ANGIOGRAPHY

Introduction

Angiography: Study of blood vessels, by the use of contrast to make the

vessels visible under fluoroscopic procedures.

It refers to radiologic imaging of blood vessels after injection of a contrast

medium.

To visualize these low-contrast structures, contrast media is injected by a

catheter that is placed in the vessel of interest.

Positive contrast media are more commonly used, but there are instances
when use of negative contrast media isindicated.

Highly specialized imaging equipment is required for these procedures.

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Indications
• Narrowing or blockage
• Acute stroke
• Therapeutic reasons
• Map of the brain prior to neurosurgery
• Bleeding within the skull
• Inflammation
• Bulges in arterial walls/Aneurysms
• Blood clots in the brain
• Intra cerebral hemorrhage
• Arterio venous & fistulae malformations
• Highly vascular extra and intra cranial tumors

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VESSEL ACCESS FOR CONTRAST MEDIA INJECTION
#To visualize the vessel(s) of interest, a catheter must be introduced into
the patient's vasculature, through which the contrast media will be injected.

#A commonly used method for catheterization is the Seldinger technique.

#This technique was developed by Dr. Sven Seldinger in the 1950s and
remains popular today.

#It is a percutaneous (through the skin) technique that can be used for
arterial or venous access.

Four vessels are typically considered for catheterization:

(1) femoral,
(2) axillary,
(3) brachial, and
(4) radial.
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The angiographer will make the selection
based on the strong presence of a pulse and
the absence of vessel disease.
#The femoral artery is the preferred site for an
arterial puncture because of its size and easily
accessible location.
#It is punctured just inferior to the inguinal
ligament.
#If a femoral artery puncture is contraindicated
because of previous surgical grafts, the presence
of an aneurysm, or occlusive vascular disease,
the axillary, brachial, or radial artery may be
selected.
#The femoral vein would be the vessel of choice
for venous access.

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Seldinger Technique

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Contraindications

Contraindications for patients to experience angiography include

#Contrast media allergy,

#Impaired renal function,

#Blood-clotting disorders

#Anticoagulant medication, and

#Unstable cardiopulmonary/neurologic status

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Risks /Complications
Angiographic procedures are not performed without always involving
some level of risk for the patient. Some of the most common risks and
complications include the following:
•Bleeding at the puncture site: this usually can be controlled by applying
compression
•Thrombus formation: a blood clot may form in a vessel and disrupt the
flow to distal parts
•Embolus formation: a piece of plaque may be dislodged from a vessel
wall by the catheter. A stroke or other vessel occlusion may result
•Dissection of a vessel: the catheter may tear the intima of a vessel
•Infection of puncture site: this is caused by contamination of the sterile
field
•Contrast media reaction: this may be mild, moderate, or severe

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Automatic Electromechanical Contrast Medium Injector

# As contrast media is injected into the circulatory system, it is diluted by blood.

# The contrast material must be injected with sufficient pressure to overcome the
patient's systemic arterial pressure and to maintain a bolus to minimize dilution
with blood.

# To maintain the flow rates necessary for angiography, an automatic

electromechanical injector is used.

# The flow rate is affected by many variables, such as the viscosity of the
contrast medium, the length and diameter of the catheter, and injection
pressure.

# Depending on these variables and the vessel to be injected, the desired flow
rate can be selected before injection.

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Cerebral Angiography
Cerebral angiography is a radiologic study of the blood vessels of the
brain. The primary purpose of cerebral angiography is to provide a
vascular “road map” that will enable physicians to localize and diagnose
pathology or other anomalies of the brain and neck regions.

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Pathologic Indications
Pathologic indications for cerebral angiography include the following:
•Vascular stenosis and occlusions
•Aneurysms
•Trauma
•Arteriovenous malformations
•Neoplastic disease

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Catheterization

The femoral approach is preferred for the catheter insertion. The catheter is
advanced to the aortic arch, and the vessel to be imaged is selected.
Vessels commonly selected for cerebral angiography include the common
carotid arteries, internal carotid arteries, external carotid arteries, and
vertebral arteries

Major vessels involved in cerebral angiography include:

– Carotid arteries: supply blood to the anterior
and middle portions of the brain
– Vertebral arteries: supply blood to the
posterior portions of the brain
– Jugular veins: venous drainage of the brain
– Femoral artery: accessed site for arterial
puncture

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Equipment

– Image intensifier fluoroscopic unit

– Angiographic table with movable or free-floating top
– Rapid sequence film changers
– Electromechanical contrast injector
– Digital subtraction capabilities
– Sterile tray set up with all the appropriate tools for a
cerebral angiogram
– Guidewires: based on personal preference
– Catheters: based on personal preference/single end hold
w/no side holes

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Procedure Details

• Local anesthetic at puncture site

• Small incision over the femoral artery
• Needle placed into vessel using Seldinger Technique
• Guidewire placement
• Catheter placement
• Contrast injected

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Lateral Views of Carotid Arteries

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Digital subtraction angiography
Conventional angiography, or more specifically digital subtraction
angiography (DSA) can be used for both diagnostic and interventional
angiography. Its high resolution have maintained DSA as a very important
tool.

DSA is a method of fluoroscopy where an initial mask image is taken prior

to administering contrast and saved. After administering contrast,
fluoroscopy is continued and the saved pre-contrast mask is subtracted
from these newer images obtained after giving contrast. The result is an
image with the background subtracted from the image such that only the
contrast enhanced vessels are seen.

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The initial image (left) illustrates high grade narrowing of the proximal internal carotid artery.
The subsequent (right) image demonstrates improved angioplasty and stent placement.

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• Useful for vessels that cannot be seen due to bony structure
overlapping.
• Arterial, capillary, venous phase subtraction films are routine in
cerebral angiography.
• Small lesions, that are virtually undetectable on routine films are
often clearly visible.

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