Standards Of Pre-procedural Steps For DSA.pptx

important pre DSA steps for safety of patients and proper procedure outcome

1. Standards Of Pre-procedural Steps For DSA Dr Sumeet Singh Senior Resident Neurology GMC, Kota

2. Introduction Digital subtraction angiography (DSA) is an X-ray procedure Acquisition of digital fluoroscopic images combined with injection of contrast material Real-time subtraction of pre and postcontrast images The Portuguese neurologist Egas Moniz,( Nobel Prize winner 1949), in 1927developed the technique of contrast x-ray cerebral angiography to diagnose diseases The idea of subtraction images was first proposed by the Dutch radiologist Ziedses des Plantes in the 1935 Raja SM, Othman SA, Roslan RM. A Short Review on the Imaging Technology in Radiation Therapy. e- Jurnal Penyelidikan dan Inovasi . 2023 Apr 30:108-22 .

3. Introduction cont … A team of neurointerventionist, anesthesiologist, radiographer, nurses do the procedure. Iodine-containing contrast medium is injected directly into an artery or vein. A plastic tube (catheter) is passed from the groin or over the arm to the carotid arteries Contrast medium is then injected via the catheter and subsequently images of the blood vessels are taken Scollan ME, Azimov N, Garzon MC, Tulin ‐Silver S. An overview of interventional radiology techniques for the diagnosis and management of vascular anomalies: Part 1. Pediatric dermatology. 2023 Mar;40(2):242-9 .

4. The scout film shows the structural details of the adjacent soft tissue. Angiogram film shows exactly the same anatomic details, if the patient does not move, plus the opacified blood vessels. If all the information in the scout film could be subtracted from the angiogram film, only the opacified vessel pattern remains visible.

5. Pre procedural preparation 1.Routine pre-procedure workup : (a)History and physical - Prior surgery(vascular), vascular event, Diabetes ,Medications, Prior imaging (b)Neurological exam- pulse distal to the site of access on both sides (c) Imaging(CTA of head, neck vessels and arch of aorta) (d) Blood work (CBC, Cr, PT, PTT) (e) EKG (f) Anesthesia evaluation, if needed Gruschwitz P, Hartung V, Kleefeldt F, Peter D, Lichthardt S, Huflage H, Grunz JP, Augustin AM, Ergün S, Bley TA, Petritsch B. Continuous extracorporeal femoral perfusion model for intravascular ultrasound, computed tomography and digital subtraction angiography. Plos one. 2023 May 23;18(5):e0285810.

6. 2.Informed Consent : Taken by the doctor doing the procedure or trained staff. Patient information Details of diagnosis and prognosis if left untreated Options for treatment or management of the condition, including the option not to treat. Benefits and probabilities of success Frequently occurring/serious risks involved Reminder that patients are entitled to change their minds about a decision at any time or take a second opinion

7. Consent for any medical emergencies: Provide medical treatment in order to save life or avoid significant deterioration After recovery inform patient what and why the procedure done Ganaie HA, Sanaie BA, Maqsood S, Raina A, Shaheen F, Asimi R, Hilal S, Zaffar DS. Utility and Safety of Digital Subtraction Angiography in Management of Cerebrovascular Diseases. European Journal of Molecular & Clinical Medicine.;9(07):2022 .

8. 4.Foley catheter (a) Insert in the patient’s private room or pre-op area for awake patients (b) Insert in the angiography suite, after induction of anaesthesia, for asleep patients 5. NPO after midnight or 6 h prior to the procedure except for medications. 6. Place thigh-high sequential compression device (SCD) sleeves on both legs for deep venous thrombosis prophylaxis .

