before the procedure

52. T reatment of anaphylactoid reaction:- M aintenance of ABC with IV fluids along with epinephrine if necessary. Delayed reaction :- headache, fever, itching, musculoskeletal pain Oral steroids maybe helpful in delayed reaction.

53. Thank you