1. Chapter 25 Circulatory System and Cardiac Catheterization
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Systems of Circulatory System
Major portion- Blood-Vascular System- transports blood
Minor portion-Lymphatic System- collects fluid from tissue spaces, filters through lymph s
Both carry oxygen and nutrients to tissues in continuous, endless unidirection
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

3. Anatomy: Blood-Vascular System
Consists of
Heart
Arteries
Capillaries
Veins
Heart = pumping mechanism to keep blood in motion through vessels
Arteries = carry blood away from heart
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

4. 2 Circulatory Systems
Both transport waste products to organs of excretion
Skin
Lungs
Liver
kidneys
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

5. Anatomy: Blood-Vascular System
Veins = carry blood toward heart
Heart has two circulation circuits
Systemic
Pulmonary
System circulation carries oxygenated blood to organs and tissues
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

6. Anatomy: Blood-Vascular System
Pulmonary circulation takes blood to lungs to exchange carbon dioxide for oxygen
Then carries oxygenated blood from lungs to heart for the systemic circulation
Two main trunk vessels arise from heart
Aorta = branch that begins systemic circulation
Pulmonary trunk = branch that begins pulmonary circulation
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

7. Anatomy: Systemic Circulation
Aorta exits left ventricle of heart
Artery = main branch of aorta; usually named by location
Arteriole = smaller branch of artery
Capillary = smallest vessel; connects arterioles and venules; supply oxygen and remove waste
Venule = smaller branch of vein
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

8. Anatomy: Systemic Circulation
Vein = larger vessel for returning blood to heart; usually lie parallel to main artery and carry same name
Superior and inferior vena cava = primary (largest) veins; return systemic blood to right atrium to begin pulmonary circuit
Portal system = pathway of venous drainage from abdominal organs through liver before returning to inferior vena cava
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

9. Anatomy: Circulation System
Pulmonary, systemic, and portal circulation; red = oxygenated, blue = deoxygenated, purple = nutrient-rich
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

10. Anatomy: Heart Central organ of blood vascular system
Four chambers = two atria and two ventricles; divided by septum
Myocardium = muscular wall of heart
Endocardium = inner lining of heart
Epicardium = thin membrane that covers heart
Pericardial sac = double-walled outermost covering of heart
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

11. Anatomy: Heart Atria = upper, receiving chambers
Ventricle = lower, distributing chambers
Right atrioventricular (AV) valve or tricuspid valve = controls opening between right atrium and ventricle
Left AV valve or mitral valve = controls opening between left atrium and ventricle
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

12. Anatomy: Heart
Heart and great vessels; black arrows = deoxygenated blood flow, white arrows = oxygenated blood flow
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

13. Anatomy: Heart
Right side of heart handles venous, or deoxygenated blood
Left side of heart handles arterial, or oxygenated blood
Coronary arteries supply blood to the myocardium of heart
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

14. Anatomy: Coronary Arteries
Anterior aspect
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

15. Definitions and Indications
Blood Vascular System
Definitions and Indications
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 15

16. Definitions
Angiography = general term referring to radiologic examination of vascular structures after the introduction of a contrast medium
Arteriography = refers to the radiologic examination of arteries via contrast injection
Venography = refers to the radiologic examination of veins via contrast injection
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

17. Indications and Definitions
Claudication - leg pain and cramping
Stenosis - narrowing of vessel; usually due to atherosclerosis
Occlusion -blockage of a vessel; often caused by atherosclerosis
Aneurysm = weakened area of artery
“ballooned”
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

18. Indications Suspected tumors Anatomic variances
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

19. Vascular Procedures Contrast media Injection techniques Equipment
Catheterization
Procedures
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

20. Contrast Media Water-soluble iodinated medium used most commonly
Nonionics cause fewer physiologic side effects and allergic reactions
Nonionics are also less nephrotoxic than ionics
Different concentrations used for various procedures
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

21. Injection Technique Automatic injector is most commonly used
Has settings for injection rate, volume, and maximum pressure
Also has a time interval setting to reduce chance of catheter whiplash
Injectors are programmed to coincide with the filming sequence
Manual injection is done rarely
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

22. Equipment Digital equipment most commonly employed
Digital subtraction is widely used
Instantly “subtracts” overlying bony structures from images to allow better visualization of contrast-filled vascular structures
Cinefluorography also still used in cardiac catheterization procedures
Rapid film changers are rarely seen today
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

23. Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

24. Catheterization
Catheter is a small, flexible tube inserted into the vessel through which contrast is introduced
Advantages
Less risk of extravasation
Allows selective injections of specific vessels
Flexible patient positioning
Can be safely left in body while images are acquired
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

25. Catheterization
Seldinger technique = most widely used method of catheterization
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

26. Patient Care Complications include Vasovagal reaction Stroke
Heart attack
Death
Bleeding at puncture site
Nerve, vessel, or tissue damage
Allergic reaction to contrast
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

27. Preparation of Examination Room
Prior to patient arrival
Clean and prepare room
Check equipment for proper operation
Set exposure technique
Check crash cart for operation and stock
Obtain sterile procedure tray
Set nonsterile supplies in convenient location
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

28. Angiographic Team Members
Physician – usually an interventional radiologist
CIT = cardiovascular-interventional technologist
Other specialists, e.g., anesthetist, nurse
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

29. Procedures Aortography Pulmonary arteriography
Thoracic
Abdominal
Pulmonary arteriography
Selective abdominal visceral arteriography
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

30. Procedures Central venography Selective visceral venography
Peripheral angiography
Upper limb arteriography
Upper limb venography
Lower limb arteriography
Lower limb venography
Cerebral angiography
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

