Peripheral angiography

angiograqhy pqrocedures

1. Peripheral Angiography SONI NAGARKOTI B.Sc.MIT 2 nd Year NAMS,Bir Hospital

2. Overview Introduction General anatomy Indication Equipments and accesories Procedure Filming Aftercare of patient Advancements

3. Angiography Angiography is the one of the radiological imaging procedure available for detailed investigation of heart and blood vessels after injecting the contrast media . Angiography can be more specifically described as follows: •Arteriography: imaging of the arteries •Venography: imaging of the veins/ phlebogram •Angiocardiography: imaging of the heart and associated structures • Lymphography : imaging of the lymphatic vessels/nodes

4. Importances Shows blockage, deformities in the vessels Could be both therapeutic and diagnostic Angiography followed by angioplasty and stenting could be life saving in case of arterial blockage or narrowing of vessels Angioplasty is beneficial for reducing angina Could be beneficial to reduce ischemia due to blockage in any peripheral or coronary arteries

5. Peripheral angiography Peripheral Angiography is a radiologic examination of the peripheral vasculature (artery) after the injection of contrast media . Could be upper limb angiography or lower limb angiography

6. General anatomy

7. Vasculature of upper limb

8. Vasculature of lower limb

9. Peripheral arterial diseases(PAD) Narrowing of peripheral arteries serving the legs, arms, head Cause = atherosclerosis (if severe blocked blood flow can cause ischemia, necrosis or tissue death and may l ead to amputations) Symptoms= crampings , pain, tiredness in leg or hip muscles , change in skin colour Risk factors= smoking, old age, diabetes, HTN, high blood cholesterol, heart diseases

10. Indications Atherosclerotic disease Embolus and thrombus Arterial ischemia, stenosis or occlusion . Trauma to a limb with arterial involvement Congenital abnormalities Buerger’s disease or other forms of arteritis Prior to and following vascular surgery Neoplasm Angioma Popliteal artery entrapment syndrome

11. Contraindications Hypersensitivity to iodinated contrast media. Blood–clotting disorders or bleeding disorder Anti coagulant medication Impaired renal function Local infection of the puncture site. Unable to do vascular surgery. High grade fever Low Hb

12. Relative contraindications Blood dyscrasias Aneurysms or pseudoaneurysms Local soft tissue infections Severe hypertension Ehlers- Danlos syndrome

13. Equipments and accesories Equipment includes:- - High power x-ray generator. - X-ray tube - Floating/tilting type of x-ray table - Fluoroscopic unit with II TV system - Rapid serial film changer. - Auto-injector - Resuscitative apparatus

14. Generator- required 3 phase 12-pulse unit with a power rating of 85-100kw at 100k (to withstand heat) Fast screen film combination. grid also necessary to reduce scatter radiation . Automatic injector is required for bolus injection at predetermined amount and preset rate . physiologic monitoring equipment is required for constant cardic and intravascular pressure recording.

15. Accessories include Local anesthesia Puncture needle / introducer needle Guide wire/ glide wire(glide wire is hydrophilic or lubricated guide wire) Angiography catheter Angiographic sheath with dilator Sterile angiographic tray Surgical blade Gloves

16. Introducer needle Consists of : Outer thin walled blunt cannula Inner needle Stilette Size based on external diameter of needle. (18G ) Internal diameters should be known to allow for appropriate Guide-wires matching Proper needle gauge and guide wire diameter are chosen because : - large diameter could result in backflow of blood through cannula of needle, blood loss - small needle gauge cause difficult or impossible for wire to pass through the cannula of the needle

17. Guide wires Used as a platform over which a catheter is to be advanced. Is a stainless steel wire that acts as a guide until the catheter reaches the area of interest. Outside of the guidewire is teflon . ( teflon reduces friction and clot formation) May saturated with heparin. Inner core is fixed or moveable. Available with straight or j- shapped tips . (J tipped wires is useful for negotiating with vessels having irregular walls)

18. Contd … Guide-wires ranges from 20-57 inches (50-145cm) Diameter ranges from – 0.014 – 0.052 inches (0.03 – 0.13 cm) Frequently used diameter – 0.035 inches(0.09cm) and 0.038 inches (1.0cm). (glide wires are slippery with excellent torque and are useful for tortous vessels)

19. Angiographic sheath with dilator Sheath is short flexible plastic tube having hole in one side and valve at another side . It is used to prevent the blood clot Dilator is rigid structures which gives support to sheath during insertion.

