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aortic segment. A less than 50% dilation of the aorta is referred to as
81,82
ectasia.
for AAA, CTA is often required to assess the extent and complications
of an AAA and to plan treatment.
CTA exam, true short- and long-axis measurements of the aneurysm
must be reported. The distance between the lowermost renal artery
CH
and the superior border of the aneurysm, referred to as the neck, p r o-
14
vides a standardized description of its location. Computed tomographic angiography can assess the shape and angulation of the neck,
measure the maximum diameter of the AAA, and provide a thorough
assessment of the iliac and femoral arteries. These determinations are
important, especially when consideration is being made for endovascular aneurysm repair (EVAR;
angiography can visualize mural thrombus and calcification within
the aneurysm, which have important implications for EVAR (
Identifying the number and location of the renal arteries, the presence
of a retroaortic left renal vein, and assessment of the mesenteric and
hypogastric arteries also are important for operative planning.
SurveillAnce following endovASculAr AneurySm repAir
Computed tomographic angiography is the modality of choice
for surveillance of patients who have undergone EVAR because it
assesses potential complications, including endoleaks. A post–stentgraft examination consists of precontrast dynamic first circulation
imaging, and immediate delayed postcontrast imaging. The precontrast study allows identification of calcification so that it is not confused with endoleak. The immediate delayed postcontrast study
may identify a slow endoleak that might be missed on the dynamic
first circulation study.
used to measure the maximum external dimensions of the aneurysm sac, the lumen of the aortic stent-graft along with its two limbs,
the distance between the proximal margin of the stent-graft and the
inferior margin of the most inferior renal artery, and the lower margin of the stent-graft and the iliac artery bifurcation of each side.
and thereby increase the potential for continued aneurysm growth
and rupture. A type I endoleak is either a proximal or distal
Although ultrasound is the preferred screening modality
81
Regardless of the indication for a
Fig. 14-5). Computed tomographic
83
Computed tomographic angiography is
Endoleaks cause increased pressure within the aneurysm sac
Fig. 14-6).
attachment site endoleak, and is usually discovered during implantation. Delayed type I endoleak may be related to changes in tortuosity of the aorta secondary to aneurysm reshaping and should
be suspected on CT when acute hemorrhage or contrast pooling
is found in the aneurysm sac adjacent to the device attachment
84
site.
Type II endoleak, the most common form of endoleak, is
caused by continued blood flow into the aneurysm sac through
a small arterial branch that is excluded by the stent-graft. This type
of endoleak resolves spontaneously in most instances and is seen
as a small area of contrast opacification within the aneurysm. It
is often located at a distance from the graft.
85
Type III endoleak is
caused by mechanical disruption of the material of an endograft
or by separation of an iliac extender from the main graft. This type
of endoleak is considered high pressure and carries a high risk for
rupture. It appears as a large central collection of contrast distant
from the landing zone of the graft.
86
A type IV endoleak is due to
graft porosity, which is often detected near the time of implantation prior to endothelialization of the graft conduit. This type of
endoleak is self-healing and resolves with cessation of anticoagulation. A type V endoleak is result of endotension from arterial pressurization within the aneurysm sac and is without an identifiable
cause. This is a diagnosis of exclusion after CTA and invasive angiography fail to identify an alternative type of endoleak.
84
Vasculitis
In the abdomen, CTA also has a role in assessing vascular wall and
branch vessel changes associated with large-vessel and mediumvessel vasculitis, such as Takayasu arteritis and poly arteritis
nodosa, respectively. There are four subtypes of Takayasu's arteritis (see Chapter 42): type 1 is confined to the aortic arch and
branches, type 2 involves the descending thoracic and abdominal aorta, type 3 includes type 1 and 2 components, and type 4
combines type 1, 2, and 3 with pulmonary artery involvement. In
patients in the acute stage of vasculitis, CTA findings include thickening and enhancement of the vessel wall. In the chronic form of
the disease, there may be arterial stenosis, occlusion, or aneurysm
formation.