31. Thoracic Aortography Purpose
Rule out aortic aneurysm
Evaluate congenital or postsurgical conditions
Evaluate aortic dissection
Biplane imaging recommended so PA and lateral obtained with one contrast injection
CR directed perpendicular to T7
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

32. Thoracic Aortography Vessels demonstrated Thoracic aorta
Proximal brachiocephalic
Proximal carotid
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

33. Abdominal Aortography
Purpose
Abdominal aortic aneurysm
Occlusion
Atherosclerotic disease
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

34. Abdominal Aortography
Injection rate
25 mL/sec
60 mL total volume
Image acquisition rate
Two exposures/sec for 4 seconds
Then slows to one/sec for 4 seconds
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

35. Abdominal Aortography
Vessels demonstrated – AP
Abdominal aorta from diaphragm to bifurcation
Renal artery origins
Aortic bifurcation
Course and general condition of visceral branches
Vessels demonstrated – lateral
Origin of celiac artery
Origin of superior mesenteric artery
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

36. Pulmonary Arteriography
Purpose
Evaluation of pulmonary embolic disease
Simultaneous AP and oblique projections recommended
Injection rate
25 mL/sec for 50 mL total volume
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

37. Pulmonary Arteriography
Image acquisition rate
Two to four images/sec for 4 seconds
Then slows to one/sec for 4 seconds
Vessels demonstrated
Pulmonary arteries
Left atrium
Left ventricle
Thoracic aorta
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

38. Selective Abdominal Visceral Arteriography
Purpose
Visualize tumor vascularity
Rule out atherosclerotic disease
Thrombosis
Occlusion
Bleeding
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

39. Central Venography Two studies Purpose Superior venacavogram
Inferior venacavogram
Purpose
Rule out existence of thrombus or occlusion of central veins
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

40. Central Venography
Superior venacavogram performed by accessing axillary or subclavian vein
Inferior venacavogram performed by accessing femoral vein and placing catheter in common iliac vein or inferior aspect of inferior vena cava
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

41. Peripheral Angiography
Upper limb arteriography
Used primarily to evaluate traumatic injury, atherosclerotic disease, or other vascular lesions
Upper limb venography
Purpose: rule out thrombosis or occlusions
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

42. Peripheral Angiography
Lower limb arteriography
Purpose: demonstrate atherosclerotic disease
Lower limb venography
Used to rule out deep vein thrombosis
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

43. Cerebral Angiography
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

44. Anatomy Basilar bifurcates into R and L posterior cerebral arteries
Anterior and posterior cerebral arteries connected by communicating arteries at midbrain level to form circle of Willis
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

45. Purpose Investigate intracranial vascular lesions such as Aneurysms
AVMs
Tumors
Atherosclerosis
Stenosis
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

46. Interventional Radiology
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 46

47. Interventional Radiology
Percutaneous transluminal angioplasty
Transcatheter embolization
Percutaneous nephrostomy tube placement
Inferior vena cava filter placement
Transjugular intrahepatic portosystemic shunt
Other procedures
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

48. Percutaneous Transluminal Angioplasty
PTA = therapeutic procedure designed to dilate or reopen stenotic or occluded area in vessel
Balloon angioplasty is used to dilate strictures in venous structures, ureters, and GI tract
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

49. Transcatheter Embolization
Involves therapeutic introduction of various substances to occlude or drastically reduce blood flow within a vessel
Three main purposes
Stop active bleeding sites
Control blood flow to diseased or malformed vessels (e.g., tumors or AVMs)
Stop or reduce blood flow to a particular area before surgery
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

50. Inferior Vena Cava Filter
Used to trap emboli to prevent pulmonary embolism resulting from deep vein thrombosis of lower limbs
Filters available in a variety of shapes
Delivered via a catheter system and assume their functional shape as they are released
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

51. Other Procedures Thrombolytic therapy Foreign object removal
Used to dissolve thrombus intravascularly
Foreign object removal
Stones and other occlusive objects can be retrieved via a special catheter with snare at the end
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

52. Other Procedures Lymphography
Radiologic examination of the lymph vessels and nodes through the use of a contrast media
Seldom used today due to advances in CT and MRI
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

53. Cardiac Catheterization
Comprehensive term used to describe a minor surgical procedure involving the introduction of special catheters into the heart, great vessels, and coronary arteries
Both diagnostic and therapeutic treatment may be done in a single procedure
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

54. General Indications
Identify the anatomic and physiologic condition of the heart
Coronary angiography = most definitive procedure for visualizing coronary anatomy
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

55. General Indications
Information from coronary angiography includes presence and extent of
Obstructive coronary artery disease
Thrombus formation
Coronary artery collateral flow
Coronary anomalies
Aneurysms
Spasm
Artery size
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

56. Risk Factors Relative contraindications Active GI bleed
Acute or chronic renal failure
Recent stroke
Fever
Severe electrolyte imbalance
Severe anemia
Short life expectancy due to other illness
Digitalis intoxication
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

57. Risk Factors Relative contraindications – cont’d
Patient refusal of therapeutic treatment such as PTCA or bypass surgery
Severe uncontrolled hypertension
Coagulopathy and bleeding disorders
Acute pulmonary edema
Uncontrolled ventricular arrhythmias
Aortic valve endocarditis
Previous anaphylactic reaction to contrast
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

58. Specialized Equipment
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

59. Specialized Equipment
Physiologic monitoring equipment
ECG
Hemodynamic
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

60. Specialized Equipment
Other
Emergency crash cart
Oxygen and suction
Temporary pacemaker
Pulse oximeter
Defibrillator
Blood pressure cuff
Intraaortic balloon pump
ACT machine
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.

61. Catheter Introduction
Femoral artery = most common introduction site
Also used
Radial
Brachial
Axillary
Jugular
Subclavian
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.