20. Angiography catheters Serve as a principle pipeline through which contrast media is transported. Made up of polyethylene, polyurethane, nylon and teflon . Polyethylene catheter is mostly used . Catheters are vary in length, size and no. of side holes. When using the femoral approach, short-length catheters (60–80 cm) are adequate for angiography of the structures below the diaphragm, whereas long catheters (100–120 cm) are needed for carotid artery, subclavian artery, or arm angiography.

21. Five- to six-French (1-F catheter = 0.333 mm) diameter catheters are most commonly used.(3F = 1mm) For DSA, 5-F catheters are sufficient. They may have an end hole, side holes, or both end and side holes. Side holes are important as they affect the flow rate and allow large volume of the contrast medium and pressure exerted on the catheter.( safe) ‘ideal catheter ’ should be able to sustain high pressure injection, to track well, be non- thrombogenic , have good memory, and should torque well.

22. Notes Introduction of catheter over a guide wire is faciliated by dilation of path by dilator If the patient has large amount of subcutaneous fat in the puncture area, catheter control will be better by using introducer sheath

23. Types of catheter Name of catheter function Cobra visceral 2. Head hunter Carotid subclavian 3. Simmons Celiac trunk 4. Shephard hook Visceral , spinal 5.Renal double curve Renal 6. Bernstein left carotid 7. Straight Lower limb 8.Pigtail Non selective 9.Balloon angioplasty

24. Angiographic tray A sterile tray contains the basic equipment necessary for a Seldinger catheterization of a femoral artery. Basic sterile items include the following: 1.Hemostats 2.Prep sponges and antiseptic solution 3.Scalpel blade 4.Syringe and needle for local anesthetic 5.Basins and medicine cup 6.Sterile drapes and towels 7.Band-Aids 8.Sterile image intensifier cover if C arm is used

25. Contrast media includes non-ionic, low osmolar - for lower extrimities :- 30-40ml of 300mgI/ml - for upper extrimities :- 20-30ml of 300mgI/ml For eg ultravist omnipaque

26. Drug includes Local anesthesia ( inj. xylocane 2%) - Heparin - Atropin - Adrenaline - hydrocortisone - inj. Cefazolin 1g

27. Angiographic team in A ngio roo m Radiologist ( or other specialist) Cardiovascular nurse Radiologic Technologists (CV) Sometimes Anesthesiologist depending on the procedure

28. Role of CIT Proper positioning of the patient Exposure in adequate time Changing of cassette Moving the tube Lowering the radiation dose as much as possible. In case of c-arm the exposure is auto adjusted. Otherwise have to change the kv for each time from reaching thicker part to thinner part (from femur to ankle).

29. PATIENT PREPARATION Admission in hospital 24 hrs prior to examination, Prothrombine time and bleeding duration must be checked Serological test (HIV, HCV, HbsAg ) must performed. Puncture site should be shaved. Informed consent must be taken and explain about the procedure. NPO at least 4-6 hrs prior to examination. Patients must bring all the previous records : x-ray, ECG reports, CT reports, catheter, IV-cannula, disposal syringes – 10ml and 20 ml, heparin injection, normal saline, contrast media. Micturation should be done before examination.