87
FIGURE 14-5 Aortoiliac composite
stent-graft. Multiplanar projection
reformation images depicting usual
appearance of an aortoiliac stent-graft
in axial (left) and sagittal oblique views
(right).
Ave. Diameter 17.45 mm
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Area 239.27 mm
2
Ave. Diameter 13.33 mm
Area 139.58 mm
2
193
CH
14
ComPuTEd TomogRAPHiC AngiogRAPHy
FIGURE 14-6 Aortoiliac composite stent-graft. Three-dimensional (3D) computed tomographic angiography (CTA) volume-rendered image (left) and curved
planar reformation (CPR) (right) showing an aortoiliac stent-graft.
Other Applications of Computed Tomographic
Angiography
RENAL ARTERY DISEASE
The superb isotropic spatial resolution (0.5 × 0.5 ×
CTA enables assessment of the renal arteries that is unsurpassed
by other imaging modalities. There are approximately 6 seconds
between initial renal arterial and venous opacification because of
the rapid transit time within the kidney.
88
This requires acquiring
images with a very high temporal resolution to decrease the
degree of venous contamination. Common applications for CTA
of the renal arteries include renal artery stenosis (RAS) either
from atherosclerosis or FMD, acute renal artery occlusion, and renal
artery aneurysms. Atherosclerotic renal artery disease manifests as
a stenosis occurring at the vessel origin or proximal segment (typically within 2 cm of the ostium).89 Fibromuscular dysplasia often
involves the mid- to distal renal artery and appears as multiple
sequential stenoses (“string of pearls”) and possibly renal artery
aneurysm.
infarction.
90
Acute renal artery occlusion may rapidly lead to renal
89
The CTA appearance includes occlusion of a renal
artery with or without an intimal flap, the former indicting propagation of dissection. Renal artery infarction manifests as wedgeshaped or global perfusion abnormalities. Renal artery aneurysms
are rare and are most commonly detected incidentally (
The most common cause of renal artery aneurysms is associated with atherosclerosis but may also be related to FMD, connective tissue disease, mycotic infection, or vasculitis (e.g., Behçet's
syndrome, polyarteritis nodosa).
89,91
Computed tomographic
0.5 mm) of
Fig. 14-7).
angiography also has a role in surveillance of patients after renal
artery stenting. The biggest limitation of CTA use is that a large proportion of patients with renal artery disease also have advanced
renal dysfunction, precluding a CE-CTA study.
MESENTERIC ARTERY DISEASE
Computed tomographic angiography is useful in the assessment
of mesenteric artery disease, including mesenteric artery aneurysms, dissection, vasculitis, and FMD (Fig. 14-8). Mesenteric artery
aneurysms involve the splenic (60%), hepatic (20%), superior mesenteric (5.5%), celiac (4%), pancreatic (2%), and gastroduodenal
arteries (1.5%).
92,93
Traditionally, these types of aneurysms were
diagnosed by invasive angiography. With the increased speed
and resolution of CTA, they are increasingly detected noninvasively. Usually, celiac artery and superior mesenteric artery (SMA)
dissections result from propagation of aortic dissection. On CTA,
the dissection flap may be visualized in the proximal vessel and
may cause complete occlusion. Rarely, spontaneous dissections
of the SMA may occur. These have a relatively high mortality
94,95
rate.
Stenosis of the celiac axis may be due to a fibrous band
that unites the crura on both sides of the aortic hiatus. This is
termed median arcuate ligament syndrome. Typically, the ligament
crosses superior to the origin of the celiac axis, but in some people there is a variant in which it crosses inferiorly and can cause
compression of the proximal portion of the celiac axis.
96
This diagnosis is suggested by CTA when there is focal narrowing with a
“hook-like” appearance in the proximal celiac axis.
194
CH
14
FIGURE 14-7 Renal artery aneurysm.
Maximal intensity projection (MIP) images
of a distal right renal artery aneurysm
with peripheral calcification.
