Angiogram

More than 70 million

angiograms are done
per year worldwide
 Types
A. Type of vessel:
• Arteriogram
• Venogram
• Lymphangiogram
B. Invasiveness:
a. Invasive
• Conventional
• DSA
b. Noninvasive
• CTA
• MRA
• CTV
• MRV
• CT-Lymphangiogram,
 Types-contd.
C. Anatomy:
• Central (Coronary, cerebral)
• Peripheral
D. Direction:
• Antegrade
• Retrograde
E: Application:
• Diagnostic
• Therapeutic
 Types-contd.
F. Peri-operative:
• Pre-operative
• Per-operative (Diagnostic, Completion)
• Post-operative
G. Site:
• Non-selective
• Selective
• Super-selective
 Conventional- Angiogram
• The technique was first developed in 1927
by the Portuguese physician and
neurologist Egas Moniz to provide
contrasted x-ray cerebral angiography
• Moniz performed the first cerebral
angiogram in Lisbon in 1927
 Seldinger technique
• Procedure to obtain safe access to
blood vessels and other hollow organs.
• Dr. Sven-Ivar Seldinger (1921-1998),
a Swedish radiologist, who introduced the
procedure in 1953
 Procedure
• The desired vessel or cavity punctured with a
sharp hollow needle called a trocar
• A round-tipped guidewire is then advanced
through the lumen of the trocar, and the trocar is
withdrawn.
• A "sheath" or blunt cannula is passed over the
guidewire into the cavity or vessel.
• After passing a sheath of tube, the guidewire is
withdrawn.
 Diagnostic Catheters and Guide
Wires
• Vascular access is commonly obtained with an 18-gauge
needle that will accommodate most 0.038 inch or smaller
wires. A smaller 21-gauge needle with a 0.018-inch wire
is available in “micropuncture kit” (Cook, Bloomington,
IN) that can be used for difficult femoral, brachial, radial,
or antegrade femoral approaches (Figure 20-2). For a
nonpalpable pulse Doppler, integrated needle (smart
needle) can be used.
• Wires are available in 0.012 to 0.052 inch in diameter.
• Most commonly used are wires of 0.035 and 0.038 inch.
• In a standard guide wire, a stainless steel coil surrounds a tapered inner
core. A central safety wire filament is incorporated to prevent separation in
case of fracture.
• Typically they are 100 to 120 cm in length but can also be 260 to 300 cm.
Wires are available when wire position needs to be maintained for catheter
exchanges.
• Long wires are frequently required in peripheral angiography, more so than
in coronary angiography and their use is encouraged when in doubt.
• The tip of the wires can be straight, angled, or J-shaped.
• Some wires have the capability of increasing their floppy tip by having a
movable inner core.
• Varying degrees of shaft stiffness, e.g., extra support, to provide a strong
rail to advance catheters in tortuous anatomy versus extremely slick
hydrophilic with low friction for complex anatomy have made peripheral
vascular angiography and interventions aviable and many times a preferred
treatment of PAD.
• Catheters are made of polyurethane, polyethylene, Teflon or nylon.
They have a wire braid in the wall to impart torquibility and strength.
They are available in different diameters and lengths.
• They can have an end hole, side holes, or both end and 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.
• Five- to six-French catherter (1-F catheter = 0.333 mm) diameter
catheters are most commonly used.
• Three- to four-French catheters are used for smaller vessels.
• Side-hole catheters are safe and allow large volume of contrast at a
rapid rate with power injectors, e.g. pigtail, Omniflush, Grollman.
They are commonly used for angiography of ascending aorta, aortic
arch, and abdominal aorta.
 Femoral Approach
• CFA is ideally suited because of its large caliber that can
accommodate up to 14-F sheaths percutaneously and its
central location, enabling access to all vascular
territories.
• When compared to the arm approach, there is less
radiation exposure but more incidence of bleeding and
delayed ambulation.
• Both retrograde (toward the abdomen) and antegrade
(toward the feet) CFA punctures are routinely done.
• For the antegrade approach, micropuncture technique
using 21-gauge needle with 0.018-inch wire is
recommended.
• It should always be done under fluoroscopy
• The skin puncture is made at the top of the femoral head.
• A less acute, less than 45-degree angle is usually required for
smooth insertion of the sheath and catheters.
• Long tapered introducer-sheath instruments are sometimes needed.
• A short 4- to 5-F sheath should be introduced first and a cine
angiogram performed to confirm access in the CFA, and wire
position in the superficial femoral artery (SFA) before inserting the
larger and longer sheaths and initiation of anticoagulation
• An ipsilateral 30 to 50 degrees angulation will open up the
superficial and deep femoral artery (DFA) bifurcation.
• Anticoagulation can be reversed at the end of the procedure for
early removal of sheath and to decrease the incidence of bleeding.
 Brachial and Radial Approach