9. Safety Consideration Radiation Exposure Fluoroscopy only when needed Use pulsed Fluoro modes(Use < 10 pulses per second ) Wear lead aprons , thyroid shields, leaded glasses, and radiation badges. • Ergonomic Considerations Degenerative disease of neck and spine needs to be taken care Proper positioning of the patient table Careful positioning of the controls and monitor Shaban S, Huasen B, Haridas A, Killingsworth M, Worthington J, Jabbour P, Bhaskar SM. Digital subtraction angiography in cerebrovascular disease: current practice and perspectives on diagnosis, acute treatment and prognosis. Acta Neurologica Belgica . 2021 Sep 22:1-8 .

10. Premedication : (a)Continue antiplatelet therapy. (b) Protection from nephrotoxicity with creatinine ≥1.5 mg/dL: PO hydration (water, 500 mL prior to the procedure and 2000 mL after the procedure). IV hydration with 0.9% sodium chloride . Acetylcysteine 600 mg (3 mL) PO BID on the day before and the day of the procedure . (c) Protection against anaphylaxis for patients with history of contrast allergy: Prednisone 50 mg PO (or hydrocortisone 200 mg IV) 13, 7, and 1 h prior to contrast injection Diphenhydramine 50 mg IV, IM, or PO 1 h prior to contrast injection. Steroids(if needed)should be given at least 6 h prior to the procedure

11. D) Warfarin - Stop 3 days prior ,Check INR previous day (INR <1.5) E) Antidiabetic medications Insulin: Reduce by 50% with 5D infusion with RBS monitoring Metformin: stop 48 hrs prior , Check RFT before restarting Others: stop on the day of procedure, restart on taking food Harrigan MR, Deveikis JP, Harrigan MR, Deveikis JP. General considerations for neurointerventional procedures. Handbook of Cerebrovascular Disease and Neurointerventional Technique. 2018:167-246 .

12. Steps of handwashing Step 1: Wet Hands Wet your hands and apply enough liquid soap to create a good lather. The temperature of the water should be between 35ºC and 45ºC. Step 2: Rub Palms Together Rub your hands palm to palm in circular motions. Rotate clockwise and anticlockwise HAO M, HE J, ZENG Y, HAN W, SAI A, YAMAUCHI T. A comprehensive assessment of hand washing: knowledge, attitudes and practices (KAP) and hand-washing behaviors among primary school students in northeast China. Sanitation Value Chain. 2022;6(1):13-22 .

13. Step 3: Rub the Back of Hands With your fingers linked through the other hand, use your right palm to rub the back of your left hand. Then swap Step 4: Interlink Your Fingers Link your fingers together, facing each other, into clasped hands. Then rub your palms and fingers together.

14. Step 5: Cup Your Fingers Cup your fingers together, with your right hand over and your left hand under. With your fingers interlocked, rub the backs of them against your palms. Then swap Step 6: Clean the Thumbs Enclose your right hand around your left thumb and rub as you rotate it, then swap.

15. Step 7: Rub Palms with Your Fingers Rub your fingers over your left palm in a circular motion, then swap. Step 8: clean your w rists : Extend the scrubbing to your wrists and lower arms, especially if they've been exposed to contaminants Step 9: Rinse Thoroughly Step 10: Avoid Touching the Tap Step 11: Dry Your Hands with sterile towel or air dryer Step 12: Dispose of Towel Properly Step 13: Use of hand sanitizers

16. Part preparation and cleaning of puncture site Shaving : Hair around the puncture site should be shaved to ensure proper adhesion of sterile drapes and minimize infection risk. Patient Positioning : Ensure that the patient is in the appropriate position(supine) for the puncture. Sterile Field : Establish a sterile field around the puncture site to minimize the risk of contamination. Gather Supplies : Assemble all the necessary supplies, including an appropriate antiseptic solution, sterile gauze, and sterile drapes . Skin Antisepsis : Use an appropriate antiseptic solution to cleanse the skin at the puncture site. Common choices include chlorhexidine or iodine-based solutions Singh DK, Yadav K, Singh AK, Sinha K, Kaif M, Kumar R, Chand VK. Digital Subtraction Angiography of Cerebral Vessels: Basic Technique. Neurology India. 2023 Jan 1;71(1):31 .

