angiography basics

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

2. © Vascular 2007 2
Types of angiographyTypes of angiography
Conventional
angiography
Digital
subtraction
CT
angiography
MR
angiography
You can see the
bony skeleton
The bony
skeleton is
subtracted
Index

4. So advanced CT, US and
MRA techniques made
conventional angiography
limited to therapeutic
purposes (Angioplasty).

5. Technique
of
angiography

6. Personnel in the Angio Room
 Radiologist ( or other specialist)
 Cardiovascular nurse
 2-3 Radiologic Technologists (CV)
 Sometimes Anesthesiologist depending
on the procedure

7. 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

8. Angiography/ Interventional/
Cardiovascular
 Procedure Room
(Suite)
 Room size- 400-
600 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

9. Equipment found in all
Advanced Procedure Rooms
 X-ray generators
 Controls
 X-ray Tubes
 System to record events of procedure
 Automatic Injectors

10. X-Ray Tube Requirements
 Detail
 Withstand high heat- rapid exposure
sequences
 Use smallest possible focal spot

11. 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

12.  Electromagnetic Injectors
 Monitoring Equipment- BP & ECG
 Island Tables- access from all sides,
height adjustments, floor controls
 Tables do not usually tilt

13. Digital Imaging- Analog VS
Digital Concepts
 Analog- image seen after chemical
process
 Digital- image manipulated by software
 Information changed through use of
computer algorithm

14. 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)

15. 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

16. Seldinger Technique
 Method for catheterization of vessels
 Developed 1950’s 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

17.  Selection based on
strong pulse w/
absence of disease
 Site cleaned, area
draped, local given

18. Seldinger Technique ( step-by-
step)
 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

19. SELDINGER TECHNIQUE

20.  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

21. Let’s Look at Needles, Guide
wires and Catheters
 Cannula
 connecting hub (luer
lock)
 Baseplate
 transparent tubing

22. 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

23. GUIDEWIRES

24. 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

25.  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

26. CATHETERS

27. 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

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

29. Post Procedure Care
 Catheter removed – compression
applied
 Bed rest- min 4 hrs/ head elevated 30
degrees
 Vital signs
 Extremity watch

30. 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

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

32. 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