• For radial artery (RA) and 5- to 6-F

sheaths and for
• brachial artery 5- to 7-F sheaths can be
used.
Catheters
Station number 10: Describe the image , how you will manage the case
DSA
 occluded left
subclavian artery
Left subclavian artery widely patent
after stenting.
(1)occlusion of left
superficial femoral artery. (2) Collateral vessels reconstituting
popliteal artery.
Atretic ulnar artery in a patient with
equivocal Allen’s test.
Super selective DSA
PA DSA
PA DSA
DSA
 Extensions

• Color (DSA) - provides a dynamic flow

evaluation, greater understanding of the contrast
flow within the pathology. Assists the clinician in
planning of surgical procedures, and clearly
demonstrate post-procedural results.
• 3D Angiography - provides the radiologist with
a 3D view of vascular structures. 3D view - helps
determine spatial layout vascular structures and
simplifies planning of surgical procedures.
 Contrast Agents
*All current contrast agents are iodine-based.
Classified as
a. ionic or nonionic
b. high-osmolar, isoosmolar and low-osmolar (Low
and iso-osmolar agents cause fewer side effects
in peripheral angiography and are better
tolerated )
• The nonionic agents cause less allergic side-
effects and may also be less nephrotoxic.
• The nonionic, hypo-osmolar and iso-osmolar
agents are more expensive.
 Commonly used iodinated
contrast agents (Generic)
A. Ionic (High osmolar)
• Diatrizoate (Hypaque 50)Monomer300 mgI/ml1550High OsmolarIonic
• Metrizoate (Isopaque 370)Monomer370 mgI/ml2100High OsmolarIonic
• Ioxaglate (Hexabrix)Dimer320 mgI/ml580High Osmolar

B. non-ionic( Low osmolar)

• Iopamidol (Isovue 370)Monomer370 mgI/ml796Low OsmolarNon-Ionic
• Iohexol (Omnipaque 350)Monomer350 mgI/ml884Low OsmolarNon-Ionic
• Ioxilan (Oxilan 350)Monomer350 mgI/ml695Low OsmolarNon-Ionic
• Iopromide (Ultravist 370)Monomer370 mgI/ml774Low OsmolarNon-Ionic
• Iodixanol (Visipaque 320)Dimer320 mgI/ml290Low Osmolar
 Typical Contrast Injection Volumes for
Various Vascular Regions (ml)
• Aortic arch (40)
• Selective carotid (10)
• Selective vertebral (5)
• Selective subclavian/brachial (10)
• Abdomina aorta (40)
• Renal/mesenteric (10)
• Iliac artery (10)
• Infrainguinal segments (10)
• Aorta to pedals (90)
 Commonly Used Contrast Agents
(Brand)
A. Ionic B.Non-ionic
• Hexabrix (dimer 600) • Ioxlian 350
• Bracco (292) • Isovue-200,300,370
• RenoCal-76 (370) • Optiray 160, 320
• Omnipaque 140,
300,350
• Ultravist 150,150
• Visipaque 270 ,320
• Many agents are commercially available in the market based on
their ratio of iodine to ions and concentration of sodium (that
determines their osmolality).
• High-osmolar ionic ratio 1.5 agents contain three atoms of iodine for
every two ions, e.g., Renografin (Bracco), Hypaque (Nycomed), and
Angiovist (Berlex). Their sodium concentration is roughly equal to
that of blood, making their osmolality very high (>1500 mosm/kg).
• They cause significant pain and are generally not tolerated well by
patients undergoing peripheral angiography.
• Low-osmolar ionic ratio-3 agents have three atoms of iodine for
every one ion and are low osmolality agents. Their osmolality is
roughly twice that of blood, e.g., Ioxaglate (Hexabrix, Mallinckrodt).
• Low-osmolar nonionic ratio-3 agents are water-
soluble and do not have any ions, e.g.,
Iopamidol (Isovue, Bracco), Iohexol
(Omnipaque, Nycomed), Ioversol (optiray,
Mallinckrodt). Their osmolality is also twice that
of blood and cause burning in many patients.
• Iso-osmolar nonionic ratio-6 agents have
osmolality equal to that of blood (290 mosm/kg).
They are very well tolerated by patients. Most
commonly used is Iodixinol (Visipaque,
Nycomed).
 contrast medium reactions

