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A. C. Roberts and J. E. Silberzweig
as often performed for native artery or arterial bypass
graft occlusions, is no longer performed for hemodialysis
access grafts because the procedure would take hours to
days to dissolve the thrombus.
Pulse-spray thrombolysis
Pulse-spray thrombolysis is the technique most commonly used for administration of thrombolytic agent into
a thrombosed AVG. This technique is characterized by
the high-pressure delivery of small aliquots of highly concentrated thrombolytic agents via a multi-sidehole catheter. It allows for the homogeneous and simultaneous distribution of concentrated thrombolytic agent throughout
the entire length of the occluded graft. This type of
distribution enhances the diffusion of the thrombolytic
agent in the clot and produces some mechanical disruption of the clot matrix, increasing the surface area exposed to the thrombolytic agent. Although the thrombolytic agent lyses most of the graft thrombus, residual
thrombus is often within the graft. Removal of the residual graft thrombus requires additional maneuvers, including balloon maceration of the thrombus or balloon
thrombectomy.
A number of commercially available catheter systems
are suitable for pulse-spray procedures. The catheters
used most often are the multi-sidehole infusion catheter
(Cook Inc.) and the multislit catheter (Angiodynamics,
Queensbury, NY, U.S.A.). These catheters have multiple
sideholes or slits over a length of 4 to 30 cm. A tip-occluding guidewire is used to allow the thrombolytic agent to
spray out the sideholes rather than primarily exiting the
larger endhole. A hemostatic Touhy-Borst (Y adapter)
allows injections around the guidewire. Injections of the
0.2 mL aliquots of urokinase are performed every 20 to
30 seconds. If the length of sideholes on the catheter is
shorter than the clot being treated, after about half of the
urokinase has been administered, the catheter is repositioned to treat the remainder of the clot.
Lyse and wait
One variation of the thrombolytic infusion technique is
known as “lyse and wait.” This technique was originally
described as injection of 250,000 U of urokinase mixed
with 5000 U of heparin through a standard intravenous
catheter inserted within the venous limb of the graft. The
graft was then manually compressed at the arterial and
venous anastomoses while the urokinase–heparin mixture was infused over 1 minute into the graft. This portion
of the procedure can be performed in a holding area
outside the interventional radiology suite. After at least 30
minutes, the patient was transferred to the interventional
radiology suite, and the declotting procedure was continued. Introducing the urokinase–heparin mixture into the
graft before bringing the patient into the interventional
radiology suite resulted in the declotting portion of the
procedure using little or no room time and avoided the
added expense of an infusion catheter.
28
The “lyse and
wait” technique has recently been reported with the use of
29
tPA.
Mechanical thrombectomy
Percutaneous mechanical thrombectomy (PMT) is becoming an established means of restoring flow to thrombosed hemodialysis access grafts. The term percutaneous
mechanical thrombectomy refers to the use of mechanical
energy to clear thrombus percutaneously with the use of
any combination of mechanical dissolution, fragmentation, and aspiration. Compared with other thrombolytic
techniques, mechanical thrombolysis with a device offers
the potential for more efficient clot removal. The following devices and techniques have been used for dialysis
graft declotting.
Pulse-spray with heparin
One clinical study suggested that pulse-spray intrathrombic injection of heparinized saline without thrombolytic
agent is as effective for AVG declotting as pulse-spray
injection of urokinase, indicating that mechanical effects
are primarily responsible for clot lysis.
studies, however, concluded that forced intrathrombic
injection of urokinase produce faster and more thrombolysis compared with intrathrombic injections of sa-
31,32
line.
Percutaneous aspiration thrombectomy
(thromboaspiration)
Percutaneous aspiration thrombectomy involves the removal of thrombus by manual suction through a large-lumen aspiration catheter such as a vascular sheath or a 7
to 8 French angled guiding catheter. One recent study
using manual thromboaspiration for thrombosed hemodialysis access grafts showed a high technical success rate;
however, the mean procedure time was nearly 2 hours.
