Carotid Angiography: Information Quality and Safety Michael J. Cowley, M.D., FSCAI

Carotid Angiography Indications and contraindications Non-invasive methods of vascular evaluation and their utility/appropriateness Potential complications & management Ability to assess risk / benefit Essential Cognitive Knowledge

Carotid Angiography Cerebrovascular pathology: Atherosclerosis - Typical disease states and appearance - Unusual forms of disease Aneurysms AVM’s Bleed Tumor Essential Cognitive Knowledge

Carotid Angiography Vascular Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Technique

Carotid Angiography Vascular Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Technique

Catheter Access Femoral approach whenever possible Better angle of entry to arch vessels Allows forming of complex curve catheters Brachial access is possible but: requires more advanced skills higher complication rates

Carotid Angiography Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Technique

Aortic Arch Angiography To evaluate access to great vessels Identify Arch Type Identify variant anatomy (Anomalies) 5 or 6F Pigtail catheter degree LAO view Hand or power injection ml/sec for 2 seconds

Aortic Arch Angiography To evaluate access to great vessels Identify Type of arch Identlfy ; anatomic variants (anomalies) 5 or 6F Pigtail catheter degree LAO view Field of view: origin of great vessels extending to the carotid bifurcation Patient’s head should be straight with chin turned upward Hand or power injection ml/sec for 2 seconds

Aortic Arch Angiography To evaluate access to great vessels 5 or 6F Pigtail catheter degree LAO view Field of view: origin of great vessels extending to the carotid bifurcation Patient’s head should be straight with chin turned upward Hand or power injection ml/sec for 2 seconds

Courtesy of Mark Burket, M.D. Conventional Arch

Aortic Arch Angiography Variations in Arch Anatomy Configuration: Arch Type Anomalous Vessel Origins Angulation of the arch vessels and the carotid bifurcation angle between the ICA and ECA increases with age Anatomic Features

65-70%:Usual pattern 20-25%:Bovine arch (Left CCA from brachiocephalic) 3%:Separate origin of left vertebral 5%:Various patterns, including right subclavian from distal arch Aortic Arch Angiography Anatomic Features

Tortuous Right Common Carotid LEFT It’s Not Just The Arch That Gets Longer!

Aortic Arch Types

Carotid Angiography Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Technique

Carotid Angiography Ipsilateral oblique and lateral views (additional views may be necessary) Contralateral carotid (Circle of Willis, collaterals, etc) 5 or 6 F with appropriate curve Intracranial angiography also important

Carotid Angiography Site of stenosis Bifurcation involvement Landing zone for EPD Patency of ECA Presence of ICA tortuosity Presence of ulceration Severity of stenosis Lesion length Degree of calcification Presence of thrombus Key Information for Carotid Stenting

Catheter Shapes Simple Curve Catheters Have only a primary (distal) curve Do not need to be formed May not be adequate in tortuous anatomy Complex Curve Catheters Have a primary and secondary curve Must be formed Often will not track over standard wires

Simple Curved Catheters IMA Modified AR1 JR 4 ‘Coronary catheters’ Consider using dedicated catheters!!! Consider using dedicated catheters!!!

Primary Curve Catheters First choice for most selective angiography Wide variety of catheters available, chose one and perfect its use Glide catheters provide improved tracking over softer wires Chose a catheter that will be less traumatic and still allow selection of the arch vessels

H1 or Vertebral Artery Catheter These catheters work well for flat aortic arches

Complex Curved Catheters Simmons 1, 2, and 3 curves VTK

Simmons Catheter: A Closer Look Ideal for Type II-III arch Technique Tip: Re-shape in subclavian artery with an exchange wire to avoid arch manipulations

Vitek, Simmons 1,2,3 Catheters Selective Catheter Choice

Complex Curve Catheters Allow for access proximally displaced vessels (Type 2 & 3 Arch or bovine arch Can be formed by placing the primary curve in the left subclavian artery and advancing the secondary curve toward the ascending aorta Avoid forming in the ascending aorta whenever possible Do not track well over most wires May require exchange length wires to change to a simple curve catheter after access is obtained

Complex Curve Catheters Allow for access proximally displaced vessels (Type 2 & 3 Arch or bovine arch Can be formed by placing the primary curve in the left subclavian artery and advancing the secondary curve toward the ascending aorta Avoid forming in the ascending aorta whenever possible Do not track well over most wires May require exchange length wires to facilitate placement of a simple curve catheter once access is obtained

Engaging a Simmons II Engaging a Simmons II Catheter

Carotid Angiography Dx catheter engages innominate and road map of carotid bifurcation done Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance Catheter advanced over guidewire into CCA Guidewire removed Angio performed in ipsilateral oblique and lateral views (and other views if necessary) Right Common Carotid Artery

Extracranial: - Ipsilateral oblique - Lateral - AP Intracranial: - AP cranial (Townes view) - Lateral - Ipsilateral oblique, caudal Carotid Angiography Views

Right Carotid Artery Pass angled guidewire into CCA using road map image Avoid advancing wire across diseased segment Fix wire and advance catheter over wire Position catheter tip in porox 1/3 of CCA Remove wire slowly from catheter

Carotid Angiography Using roadmap, retract catheter from Asc Aorta with clockwise rotation Position catheter close to origin of L CCA and turn counter- clockwise to engage CCA Pass angled guidewire into CCA using road map image; avoid advancing across diseased segment Fix wire and advance catheter over wire Position catheter tip in porox 1/3 of CCA Remove wire slowly from catheter Left Carotid Artery

Carotid Angiography Dx catheter engages innominate and road map of carotid bifurcation done Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance Catheter advanced over guidewire into CCA Guidewire removed Right Common Carotid Artery

Intracerebral Angiography Anterior cerebral circulation viewed by PA cranial (15-20 degrees) and lateral views Important to visualize both arterial and venous phases: - Intracerebral disease - Collateral circulation - Presence of AVM, aneurysm, isolated hemisphere - Missing arterial phase vessels (allows identification of embolization post CAS)

Intracerebral Angiography

Carotid Angiography Non-ionic contrast preferred Minimize contrast volume used Use lower risk catheter curves when possible Minimize catheter manipulations Avoiding Complications

Avoid Excessive catheter manipulation

Severe Atheroma of the Aorta

Carotid Access Issues Clinical status: Symptomatic vs Asx Technical challenges: - Duration of catheter dwell time - Number of catheter exchanges - Contrast volume, fluoro time High risk anatomic features (not high risk clinical features) Complication Risk determined primarily by case selection Complications

Carotid Angiography High quality baseline angiography is essential for optimal carotid stenting Understanding necessary elements and anatomic variations assures quality imaging Intracranial and extracranial angiography is essential for pre and post intervention Proper catheter selection and careful technique insures safest possible angiography Summary