PERIPHERAL ARTERY DISEASE
Technical Considerations
Contemporary MDCT scanners are capable of assessing the distal
vessels in lower extremities. To image vessels smaller than 1 mm
in diameter, as is the case in pedal vessels, submillimeter detector
collimation is necessary. Patients are placed in a supine position
on the scanner table in a feet-first orientation. The typical field-ofview (FOV) should extend from the diaphragm to the toes, with
an average scan length of 110 to 130 cm. The scanning protocol
begins with a scout image of the entire FOV, followed by a test
bolus or bolus triggering acquisition. Breath-holding may be necessary for the more proximal abdominal station, but not for the
distal stations. This is followed by a CE angiographic acquisition
FIGURE 14-8 Fibromuscular dysplasia (FMD) of celiac artery. Maximal
intensity projection (MIP) images show proximal FMD of celiac artery in lateral
oblique and axial (upper left) orientations.
during the arterial contrast phase. With newer scanners, care must
be taken to set the gantry rotation times and pitch appropriately
to avoid the risk of “outrunning” the contrast bolus. A second late
acquisition of the calf vessels can be obtained in the event of inadequate pedal opacification during the arterial phase. For most CTA
applications, 100 to 140 mL of contrast (with an iodine concentration between 350-370 mg/mL) is administered at a rate of 4 mL/s
and followed by a saline flush.97 Recently a fixed time strategy has
been recommended to image peripheral artery disease (PAD)
(
Table 14-1). In this strategy, the pitch is varied to accomplish a
98
fixed scan time of 40 seconds in all patients. A biphasic injection
protocol is used to provide sustained opacification of the arterial system. This approach standardizes PAD imaging protocols
and consistently enables good-quality scans. Images are reconstructed using a smooth kernel into one data set of thicker slices
at 5.0-mm slice thickness for general assessment, and another data
set of thinner slices of 0.6 to 0.75 mm, incorporating a 25% to 50%
overlap. When stenosis is present, the determination of severity is
typically by visual estimation rather than a computer-based technique. The combination of MIP, CPR, and axial plane imaging will
allow the experienced reader to discern mild (0%-50%), moderate
(50%-70%), and severe (>70%) stenosis.
TABLE 14-1
Contrast agent Low-osmolar nonionic, 350-370 mg/mL
Scan time Fixed at 40 s
Injection duration 35 s
Pitch Variable and adjusted to scan time of 40 s
Delay Bolus trigger to occur on reaching threshold of
Weight-based biphasic
injection rate
HU, Hounsfield unit; s, second.
Biphasic Injection Protocol for Peripheral
Artery Disease Imaging
Suggested Injection Protocol
150-200 HU
< 55 kg: 20 mL (4 mL/s) + 96 mL (3.2 mL/s)
56-65 kg: 23 mL (4.5 mL/s) + 108 mL (3.6 mL/s)
66-85 kg: 25 mL (5.0 mL/s) + 120 mL (4.0 mL/s)
86-95 kg: 28 mL (5.5 mL/s) + 132 mL (4.4 mL/s)
> 95 kg: 30 mL (6.0 mL/s) + 144 mL (4.8 mL/s)
99,100
Atherosclerotic Peripheral Artery Disease
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The major indication for CTA in the evaluation of PAD is in the
diagnosis and preinterventional evaluation of symptomatic
patients (
use open surgical or endovascular therapy for revascularization.
Fig. 14-9). Findings from CTA can assist the decision to
101
Computed tomographic angiography is less useful in patients with
tibioperoneal atherosclerotic disease, since these patients are typically diabetic and have heavily calcified vessels that may preclude
accurate assessment of the degree of stenosis. A meta-analysis of
CTA in PAD including mostly 4-slice systems reported a pooled sensitivity and specificity for detecting a stenosis of greater than 50%
per segment of 92% (95% confidence interval [CI], 89%-95%) and
93% (95% CI, 91%-95%), respectively. The diagnostic performance of
CTA in the infrapopliteal tract was lower, but not significantly different from that in the aortoiliac and femoropopliteal levels.