17. Pre-Cleanse Assessment : Examine the patient's skin for any visible contaminants, such as dirt, debris, or organic matter. If present, remove these contaminants with a gentle, sterile saline solution. Antisepsis Application : Apply the prepared antiseptic solution to the surgical site using aseptic technique. Start at the center and work outward in a concentric manner. Use sterile gauze or swabs soaked in the antiseptic to scrub the area for the recommended duration, usually 2-5 minutes, depending on the product.

18. Draping Start at the near side (closest to your body) then place the drapes at either end and then at the far side. If a drape needs adjustment, only move away from sterile area, not towards or over it. When placing the clip grasp sufficient, but not an excessive amount, of skin . Gao C, Zhu J, Bai Z, Lin Z, Guo J. Novel ramie fabric-based draping evaporator for tunable water supply and highly efficient solar desalination. ACS Applied Materials & Interfaces. 2021 Feb 2;13(6):7200-7.

19. Instruments and tools for DSA Access Needle ONE PIECE Sharp beveled tip Guidewire introduced directly through it Both arterial and venous access TWO PIECE Blunt tip with sharp stylus Less vascular injury with the blunt tip Guide wire inserted after removing the stylet Usually for arterial puncture MC needle Size – 19/18 G in diameter and 2 1/4 - 5 inches in length YAJUN N. A Analysis of the Practice Effectiveness of Care Management in Digital Subtraction Angiography Composite Operating Rooms. Archives of Clinical Psychiatry. 2022;49(6) .

20. Micro puncture Access Systems Small access needle – made bigger with plastic introducer 21 G needle for access Guide wire 4F or 5F Dilator Singh DK, Yadav K, Singh AK, Sinha K, Kaif M, Kumar R, Chand VK. Digital Subtraction Angiography of Cerebral Vessels: Basic Technique. Neurology India. 2023 Jan 1;71(1):31 .

21. Dilator Plastic catheter Purpose: Spread the soft tissues and vessel wall to facilitate catheter entry Sequential dilatation to prevent trauma Usually 18G access needle uses 5F initially >50% diameter of the vessel diameter – obviates manual compression

22. SHEATHS Open at one end with capped hemostatic valve in the other Atraumatic vascular access Simplify catheter exchange through a single access Maintain guidewire position Prevent bleeding Size 4-9 F Summers, M.R., Lavigne, P.M. and Mahoney, P.D., 2022. Completion peripheral angiography in single‐access, Impella ‐assisted, high‐risk PCI: using a buddy microcatheter sheath after MANTA closure for imaging and potential bailout. Catheterization and Cardiovascular Interventions, 99(6), pp.1778-1783 .

23. Guidewires : The guidewire should have a thickness that matches or is slightly smaller than the size of the tip of the catheter or device that it guides. It comprises a central stiff core, which provides stability, and an outer wrap wound around it The guidewire is designed to withstand damage To enhance safety, a small safety wire is incorporated within the guidewire, securely attached at both ends. The safety wire prevents the guidewire from unwinding if it happens to break during use. Average Length : 145-160cm( Exchange length guide wire - 260-300cm)

24. Types of guidewires : Stiff guidewire – introducing catheter and devices Flexible : negotiating tortuous and diseased vessels Movable core guidewire – adjust flexibility Mandril Guidewire : Only wrapped at the tip- micro guidewire and extra rigid large diameter guidewire Tip Deflecting guidewire : manipulate the radius of tip Hydrophilic coated guide wire Coated central core Reduces friction Needs to be moist always

25. Diagnostic Catheter : Made of polyurethane, polyethylene, Teflon, or nylon Catheters vary based on their intended use Non selective aortography – Thick walled with pig tail tip , multiple side holes Selective catheter : Thin walled with tapered tip , single end hole and metal /plastic strand BRAID tip Length – 50 -125 cm Size :4F-6F Singh DK, Yadav K, Singh AK, Sinha K, Kaif M, Kumar R, Chand VK. Digital Subtraction Angiography of Cerebral Vessels: Basic Technique. Neurology India. 2023 Jan 1;71(1):31 .

