Angiography specifically described as: 1- Arteriography which is the imaging of the arteries . 2- Venography which is the imaging of the veins . 3- Angiocardiograhy which is the imaging of the heart . 4- Lymphograpy which is the imaging of the Lymphatic nodes /vessels .

The angiography Team 1- Radiologist The angiography Team 1- Radiologist . 2- Nurse ( or technologist assists with sterile and catheterization procedures) 3- Radiologic technologist .

Consent and preprocedural patient care Consent and preprocedural patient care * Medical history should be obtained ( allergy – renal function ) . * Medication history ( drugs) – some drugs can cause bleeding during the exam . * Detailed examination will be give to the patient (possible risks and complications). * No food 8 hours before exam . * Patient well hydrated . * Premedication drug to keep the patient calm * Vital signs obtained and recorded . * Puncture site shaved and cleaned . * Continual communication with the patient .

Vessel access for contrast media injection To visualized the vessel of interest , a catheter must be introduced to inject contrast media . Commonly method of catheterization is Seldinger technique . It is a percutaneous ( through the skin) technique . Three vessels for catheterization: 1- femoral . 2- Brachial . 3- Axillary .

Selection based on : 1- Strong presence of pulse Selection based on : 1- Strong presence of pulse . 2- Absence of vessel diseases . Femoral artery is preferred site because: 1- It size . 2- Easily accessible location . If it is contraindicated because of :- 1- Previous surgical graph . 2- Presence of aneurism . 3- Occlusive vascular disease . Brachial or Axillary artery or vein may be selected .

Step one :- Insertion of the needle . Seldinger Technique Step one :- Insertion of the needle . Step two :- Placement of needle in lumen of the vessel . * Step three :- Insertion of the guide wire . * Step four :- Removal of the needle . * Step five :- Threading of catheter to area of interest . * Step six :- Removal of guide wire .

Other Technique 1- Cut-down : Requires a minor surgical procedure to expose the vessel of interest . 2- Trans-lumber : Patient placed in prone position and a long needle be passed through the abdomen at level of T12 or L2 into the aorta .

CONTRAINDICATIONS 1- Contrast media allergy . 2- Impaired renal function . 3- Blood clotting disorders 4- Unstable cardiopulmonary / neurologic status .

Risks and Complications 1- Bleeding at the puncture site (control by applying compression ) . 2- Thrombus formation ( A blood clot may form in a vessel and disrupt the flow to distal part .). 3- Embolus formation ( A piece of plaque from the vessel wall due to catheter and occlusion may result ) . 4- Dissection of the vessel ( A catheter may tear the intima of the vessel ). 5- Infection of the puncture site(Due to contamination of the sterile field ) . 6- Contrast reaction( Mild , moderate , severe ).

Post procedural care After procedure , catheter is removed and compression applied to the puncture site . The patient remain in bed rest for a minimum 4 hours , head elevated 30 degree , monitored and fetal signs regularly checked – Extremity checked for warmth and color to ensure circulation good – If bleeding from puncture site happen apply pressure – Oral fluid and analgesics given.

Pediatric Application Generally heavily sedated or under general anesthetic for the procedure , depending on the patient age and condition. Neonates are covered with warming blankets to maintain their body temperature . Parents and guardians are not usually permitted in the angiography unit . However , they should given a thorough explanation of the procedure before signing the consent .

Angiographic Imaging Equipment Angiographic Room Equipped for all types of angiographic and interventional procedures and has a wide variety of needles , catheters , and guide wires . It is larger than conventional radiographic rooms and has a sink and scrub area , outlets for oxygen and suction , and emergency medical equipment .

Equipment requirements 1-Table provides access to the patient from all sides .It should have four - way floating capability , adjustable height , and a tilting mechanism . 2- An analog to digital convertor (ADC) system with the image intensifier . 3- Programmable digital image acquisition system that allow selection and acquisition of the imaging rate and sequence , and processing of the images . 4- Specialized x-ray tube with high heat load capacity with rapid cooling . 5- Electromechanical injector for delivery of contrast media . 6- Physiologic monitoring equipment that allows monitoring of the patient venous and arterial pressure and ECG (Especially important for angioplasty and catheterization ) 7- Image archiving method linked to a picture archiving and communication system (PACS) . 8- Laser printer .

Contrast media Water - soluble , non-ionic iodinated substance because of its low osomality and the reduced risk for allergic reactions . Amount depend upon the vessel under examination . Emergency equipment should be readily available and the technologist must be familiar with the protocol in case allergic of reaction by the patient .

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.

Preparing the Patient Room * Must be extensively cleaned * Equipment checked * Room thoroughly stocked * Extra supplies as needed

Angiographic Tray Sterile Items include : 1- Sponge and antiseptic solution . 2- Syringes and needles for local anesthetic . 3- Basin and medical cups . 4- Sterile drape and towels . 5- Sterile image intensifier cover 6- Scalped Blade .

Imaging 1- Once the vessel of interest is catheterized under fluoroscopic guidance – small hand injection of contrast media is given to ensure the catheter is in accurate position . 2- For imaging series , an electro mechanical injector delivers a preset amount of contrast media and images are obtained . 3- Rate of images acquisition is rapid. 4- Review the series of image to determine if additional are needed .

Radiation Protection 1- Use radiation protection devices such as lead apron , thyroid shields and lead glasses. 2- Minimize fluoroscopy time . 3- Precise collimation of the beam . 4- Lead shielding . 5- Beam filtration .

Digital Subtraction Angiography (DSA) Highly sophisticated computer subtracts or removes certain anatomic structures so that resultant image demonstrate only the vessels of interest contrast media ( appear as the reverse image ) and may demonstrate information not appear in non-subtracted .

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