102–104
At least one study has evaluated the comparative effectiveness of various imaging approaches in PAD. The outcome measures included clinical utility, functional patient outcomes,
quality of life, and diagnostic and therapeutic costs related to
the initial imaging test during 6 months of follow-up. Higher
confidence and less additional imaging were found for MRA
and CTA compared with duplex sonography, and at lower
105
costs.
Peripheral Artery Aneurysm
Approximately 10% of patients with AAAs have femoral and/or
popliteal artery aneurysms (
Fig. 14-10). Popliteal artery aneu-
rysm is defined as arterial diameter greater than 7 mm, and femoral artery aneurysm is defined as arterial diameter greater than
106,107
10 mm.
Computed tomographic angiography has great utility in diagnosing concomitant aneurysms and also helps distinguish popliteal artery aneurysm from Baker cyst or cystic
adventitial disease of the popliteal artery. In the case of femoral
artery aneurysm, CTA is appropriate to define the presence of
iliac and native femoral vessel disease and plan revascularization strategies.
108
FIGURE 14-9 Abdominal computed tomographic angiography (CTA) with
runoff. Maximal intensity projection (MIP) (left) and three-dimensional (3D) CTA
volume-rendered images showing bilateral common iliac aneurysms with distal
runoff disease of right lower extremity. (Adapted from Cohen E, Doshi A, Lookstein
R: CT angiography of the lower extremity circulation with protocols. In Mukherjee D,
Rajagopalan S, editors: CT and MR angiography of the peripheral circulation: practical
approach with clinical protocols, London, 2007, Informa UK Ltd., p. 140.)
195
CH
14
ComPuTEd TomogRAPHiC AngiogRAPHy
97
FIGURE 14-10 Peripheral arterial aneurysms. Three-dimensional (3D) computed tomographic angiography (CTA) volume-rendered images showing a focal aneurysmal
dilation of distal portion of left common iliac artery (CIA) (left), aneurysms of common femoral arteries (CFAs) bilaterally (middle) extending to origins of superficial femoral
arteries, (SFAs) and focal aneurysmal dilation of bilateral popliteal arteries (right). (Adapted from Cohen E, Doshi A, Lookstein R: CT angiography of the lower extremity circulation with
protocols. In Mukherjee D, Rajagopalan S, editors: CT and MR angiography of the peripheral circulation: practical approach with clinical protocols, London, 2007, Informa UK Ltd., p. 140.)
97
196
Vasculitis
The two most common types of arteritis affecting the lower extremity are thromboangiitis obliterans (TAO) (Buerger's disease) and
Takayasu's arteritis (see Chapters 42 and 44 and Fig. 14-10) .
Thromboangiitis obliterans typically affects the small to mediumsized arteries of the extremities, and primarily affects young male
CH
smokers. The distal nature of the disease may favor the use of CTA
14
over MRA in light of the submillimeter resolution of the technique,
which permits imaging of femoropopliteal occlusive disease extending into the tibioperoneal circuit. The angiographic appearance is
one of abrupt vessel occlusion or focal high-grade concentric stenoses associated with extensive collateral circulation, resulting in a
“corkscrew” appearance. Takayasu's arteritis mostly involves the thoracic aorta and brachiocephalic vessels, with less frequent involvement of the abdominal aorta and visceral branches.
109
of arteritis may affect the peripheral circulation but are uncommon.
These include polyarteritis nodosa, Behçet's disease, and Kawasaki
disease. As seen on CTA, the patterns and types of vessels involved
are useful in distinguishing these entities.
Endovascular Stent Evaluation
Computed tomographic angiography may be used for evaluation of
in-stent restenosis, particularly in proximal vessels such as the iliac
and femoral arteries. This may require reconstruction with alternate
kernels and adjustment of window levels. There are only limited
data comparing CT to other modalities for evaluating peripheral
110
stents,
but there are emerging data for other circulatory beds that
are similar or even smaller than lower-extremity vessels. For instance,
a recent prospective study assessed renal in-stent restenosis in 86
patients (95 stents).
111
CTA had a negative predictive value of 100%,
specificity of 99%, and positive predictive value of 90%. For renal
artery in-stent restenosis, computed tomographic angiography was
reported to have a specificity of 95% and positive predictive value
of 56%. In the coronary circulation, sensitivity and specificity using
64-slice systems exceed 90%.
