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Angiography/

Interventional Basics
How do we perform an angiographic
procedure?
Dr. ABEER FAWZY EL-SOBKY
MASTER of RADIOLOGY

Types of angiography
Conventional
angiography

Digital
subtraction

You can see the


bony skeleton

The bony
skeleton is
subtracted

CT
angiography

Vascular 2007

MR
angiography

Index

So advanced CT, US and


MRA
techniques
made
conventional angiography
limited
to
therapeutic
purposes (Angioplasty).

Technique
of
angiography

Personnel in the Angio Room


Radiologist ( or other specialist)
Cardiovascular nurse
2-3 Radiologic Technologists (CV)
Sometimes Anesthesiologist depending

on the procedure

Technologist Responsibilities
Prepare Room/ consent forms
Provide radiographic positioning / Dr Assistance
Knowledge of exam, anatomy, pathology
Prepare sterile tray, prep patient
Knowledge of catheters and guide wires
Know sterile technique/ safe clean up
Monitor ECG + pressure
Patient care skills and pharmacology

Angiography/ Interventional/
Cardiovascular
Procedure Room

(Suite)

Room size- 400600 square feet


Easily cleaned
(floors, wall, etc.)
Outlets needed for
O2, suction.

Control Room

100-150 square feet


Easy access and
communication to
procedure room
Computers, monitors and
un sterile personnel
Storage area- guide wires,
catheters and needles

Equipment found in all


Advanced Procedure Rooms
X-ray generators
Controls
X-ray Tubes
System to record events of procedure
Automatic Injectors

X-Ray Tube Requirements


Detail
Withstand high heat- rapid exposure

sequences
Use smallest possible focal spot

Equipment Requirements
High heat load tubes w/ rapid cooling

Series imaging (up to 3-4 films/sec),


intense heat

Analog- to- Digital Conversion System


Programmable digital image acquisition

system
PACS

Electromagnetic Injectors
Monitoring Equipment- BP & ECG
Island Tables- access from all sides,

height adjustments, floor controls


Tables do not usually tilt

Digital Imaging- Analog VS


Digital Concepts
Analog- image seen after chemical

process
Digital- image manipulated by software

Information changed through use of


computer algorithm

Digital Subtraction
Angiography (DSA)
Computer subtracts out all anatomy

except contrast-filled vessels


Looks like a reverse image
Can be more diagnostic for vessels

( clots, constrictions)

Electromechanical Injector
Used in Angio, CT, MRI
Overcome arterial pressure + maintains

bolus
Maintains flow rate
Flow rate affected by

Viscosity
Length + diameter catheter
Injection pressure
Vessel selected

Seldinger Technique
Method for catheterization of vessels
Developed 1950s still popular today
Percutaneous (through the skin)

technique for arterial and venous access


3 vessels considered:

Femoral preferred site for arterial (size +


accessibility)
Brachial
Axillary

Selection based on

strong pulse w/
absence of disease
Site cleaned, area
draped, local given

Seldinger Technique ( step-bystep)


Insertion of needle
Placement of needle in lumen
Insertion Guide wire- thru needle, advance 10

cm
Removal of Needle- guide wire in position
Threading of catheter to area of Interest- fluoro
used
Removal of guide wire- catheter remains in
place

SELDINGER TECHNIQUE

Two less common methods used

Cut down- minor surgical procedure to


expose vessel of interest
Translumbar- patient prone, long needle
passed thru T12- L2 into aorta

Lets Look at Needles, Guide


wires and Catheters
Cannula
connecting hub (luer

lock)
Baseplate
transparent tubing

Guidewires
Guide catheter for placement in vessel
Guide wire diameter be large enough so blood

can not flow back for too long a time


Tips at the end of GW

Straight
J- tipped

longer G.W. for selective angio vessels


Short used for shorter direct vascular approach

GUIDEWIRES

CATHETERS
Straight- end hole only
Pigtail- circular tip w/ multiple side
holes to reduce whiplash and control
contrast
Sidewinder- curved to facilitate vessel
selection
Cobra- variation in curvature to facilitate
selection of vessels

The more holes at the end / the more

contrast used/ large vessels


Catheter with only end hole/ smaller
vessels/ carotid
Combo end and side holes reduce risk of
trauma to vessel, enhances contrast

CATHETERS

Interventional Imaging
Procedures
Intervene w/ disease, provide

therapeutic outcome
Purpose/ benefits

Lower risk compared to surgery


Less $
Shorter hospital stay and recovery
Alternative for non surgical patient

Preparation to procedure
Anti coagulants- what do these do?
Consent form
NPO 8 hours
Lab tests to test kidney function?

Post Procedure Care


Catheter removed compression

applied
Bed rest- min 4 hrs/ head elevated 30

degrees
Vital signs
Extremity watch

Radiation Protection
> radiation dose to angio team- fluoro
Proximity to patient
Radiation protection devices
Leaded glasses pulled into place
Minimal fluoro use as possible
Collimation
Angio personnel wear badges and ring

monitors

Contra Indications
Contrast allergy
Impaired renal function
Blood- clotting disorders
Anti coagulant medication
Unstable cardio pulmonary/ neurological

status

Risks/ Complications
Bleeding at puncture site
Thrombus formation
Embolus formation plaque dislodged

from vessel wall by catheter


Dissection of vessel
Puncture site infection ( contaminated
sterile field)
Contrast reaction