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

2. © Vascular 20072 Types 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