112
In practice, these rates may be lower
owing to significant publication bias in these reports.
Computed tomographic angiography is used to evaluate patients
who have aortoiliac, aortofemoral, or axillofemoral bypass grafts.
Surveillance of grafts is important and is primarily performed by
duplex ultrasound evaluation. Recent studies, however, suggest that
CTA may be superior to duplex ultrasound evaluation.
must be paid to the cumulative radiation dose and the use of contrast agents. Assessment of the graft should include careful evaluation of the proximal anastomotic area to exclude stenosis or
aneurysm, the body of the graft, and the touch-down site of the graft.
OTHER INDICATIONS
A variety of other conditions represent less common indications
for the use of peripheral CTA. These include persistent sciatic
artery, popliteal entrapment, and cystic medial adventitial disease
(
Fig. 14-11). Arteriovenous malformations and fistulas may be well
delineated by acquiring images during the arterial and venous
phase. Computed tomographic angiography imaging may be used
to characterize congenital vascular anomalies.
Artifacts and Pitfalls of Computed
Tomographic Angiography
There are several artifacts that can been seen with CT imaging.
Artifacts include those that are patient related, procedure related,
or reconstruction related. Three of the most common artifacts
include motion artifact, beam hardening, and partial volume
effects. Motion artifacts are due to patients’ body motion during
scanning or inability to hold their breath. Beam-hardening artifacts are due to the passage of photons through structures such as
pacemaker leads, metal clips, or calcium, resulting in lower-energy
photons being filtered out. As a consequence, dark areas are created next to these structures, which can affect assessment of lumen
Other forms
113
114
Attention
FIGURE 14-11 Popliteal artery entrapment. Three-dimensional (3D) computed
tomographic angiography (CTA) volume-rendered (VR) image (posteroanterior
view) of a young patient with right calf pain on exertion. Medial head of right
gastrocnemius muscle demonstrates an abnormal origin lateral to popliteal artery
(closed arrowhead). Inset image shows complete occlusion of right popliteal artery
(arrow) and multiple superficial collateral arteries originating just proximal to this
level. Normal origin of medial head of left gastrocnemius medial to popliteal artery
(open arrowhead) is shown for comparison. (Adapted from Cohen E, Doshi A, Lookstein R:
CT angiography of the lower extremity circulation with protocols. In Mukherjee D,
Rajagopalan S, editors: CT and MR angiography of the peripheral circulation: practical
approach with clinical protocols, London, 2007, Informa UK Ltd., p. 143.)
97
patency. Partial volume effects occur when parts of the voxel of a
structure are affected by other structures with different attenuation
properties. This results in averaging of the CT values for that voxel.
As a consequence, the image appears distorted.
The most frequent artifacts that affect interpretation of CTA are
deviations due to vascular segments affected by moderate to severe
calcification or occupied by a stent. Selection of the adequate windowing set (≈1500 window width) may reduce the unavoidable
blooming effect caused by structures with high signal attenuation.
Cross-sectional MPR images of the vessel of interest are helpful in
visualizing, at least in part, the underlying lumen in the presence
of intense calcification or a stent. Other interpretation pitfalls such
as pseudo-stenoses or pseudo-occlusions may potentially be generated by inadequate image postprocessing (e.g., partial or total
vessel removal during MIP image editing, inaccurate centerline
definition in CPR images).
Summary
With recent advances in CT technology, CT has moved to the
forefront for the diagnosis and assessment of vascular disease.
Understanding CT technology is critical to applying the correct
technique for evaluation of the vascular system. Although artifacts
from severe vessel calcification and stents are potential limitations, the high spatial resolution and rapid throughput of CTA has
enabled its widespread acceptance as a modality of choice in evaluating vascular diseases.
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CHAPTER
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15 Catheter-Based Peripheral
Angiography
Christopher J. White
Catheter-based invasive contrast angiography is the standard
method for diagnosing peripheral artery disease (PAD), and against
which all other methods are compared for accuracy. Angiography
provides the “road map” on which therapeutic decisions are based.