Balloon-assisted thrombectomy
Percutaneous balloon mechanical thrombectomy without
administration of a thrombolytic agent has been reported
to be feasible for treatment of occluded dialysis access
34
grafts.
Using this technique, all the clots are pushed into
the pulmonary circulation. The major potential drawback
of this technique is the risk of symptomatic and potentially
fatal pulmonary embolism.
35
Recirculation mechanical thrombectomy
During recirculation mechanical thrombectomy, thrombus is pulverized into microscopic fragments by using devices that generate a hydrodynamic vortex. The Amplatz
Thrombectomy Device (Microvena, White Bear Lake,
MN) uses a rotating impeller blade at the tip of the cathe-
30
Two in vitro
33
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ter that pulverizes the clot. The high rotation speed of the
impeller generates a strong recirculation vortex. The clot
enters the endhole at the tip of the device, becomes fragmented by the rotating blades, and recirculates out from
three sideholes.
36
One drawback of this system is that the
device is not steerable.
The AngioJet catheter (Possis, Minneapolis, MN,
U.S.A.) uses a saline jet and aspiration system to create a
Venturi effect. High-speed retrograde fluid jets create an
area of low pressure (Venturi effect), resulting in a zone
of hydrodynamic recirculation that pulls and fragments
thrombus. The AngioJet is a 5 Fr catheter that can track
over a guidewire.
37
Nonrecirculation mechanical thrombectomy
Thrombus is macerated with the use of mechanical fragmentation. The Arrow-Trerotola percutaneous thrombolytic device (PTD) consists of a rotating nitinol basket
driven by a hand-held electric motor (Fig. 36-5). The
rotating basket strips thrombus from the walls of the graft
and macerates the thrombus into small fragments. The
resulting fragments are aspirated from the side port of
the vascular sheath.
38
The MTI thrombolytic brush catheter (Micro Therapeutics, San Clemente, CA, U.S.A.) consists of a 6 Fr
infusion catheter housing a coaxial nylon brush with a
diameter of 6 mm and a length of 10 mm. The brush is
coaxially rotated by a hand-held electric motor used with
simultaneous infusion of thrombolytic agent through the
catheter, which results in both mechanical fragmentation
of the clot and increased clot surface area exposed to the
thrombolytic agent.
37
The Gelbfish Endo-vac system is a mechanical thrombectomy device that both fragments and aspirates thrombus. A “clot-spoon” is manually reciprocated through a 6
Fr sheath to fragment the clot. The clot fragments are
FIGURE 36-5. Fluoroscopic image of the Arrow-Trerotola percutaneous thrombolytic device within a thrombosed hemodialysis graft.
mobilized by saline irrigation through the sheath and removed by aspiration through the sidearm of the sheath.
37
Treatment of venous stenoses
When the thrombolytic agent is administered or mechanical thrombectomy is performed, it is not necessary at this
point for the graft to be completely free of clot. The most
crucial aspect of thrombolysis is the reestablishment of
flow through the thrombosed segment. It is common to
find a significant degree of clot lysis and yet still have slow
flow in the graft. Attention should be directed toward
determining why the flow is not normal. The most common reason is a venous stenosis limiting outflow from the
graft. Other possibilities include resistant thrombus at the
arterial anastomosis, incomplete administration of urokinase to the entire clot, insufficient heparinization, or
infected thrombus that is resistant to lysis. Injection of
contrast and visual evaluation of the graft should allow
determination of the venous stenosis or the residual clot
at the arterial anastomosis.
The first intervention, after administration of a thrombolytic agent or use of a mechanical thrombectomy device, is treatment of venous stenosis, which is present in
90% of thrombosed grafts.
rial inflow may also be present, but treatment of that clot
should follow the venous intervention. The venous stenosis is treated with balloon angioplasty. Relieving the
stenosis will allow outflow from the graft and minimize
bleeding from around the catheter or previous dialysis
needle-puncture sites. Residual clot within the graft then
can be macerated with the same angioplasty balloon.