30. Puncture site Femoral artery (most frequently used) Brachial artery Axillary artery Radial artery

31. Technique ( S eldinger technique) In this technique, both wall of vessel is punctured Stilette of needle is removed Needle is withdrawn in such a way that the bevel is within the lumen of vessel and blood flows from hub Guide wire is inserted through the needle Needle is withdrawn keeping guide wire in situ Catheter is threaded over guide wire Guide wire is withdrawn

32. Modified seldinger technique

33. Lower limb angiography The radiological examination of the arteries supplying pure blood to the lower limbs by the help of seldinger technique with the retrograde catheterisation of a femoral artery.

34. Patient and equipment positioning Supine in the centre of the imaging couch. Head raised on a shallow pillow. Both knees are extended with leg straight and positioned together. Feet pointing upward and rotate slightly inward ( to demonstration the gap between the tibia and fibula ) The feet are secured by a triangular wedge foam pad and restraining straps. Image intensifier is parallel to the imaging coach. Tube is placed under the table .

35. Procedure Generally, femoral artery is considered for puncture The femoral artery of leg opposite to the symptomatic leg is chosen Location and point to be punctured is cleaned with betadine solution Using aseptic technique, local anesthesia is infiltrated at the puncture site A skin incision is made on the puncture point to reduce binding of soft tissue on catheter

36. The introducer needle is then advanced through soft tissue using Seldinger technique After puncture of artery, stillette of needle is removed and needle hub is depressed so that it runs parallel to the skin A guidewire is introduced through needle and advanced gently along artery using intermittent fluroscopy The guidewire is guided from femoral artery to the bifurcation of two common iliac arteries The needle is then withdrawn over guidewire and catheter is threaded on the free portion of guidewire

37. Generally, dilators matching the patency of catheter is used to dilate the path prior using catheter The tip of the catheter is positioned above the aortic biforcation under fluoroscopic control. The contrast media is injected, the flow of contrast is observed and timed as it traverses the femoral arteries to the knees and lower down the limbs. An image acquisition protocol is prescribed to ensure complete visualization of the arterial vessels

38. Filming For a bilateral examination, the patient is positioned in the supine position for single plane AP projections and the patient is centered to the midline of the image receptor to include the area from the aortic bifurcation to the ankles Projections PA if the xray tube is undercouch AP if xray tube is overhead lateral

39. Upper limb angiography Radiological study of arterial system supplying the upper limbs by the retrograde introduction of contrast media through the femoral artery.

40. Patients and equipment position Patients lie supine on the table. Arms extended and placed along side the trunk. Palms of the hands placing upwards. In some cases arm raised above the head to investigate the effects on arterial circulation Image intensifier/film changer is positioned parallel to the imaging coach and above the region under investigation.

41. Procedure Generally, femoral artery is considered for puncture Both femoral arteries are palpated, if pulsations are of similar strength, right femoral artery is generally chosen as it is technically easier Location and point to be punctured is cleaned with betadine solution Using aseptic technique, local anesthesia is infiltrated at the puncture site A skin incision is made on the puncture point to reduce binding of soft tissue on catheter

42. The introducer needle is then advanced through soft tissue using Seldinger technique After puncture of artery, stylet of needle is removed and needle hub is depressed so that it runs parallel to the skin A guidewire is introduced through needle and advanced gently along artery using intermittent fluroscopy The guidewire is guided from femoral artery to the bifurcation of two common iliac arteries The guidewire is then guided to the abdominal aorta to thoracic aorta to the arch of aorta and finally to the tip of subclavian artery

43. Selective catheterization of the subclavian arteries is done by using headhunter catheter Contrast is then injected and flow of contrast is followed under fluoroscopy guidance

44. Filming Generally, true AP projections are taken with the arms extended and hand supinated Hand arteriograms are obtained in supine or prone arm positions Injections and imaging system depends on the equipment used A representative program for a rapid imaging system may be two films per second for 5 seconds followed by one per second for 5 seconds.