Knowledge of the vascular anatomy and its normal variations is a
core element in the skill set required to safely perform peripheral
vascular angiography and intervention.
Imaging Equipment
There are many radiographic equipment vendors and many different room layout schemes suitable for performing peripheral vascular angiography. However, if both cardiac and noncardiac types of
peripheral vascular angiography are to be performed in the same
room, equipment options become much more limited. One angiographic suite designed to perform both coronary and peripheral
vascular angiography is a dual-plane system (
system encompasses a layout with two independent C-arm image
intensifiers operated by a single x-ray generator and one computer.
A dual-plane system is not synonymous with a biplane system,
which is the simultaneous operation of an anteroposterior (AP)
and lateral (LAT) image acquisition system. In a dual-plane system,
the cardiac C-arm is a three-mode flat-panel image intensifier, and
the noncardiac C-arm should be as large as possible, usually a
15- or 16-inch flat-panel image intensifier. For peripheral vascular
imaging, particularly bilateral lower-extremity runoff angio graphy,
an image intensifier smaller than 15 inches may not be able to
include both legs in the same field. The noncardiac C-arm must be
capable of head-to-toe digital imaging.
Ability to angulate the image intensifier is necessary to resolve
bifurcation lesions and optimally image aorto-ostial branch lesions.
Of the many imaging options available, those most often used include
digital subtraction angiography (DSA), roadmapping, and a stepping
table for lower-extremity (digital subtraction) runoff angiography.
Fig. 15-1). A dual-plane
Radiographic Contrast
Ionic low-osmolar or nonionic iodinated radiographic contrast is
preferred for angiography of the peripheral vessels to avoid patient
discomfort. Low-osmolar contrast agents produce fewer side
effects (e.g., nausea, vomiting, local pain) and offer better patient
tolerability. In addition, low-osmolar agents deliver a lesser osmotic
load and thereby a lower intravascular volume, which may be
important in patients with impaired left ventricular or renal function. Digital subtraction angiography is often preferred because
nonvascular structures are removed and less contrast is required.
Alternatives to iodine-based radiographic contrast include car-
bon dioxide (CO
1,2
mine).
recommended that CO
phragm.
imaging (MRI), is relatively nontoxic in patients with adequate renal
function at a recommended dose not exceeding 0.4 mmol/kg.
To minimize the risk of distal embolization and stroke, it is
3
Gadolinium, traditionally used with magnetic resonance
) and gadolinium (gadopentetate dimeglu-
2
not be used for angiograms above the dia-
2
4
Imaging Technique
Many of the technical aspects of diagnostic cardiac imaging also
apply to performing angiography of the aorta and peripheral vasculature. The basic principle of vascular angiography is not only
to visualize the target lesion but also demonstrate the inflow and
outflow vascular segments. Inflow anatomy constitutes the vascular segment preceding the target lesion, and outflow constitutes
the vascular segment immediately distal to the target vessel and
includes the runoff bed. For example, the inflow segment for the
common iliac artery (CIA) is the infrarenal aorta, and the outflow
segment is the external iliac and femoral vessels. The runoff bed
would be the tibioperoneal vessels.
When performing selective arterial imaging, it is important for
patients’ safety that a coronary manifold with pressure measurement
9-in. Image Intensifier
16-in. Image Intensifier Table Rotates 90° Slave Monitor
FIGURE 151 Dual-plane catheterization laboratory. Note two C-arm image intensifiers (9- and 16-inch), with catheterization table able to rotate 90°.
199
200
be used to monitor hemodynamic status and ensure that damping
of the catheter has not occurred prior to injecting contrast. Use of
pressure monitoring during selective angiography can prevent a
myriad of complications—including the creation of dissections and
air injection.
CH
Angiography may be performed using a “bolus chase” cinean-
giographic method or with a digital subtraction stepping mode.