26. Types : Benston and floppy tipped wires- for standard access Hydrophilic wires- for tortuous and diseased vessels Extra stiff wires(Amplatz)- insertion of larger devices or within long tracts Exchange wires- exchange of long angiographic catheters or devices or remote distance from access Tapered wires(TAD wires)- for placement of devices into sensitive territories Low profile steerable wires- used in microcatheters for selective catheterization.

27. Based on shape : pigtail , cobra, hockey stick Designer : AMPLATZ catheter HEADHUNTER – H1,H3,H1H SIDEWINDER – SIM1, SIM2, SIM3, SIM4 NWTON – HN 3, HN 4 BENTSON, MANI – JB 1, JB 2, JB 3, MAN, CK 1 SHEPARD HOOK – SHK 0.8, SHK 1.0, RDC 1, RDC COBRA – C 1, C 2, C 3, RC 1, RC 2, RC 3, USL 2

28. Luer lock syringe : Luer lock syringes have a threaded tip For secure and leak-resistant connection with various attachments, such as needles, catheters, or extension sets. The threaded design prevents accidental disconnection during use Reduces the risk of medication leakage(contrast) and needlestick injuries

29. Three way stop cock : A three-way stopcock typically has three ports or openings that allow for the connection of multiple medical tubing or devices simultaneously. They provide a convenient and controlled way to manage the flow of fluids and medications

30. All the tools and instruments are opened from their respective packings with no touch technique They are assembled on sterile platform Instruments are checked for their patency with heparinised solution. NS is heparinized with 10,000 units of heparin per liter of saline for flushing and irrigation Bhave VM, Stone LE, Rennert RC, Steinberg JA. Complementary tools in cerebral bypass surgery. World Neurosurgery. 2022 Jul 1;163:50-9 .

31. Contrast : Should have excellent radioopacity Good mixing with blood Easy to use, inexpensive and does not harm the patient Ionic monomer-diatrizoate, iothalamate Nonionic monomer- ioppamidol , iohexol , ioversol , ioxilan, iopramide . Ionic dimer- ioxaglate Nonionic dimer-iodixanol. Patients with normal renal function can tolerate as much as 400–800 mL of Omnipaque , 300 mg /mL, without adverse effects For patients with renal insufficiency use Iodixanol ( 270 mg /mL) Chandrashekar A, Shivakumar N, Lapolla P, Handa A, Grau V, Lee R. A deep learning approach to generate contrast-enhanced computerised tomography angiograms without the use of intravenous contrast agents. European Heart Journal. 2020 Nov;41(Supplement_2):ehaa946-0156 .

32. Allergic reaction to contrast : Patients should be tested for any adverse reaction to contrast agents 2 to 50 microlitre of a 1:10 dilution of contrast with NS is injected intradermally to make 3-5mm papule Test should be done 48-72 hours before the procedure Reading is done at 20 min and 72 hours for increase in size of wheal for >3mm and erythema. If found allergic patient should be given- Prednisone 50 mg 1 hour prior to procedure Cimetidine 300mg iv on arrival to cathlab Diphenydramine , 50mg iv on arrival to cathlab

33. Contrast Induced Renal Failure: Mostly in patients with DM, preexisting renal failure(creatinine>1.5mg/dl) Management : Hydration with D5 12 hour before and 12 hour post procedure Sodium bicarbonate-154mmol/L at 3ml/kg/h prior to procedure, then 1ml/kg/h for 6 hours after the procedure N-acetylcysteine- 1200 mg orally every 12hour starting 24 hour before the procedure.