At times, it may be difficult to visualize the venous
stenosis because of the overlapping outflow veins. If necessary, multiple views of the proximal venous outflow
should be obtained so that the stenosis can be identified.
When the stenosis is found, it should be dilated with an
appropriately sized angioplasty balloon. The balloon diameter is determined by the diameter of the PTFE graft
and the size of the draining vein. Usually a 6-mm balloon
is used, but sizes from 5 mm to 8 mm may be more appropriate in some situations. Angioplasty with a high-pressure
balloon is often helpful because these stenoses are often
somewhat resistant to dilatation. In some cases, the stenosis may not respond to the first dilatation, and multiple
prolonged inflations may be necessary to expand the balloon and thus efface the stenosis completely. In some
cases, the balloon may inflate completely but the stenosis
is still present. This situation represents elastic recoil that
usually can be treated by using a larger angioplasty balloon. In some cases, insertion of a stent may be necessary
to overcome the elastic recoil (Fig. 36-6).
atherectomy also has been described for treatment of balloon-resistant lesions,
10,27,39
Resistant clot at the arte-
40,41
Directional
42
but no study has demonstrated
466 A. C. Roberts and J. E. Silberzweig
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superior results for venous lesions following atherectomy
compared with angioplasty.
43
Treatment of arterial plug
Residual thrombus at the arterial anastomosis is a common finding. This lysis-resistant plug is present at the
arterial anastomosis in up to 60% of patients.
rial plug is removed by a “balloon thrombectomy” procedure (Fig. 36-7). Thrombectomy is performed using a
standard Fogarty embolectomy balloon catheter (Baxter,
Irvine, CA, U.S.A.), an 8.5-mm occlusion balloon catheter (Meditech, Inc., Watertown, MA, U.S.A.), or an “overthe-wire” Fogarty balloon catheter (Baxter). A guidewire
is carefully positioned past the residual clot and into the
native artery. The occlusion balloon catheter then is
placed over the wire and situated just past the clot. Using
dilute contrast, the balloon is inflated and the catheter
pulled back, displacing the clot into the graft. This procedure is performed using fluoroscopy to avoid arterial
injury and overinflation of the balloon in the native artery. As the balloon is pulled back next to the clot, it is
often necessary to expand the balloon slightly to dislodge
the clot. Several passes of the balloon may be necessary
39
The arte-
to dislodge the clot from the side of the graft. After the
plug is dislodged, it may become trapped in the graft,
usually at the site of the crossed catheters. If this occurs,
the angioplasty balloon is used to macerate the clot,
which is now safely within the graft.
Unlike conventional angioplasty balloon catheters, the
compliant nature of the Fogarty balloon allows relatively
atraumatic manipulation within the inflow artery and
arterial anastomosis of hemodialysis grafts. Use of a noncompliant angioplasty balloon to pull adherent clot from
the arterial anastomosis of a hemodialysis graft may cause
excessive shear stress within the graft or native artery and
increase the risk of vascular injury. The thrombectomy
procedure is similar to surgical thrombectomy. Compared with the blind surgical procedure, however, the
angiographic procedure has the advantage of fluoroscopic guidance; a wire can be placed beyond the clot
serving as a guide for the catheter and immediate angiographic evaluation.
Completion study
Following thrombolysis, balloon dilatation of the venous
outflow stenosis, and removal of the arterial plug, the
A
Artery
Balloon
Catheter
Clot
B C
FIGURE 36-6. Lysis-resistant plug near arterial anastomosis. (A). A persistent narrowing near the
arrow
arterial graft anastomosis (
hemodialysis graft declotting. (B). The plug was mobilized with the use of a Fogarty balloon
catheter. (C). Restoration of a patent graft lumen.
) is the lysis-resistant plug frequently encountered during
Hemodialysis Access Management
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A B
FIGURE 36-7. Stent insertion for venous outflow stenosis. (A). A stenosis in the basilic vein beyond the venous anastomosis
was treated with a 7-mm balloon angioplasty. There was significant elastic recoil despite complete inflation of the angioplasty
balloon. (B). The residual narrowing was treated with insertion of an 8-mm diameter Wallstent.