15
The bolus chase technique involves injecting a bolus of contrast
at the inflow of the territory, then “panning” or manually moving
the image intensifier to follow the bolus of contrast through the
target lesion and into the run-off segment. In digital subtraction
stepping mode, the patient lies motionless on the angiographic
table. A “mask” of the segments to be imaged is taken, and then
contrast is injected. The table moves in steps to image the contrastfilled vessels, from which the mask is then subtracted, leaving only
the contrast- filled vascular structures.
Obtaining Vascular Access
Vascular access for noncardiac diagnostic angiography is most
commonly achieved at the common femoral artery (CFA), with
alternative upper-extremity sites at the radial, brachial, or axillary
5
artery.
The most common complications of angiographic proce-
dures occur at vascular access sites.
A thorough understanding of the relationship of the CFA to
anatomical landmarks is necessary to ensure safe CFA puncture
(
Fig. 15-2). The femoral artery and vein lie below the inguinal liga-
ment, which is a band of dense fibrous tissue connecting the anterior superior iliac spine to the pubic tubercle. The inguinal skin
crease, which is variable in location, is shown as a dotted line in the
figure. Current recommendations are to use fluoroscopic guidance
to image the femoral head to guide CFA puncture.
The most important landmark for femoral access is the head of
the femur. In a morphological study using CT images, there was not
a single case in which a puncture would have passed cranial to the
inguinal ligament or caudal to the femoral artery bifurcation if the
CFA were entered at the level of the center of the femoral head.
Caudal to the femoral head, the CFA is encased in the femoral sheath
and bifurcates into the superficial femoral artery (SFA) medially and
the deep femoral artery (DFA) laterally. With these anatomical observations in mind, the importance of osseous support and entry of the
needle into the CFA at the center of the femoral head is obvious.
6
Anatomical landmarks are initially identified by palpation of
the anterior superior iliac spine and pubic tubercle to locate the
inguinal ligament; position of the femoral head is confirmed fluoroscopically. Depending on the amount of subcutaneous fat, a skin
incision should be made 1 to 2 cm caudal to the level of the center
of the femoral head. The needle is directed in an oblique direction
while palpating the CFA over the center of the femoral head. Once
the CFA has been entered and brisk blood flow returns through the
needle, a soft guidewire is advanced into the iliac artery, and a vascular sheath is inserted to secure vascular access.
Complications of CFA puncture are most commonly related to
arterial entry that is either too high or too low. When the puncture
is too high, a retroperitoneal hemorrhage may occur.
of loose connective tissue in the retroperitoneal space can lead
to large hematomas. Lack of osseous support and presence of a
tense inguinal ligament at the arterial puncture site make manual
compression difficult. Low punctures may be complicated by
formation of arteriovenous fistulas (AVFs), false aneurysms, and
hematomas.
Abdominal Aortography and Lower-Extremity
Runoff
For abdominal aortography, vascular access with a 4 F to 6 F
catheter is obtained in the CFA, although brachial or radial access
may also be used. The angiographic catheter (e.g., pigtail, tennis
racquet, omni flush) is positioned in the abdominal aorta such that
the tip of the catheter reaches the level of the last rib. A power
injector is used to deliver 20 to 30 mL of contrast at 15 mL/sec for
digital subtraction (Fig. 15-3). Either biplane angiography may be
obtained or, if needed, two separate angiograms with single-plane
systems. Three visceral (mesenteric) arterial branches, the celiac
trunk, superior mesenteric artery (SMA), and inferior mesenteric
artery (IMA), arise from the anterior surface of the abdominal aorta
(
Fig. 15-4). The renal arteries originate from the lateral aspect of the
abdominal aorta at the level of L1 to L2. The AP projection allows
7
visualization of the aorta, renal arteries, and iliac artery bifurcation,
whereas the LAT view demonstrates the origin of the celiac trunk
and mesenteric arteries. Commonly in the AP view, the proximal
portion of the SMA obscures the origin of the right renal artery.
When this occurs, selective angiography of the renal artery may be
required to visualize the origin of this vessel.