34. Radiation Safety Patient Radiation Exposure : Radiation exposure to patients should be minimized Limiting fluoroscopy time. Limit the pulse rate for fluoroscopy Do only the angiographic runs that are needed. Use one 3D acquisition instead of six different oblique runs Use overhead and table-side shielding to protect body parts not being studied. Doyen B, Vlerick P, Soenens G, Vermassen F, Van Herzeele I. Team perception of the radiation safety climate in the hybrid angiography suite: A cross-sectional study. International Journal of Surgery. 2020 May 1;77:48-56 .

35. Staff Radiation Exposure : Moveable, ceiling-mounted clear lead glass shields can be draped with sterile plastic and positioned over the patient protecting the patient’s lower body and the operator from radiation exposure. Rolling floor-mounted X-ray shields should be available to shield anesthesia or other personnel. Lead aprons should provide at least 0.5 mm lead equivalent thickness Thyroid shields and lead glasses Lead apron has front cover, leaded skirt, arm and shoulder cover and belt. Lead aprons can attenuate over 90% of 80 kVp radiation

36. Pregnant staff members : The NCRP-recommended maximum gestational radiation exposure is 5 mSv per gestational period, or 0.5 mSv per month Wear an apron with 1.0 mm lead equivalent thickness Wear wraparound aprons to cover front and back Pregnant staff members should wear two radiation badges, with one under the apron to monitor fetal dose

37. Advances in Lead Apron Technology: Zero-Gravity -  a ceiling-tethered apron, reduces the load of the lead while confining the doctor to an area in the OR near the bed. Provides enhanced head protection StemRad MD –  an exoskeleton-based apron which reduces the load of shielding from the wearer while allowing movement around the OR A lso providing head protection in the form of a visor. Cost 1000-1500 US Dollars.

38. Radiation monitoring batch For Personal radiation monitoring Worn inside lead apron These batches are passive dosimeters, do not actively measure radiation but absorb it, usually through special materials like film or thermoluminescent detectors A badge consists of 3 TLD discs Th ey are collected and assessed periodically (e.g., monthly or quarterly) Read by TLD reader which is controlled by PC and a software Personnel doses should not exceed 100 mSv in 5 year or 30 mSv in 1 year.

39. Conclusion All patients should be evaluated in detail and should have a justifiable reason to go for DSA Serum creatinine should be <1.5 mg/dl and platelets >50K before the procedure Detailed Written and informed consent should be taken Patients should be NPO for at least 6 hours before the procedure Strict asepsis should be maintained while shaving and cleaning the puncture site and in the Cath lab All instruments and tools should be handled with care and flushed with heparinised solution. Patients should be checked for contrast allergy Radiation safety should be followed strictly with the use of protective shields , aprons and radiation monitoring batches.

40. References Handbook of Cerebrovascular Disease and Neurointerventional Technique Mark R. Harrigan John P. Deveikis Continuum journal. Raja SM, Othman SA, Roslan RM. A Short Review on the Imaging Technology in Radiation Therapy. e- Jurnal Penyelidikan dan Inovasi . 2023 Apr 30:108-22 Harrigan MR, Deveikis JP, Harrigan MR, Deveikis JP. General considerations for neurointerventional procedures. Handbook of Cerebrovascular Disease and Neurointerventional Technique. 2018:167-246 . Doyen B, Vlerick P, Soenens G, Vermassen F, Van Herzeele I. Team perception of the radiation safety climate in the hybrid angiography suite: A cross-sectional study. International Journal of Surgery. 2020 May 1;77:48-56 . Singh DK, Yadav K, Singh AK, Sinha K, Kaif M, Kumar R, Chand VK. Digital Subtraction Angiography of Cerebral Vessels: Basic Technique. Neurology India. 2023 Jan 1;71(1):31. Summers, M.R., Lavigne, P.M. and Mahoney, P.D., 2022. Completion peripheral angiography in single‐access, Impella ‐assisted, high‐risk PCI: using a buddy microcatheter sheath after MANTA closure for imaging and potential bailout. Catheterization and Cardiovascular Interventions, 99(6), pp.1778-1783 .

41. Thank you