45. Aftercare the punctured site is pressed at least 15 mins. Dressing is applied over the punctured site . Puncture site should be taken care of for haemorrhage Patient is advised to complete bed rest for 6hrs. Vital sign must be recorded upto 24 hrs - every 15 mins for 4 hrs. - every 4 hrs for 20 hrs . the patient is advised not to bend the limb for 24 hrs . Patients with larger catheter, anti platelet therapy, and anticoagulation require longer observation Inj.cefazolin is given immediate after procedure

46. Complications 1.Due to anaesthesia Emesis Agitation Rash 2.Due to contrast media Mild(nausea, vomiting, dizziness, headache, rashes) Moderate ( utricaria , facial edema, hypotension, hypertension, tachycardia, bradycardia) Severe ( pulmonary oedema , unconsiousss , death)

47. 3.Due to technique Haemorrhage / haematoma Arterial thrombus Infection to puncture site Pseudoaneurysms Arteriovenous fistula Air embolus Artery dissection Guidewire breakage bacteraemia

48. Radiation protection Angio team should be provided adequate protection i.e. with leaded glass observation window. Use of radiation protection devices. Minimal fluoro use as possible Proper collimation Angio personnel should wear badges and ring monitors. Avoidance of repeat exposure Cardinal rules i.e. time, distance and shielding

49. Advancements in angiography Digital subtraction angiography Rotational angiography Computed tomography angiography Magnetic resonance angiography Ultrasound

50. Conventi ona l angiography You can see the bony skeleton Digital subtraction The bony skeleton is subtracted CT angiography MR angiography

51. Digital subtraction angiography Fluoroscopy technique used in IR to clearly visualize blood vessels in a bony and soft tissue environment Compares xray image of a region of body before and after radiopaque iodine based dye has been injected Useful in diagnosis and treatment of arterial and venous occulusion including artery stenosis,, embolisms, ischaemia

52. Principle the non-contrast image (mask image) of the region is taken before injecting contrast material and therefore shows only anatomy, as well as any radiopaque foreign bodies (surgical clips, stents, etc.) as would a regular x-ray image. contrast images are taken in succession while contrast material is being injected. These images show the opacified vessels superimposed on the anatomy and are stored on the computer. the mask image is then subtracted from the contrast images pixel by pixel. The resulting subtraction images shows the filled vessels only .

53. recording can continue to provide a sequence of subtracted images based on the initial mask . the subtraction images can be viewed in real time .   Even if the patient lies still, there is bound to be some degree of misregistration of images due to movement between the acquisition of the mask image and the subsequent contrast images. The effect is prominent at high-contrast interfaces, such as bone-soft tissue, metal staples and coils, and bowel air. Pixel shifting (either manual or automatic), i.e. moving the mask retrospectively, can minimize misregistration , but focal movement such as bowel peristalsis, will not be corrected

54. Rotational angiography  Rotational angiography is a medical imaging technique based on x-ray, that allows to acquire CT-like 3D volumes during interventional catherization Also known as flat panel volume CT or cone beam CT In order to acquire a 3D image with a fixed C-Arm, the C-Arm is positioned at the body part in question so that this body part is in the isocenter between the  x-ray tube  and the  detector .  The C-Arm then rotates around that isocenter , the rotation being between 200° and 360°

55. Such a rotation takes between 5 and 20 seconds, during which a few hundred 2D images are acquired .  A piece of software then performs a  cone beam reconstruction  The resulting voxel data can then be viewed as a  multiplanar reconstruction , i.e. by scrolling through the slices from three projection angles, or as a 3D volume

56. Ceiling mounted c arm at catherization lab for rotational angiography

57. Refrences A Guide to Radiological Procedures, Chapman 5 th Edition Merrill’s Atlas of Radiographic Positions Volume 3-10 th Edition . www.radiopaedia.org www.google.com

58. Questions Which type of guide wire used in peripheral angiogram? What is its length? What is the size of catheter used in angio ? why? There are more advanced modalities for angio . Still conventional peripheral angio is in practice. why? Describe the pathway for upper limb angiography whose puncture site is femoral artery. How does DSA works?