Generally, a nonselective abdominal aortogram is obtained
before selective renal angiography, using a large format (9- to
8
Presence
FIGURE 152 Schematic of common femoral artery (CFA) anatomical
landmarks.
FIGURE 153 Femoral access. Pigtail catheter contrast injection of 20 mL/sec
for 30 mL (5° left anterior oblique [LAO]) using a digital subtraction angiography
(DSA) technique. Note bilateral renal artery stenosis.
FIGURE 154 Femoral access. Lateral (LAT ) aortogram. Aorta (Ao), with
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celiac trunk (Ce) and superior mesenteric artery (SMA) arising from anterior
aortic surface.
201
CH
15
CATHETER-BAsEd PERiPHERAl AngiogRAPHy
FIGURE 155 Selective renal angiographic catheters. Left, Sos. Middle,
Cobra. Right, Internal mammary artery (IMA) catheter.
16-inch) image intensifier with digital subtraction imaging. The
nonselective aortogram demonstrates the level at which the renal
arteries arise, presence of any accessory renal arteries and their
location, severity and location of aortoiliac pathology, and presence of significant renal artery stenosis. To optimize viewing of the
renal arteries, the angiographic catheter should be placed below
the origin of the SMA, and the image intensifier should be positioned such that the superior, inferior, and lateral borders of both
kidneys are visualized. The ostia of the renal arteries are often better seen with slight rotation of the image intensifier, usually into left
anterior oblique (LAO) position.
Selective Renal Angiography
Selective renal angiography is indicated to identify suspected
renovascular disease. Selective renal artery engagement allows
measurement of pressure gradients, particularly if ostial lesions are
suspected. When measuring pressure gradients across lesions, it is
important to use the smallest catheter possible (i.e., ≤
creating an artificial gradient. The 0.014-inch pressure wire (RADI)
is the optimal method of pressure gradient measurement. Usually,
selective renal angiography is performed with 4 F to 6 F diagnostic catheters (
renal angiography is performed using hand injections with shallow oblique angulations to optimize visualization of the renal ostia
(
Figs. 15-6 and 15-7). Caudal or cranial angulation (15° to 20°) may
occasionally be necessary for better visualization of some ostial
lesions. An optimal image will reveal the ostial portion of the renal
artery and distal branches at the cortex of the kidney.
Fig. 15-5) and a 9-inch image intensifier. Selective
4 F) to avoid
FIGURE 156 Femoral access. Internal mammary artery (IMA) catheter
selectively engaged in right renal artery.
The mesenteric arteries often arise at an inferior (caudal)
angle from the abdominal aorta, for which a shepherd's crook
catheter via femoral artery access is helpful for selective engagement. Alternatively, upper-extremity vascular access allows the
mesenteric arteries to be engaged with a multipurpose-shaped
catheter. Analogous to the renal arteries, selective engagement of
the mesenteric arteries also allows measurement of the pressure
gradient. Selective angiographic images in multiple views are
obtained with hand injections of contrast.
Selective Mesenteric Angiography
As is the case for the renal arteries, nonselective aortography (AP
and LAT) generally precedes selective angiography of the mesenteric arteries. Once the origin of the mesenteric vessel has been
identified, selective angiography may be carried out in the LAT and
oblique views using 4 F to 6 F catheters (Fig. 15-8). The celiac trunk,
SMA, and IMA arteries arise from the anterior surface of the aorta.
There commonly are collaterals between the mesenteric vessels,
and it is uncommon for stenosis or occlusion of a single branch to
cause clinical symptoms.
Aortoiliac and Lower-Extremity Angiography
The abdominal aorta bifurcates into the common iliac arteries
(CIA), which bifurcate into the internal (IIA) and external (EIA)
iliac arteries (
tric artery because this vessel commonly provides collateral circulation to the viscera. The EIA emerges from the pelvis just posterior
to the inguinal ligament. At the level of the inguinal ligament, two
small branches originate from the EIA: the inferior epigastric artery,
which follows a medial direction, and the deep iliac circumflex
artery, which takes a LAT and superior direction.
Fig. 15-9). The IIA is often referred to as the hypogas-
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