A. Mild adverse reactions of the immediate type occur:

• in 3.8–12.7% of patients receiving intravenous injections of high-osmolar, ionic CM
• in 0.7–3.1% of patients receiving low-osmolar nonionic CM
B. Severe immediate reactions have been reported to occur:
• with a frequency of 0.1–0.4% for ionic CM
• with a frequency of 0.02–0.04% for nonionic CM
C. The mortality rate has been estimated to be in the range of 1 in 100 000 examinations
Severe and fatal reactions represent a serious problem in regard to the more than
70 million applications of CM per year worldwide (8).
• The frequency of nonimmediate adverse reactions was recently reviewed by Webb et
al. (9). In the 10 studies cited in this paper, the frequency ranged from 0.5 to 23%.
This large variation may be due to the difficulty in verifying whether symptoms
occurring hours or days after CM exposure are in fact caused by the CM. When
radiological examinations with use of CM were compared with examinations without
CM, most nonimmediate symptoms except skin reactions were found to be unrelated
to the CM administration (10, 11). Thus, various types of exanthema seem to account
for the majority of the CM-induced nonimmediate hypersensitivity reactions. Such
eruptions have been reported to affect some 1–3% of CM-exposed patients (3, 11–
13).
 Symptoms of immediate and nonimmediate
hypersensitivity reactions to iodinated contrast media
A. Immediate
• Pruritus
• Urticaria
• Angioedema
• Flush Nausea, diarrohea,
• Rhinitis (sneezing, rhinorrhea)
• Hoarseness, cough
• Fixed drug eruption
• Dyspnea (bronchospasm, laryngeal edema)
• Hypotension, tachycardia, arrhythmia
• Cardiovascular shock
• Cardiac arrest
• Respiratory arrest
• Pruritus
• Urticaria
• Angioedema
• Exanthema (macular, maculopapular eruption
>50%)
• Erythema multiforme minor
• Fixed drug eruption
• Stevens–Johnson syndrome
• Toxic epidermal necrolysis
• Graft-vs-host reaction Vasculitis
• Risk factors
• The most significant risk factor for an immediate hypersensitivity reaction is
a previous immediate reaction. Previous reactors have a 21–60% risk of a
repeat reaction when re-exposed to the same or a similar ionic CM (4, 22–
24). When patients with a previous reaction to an ionic CM are subsequently
given a nonionic CM, an up to 10-fold reduction in the incidence of severe
repeat reactions has been reported (24). No data are presently available
regarding the frequency of repeat reactions to nonionic CM in patients with
previous reaction to a nonionic CM.
• Other risk factors for more severe immediate reactions are severe allergy,
bronchial asthma, cardiac disease and treatment with beta-blockers (4, 22,
25–27).
• Reported predisposing factors for nonimmediate skin reactions are a
previous CM-induced adverse reaction, interleukin-2 treatment, serum
creatinine level >2.0 mg/dl and a history of drug and contact allergy (12, 20,
21, 28).
• Other potential factors that may influence the severity of a CM reaction
include mastocytosis, viral infection at time of CM exposure and
autoimmune diseases, such as systemic lupus erythematosus (29, 30).
 Risk factors

A. Immediate hypersensitivity
• previous immediate reaction-21–60% risk of a repeat reaction
• severe allergy
• bronchial asthma
• cardiac disease
• treatment with beta-blockers
B. Nonimmediate
• skin reactions
• previous CM-induced adverse reaction
• interleukin-2 treatment
• serum creatinine level >2.0 mg/dl
• history of drug and contact allergy
• mastocytosis,
• viral infection at time of CM exposure
• autoimmune diseases, such as systemic lupus erythematosus
 Local Vascular Complications

Incidence of local vascular complications is 0.5% to 0.6%

These complications comprise:
• Vessel thrombosis,
• Dissection
• Bleeding(free hemorrhage, retroperitoneal bleeding
• Access site hematoma
• Arteriovenous fistula
• Distal embolization,
• False aneurysm (pseudo aneurysm).
Severe stenosis of right ICA
CTA showing “Circle of Willis.”
 CTA showing extremely tortuous carotid
arteries making endovascular intervention an undesirable
option in such cases.
CTA showing thoracic aortic
aneurysm.
 CTA of carotid arteries showing patent
stent in the right common and internal carotid
arteries
CTA of brachial, radial, and ulnar
arteries.
CTA of hand arteries.
 CTA of abdominal aorta and iliac
arteries showing infrarenal abdominal aortic aneurysm and
accessory bilateral renal arteries.
 Large abdominal aortic aneurysm
(arrows), only partially visualized on contrast angiogram.
The
rest of the sac is filled with thrombus.
 CTA of an abdominal aortic aneurysm
showing a large thrombus in the aneurysm not likely to be
visible on a catheter angiogram.
 CTA of an abdominal aortic endograft
showing an endoleak via a collateral between Internal iliac
and
inferior mesenteric arteries (arrow)
 MRA of renal and mesenteric
arteries showing normal vessels and abdominal aorta.
 MRA of below the knee arteries showing
occlusion of right posterior tibial artery (solid arrow) and
occlusion of all three arteries on the left
 CTA of abdominal aorta and pelvic
arteries showing severe calcification of distal aorta,
common
and internal iliac arteries.
Occlusion of the right coronary
artery
Recanalized right coronary artery (RCA) after percutaneous
coronary intervention
Angiogram showing totally occluded left
main coronary artery distally.
Angiogram showing recanalized left main coronary artery
with critical trifurcation lesion involving the distal left main
coronary artery.
Left ventriculogram using a 6F
pigtail catheter. I