467
entire graft should be evaluated. The arterial inflow, the
body of the graft, and the venous outflow to the superior
vena cava should be assessed for residual thrombus or
stenoses. Intragraft pressure measurement can be used to
assess the adequacy of the inter vention. A drop from
arterial pressure to venous pressure is expected throughout the length of the graft. An intragraft systolic pressure
of 40% of systolic arterial blood pressure can be considered borderline between normal function and dysfunc-
44
tion.
A graft pressure greater than 40% of systolic pres-
sure is suggestive of venous outflow stenosis.
If dialysis is to follow the declotting procedure immediately, the vascular sheaths can be exchanged for dialysis
sheaths (Angiodynamics, Glen Falls, NY, U.S.A.). These
sheaths come as a set; one catheter is red and directed
toward the arterialinflow, and the otheris blue and placed
with the tip directed toward the venous outflow. Placement of these catheters helps to speed the procedure because access site compression is not required and spares
the patient reaccessing the graft in the dialysis center.
Recently, vascular sheaths (Micro Therapeutics) have become commercially available through which both the declotting procedure and hemodialysis can be performed.
■ Other causes of graft thrombosis
Other causes of thrombosis are much less common than
perianastomotic venous stenoses. Arterial stenosis is a contributing factor in fewer than 15% of treated grafts.
10,39,45
Visualization of the artery is performed best by placing a
catheter just at the arterial anastomosis. Manual compression of the graft, inflation of a blood pressure cuff or
placement ofa tourniquet above thegraft, or inflation of a
Fogarty balloon catheter within the venous limb of the
graft can be used to allow reflux of contrast into the arterial inflow. Multiple angiographic projections may be
needed to assess the arterial anastomosis.
If an arterial anastomotic stenosis is identified, it may
be possible to place a wire from the graft, through the
anastomosis, and into the artery and to perform an angioplasty. If an angioplasty balloon cannot be manipulated across the stenosis from a graft approach, direct
puncture of the artery can be used to access the stenosis.
Angioplasty at the arterial anastomosis should be performed cautiously. The artery is not as forgiving as the
vein and may represent a significant blood supply to the
fingers. The size of the angioplasty balloon catheter must
be chosen carefully, and the catheterization should be
performed cautiously. In some cases, the arterial anastomosis may appear narrowed because of a surgically tapered anastomosis. Overdilatation may result in anastomotic rupture.
Stenoses within the graft are uncommon. The cause of
such stenoses is not understood. They may be caused by
mural thrombus, or they may represent hypertrophy of
the neointima that develops on the luminal surface of the
46
graft.
Central venous stenoses are another uncommon cause
of thrombosis. In the setting of graft thrombosis, there is
usually a simultaneous peripheral stenosis that is more
likely to have been the inciting cause of thrombosis. The
subclavian vein is the most common central vein to be
involved as a result of venous injury from previous dialysis
access catheters.
47,48
Patients with previous internal jugular vein catheters have a 0 to 10% incidence of significant
central vein stenosis compared with a previous subclavian
catheter, where the incidence is 42 to 50% (Fig. 36-8).
49,50
Stenoses in any portion of the outflow probably should be
treated because they may contribute to the potential for
graft thrombosis. The consequences of central vein
stenoses include the potential for compromise of future
dialysis access and significant upper-extremity swelling.
The initial treatment for central venous stenoses is balloon angioplasty. Elastic recoil after angioplasty is characteristic of central venous lesions. The results of balloon
angioplasty are poor, with a 6-month cumulative primary
patency of only 28.9% in one study.
6
One recent study of
central venous stenting reported promising short-term
patency results.
51
468 A. C. Roberts and J. E. Silberzweig
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FIGURE 36-8. Central venous stenosis. The left brachiocephalic vein stenosis probably was related to the presence of
the indwelling hemodialysis catheter (
arrow
).
■ Complications of Thrombolysis
Complications associated with pulsed-spray thrombolysis
are uncommon. Bleeding is infrequent. Occasionally,
bleeding from previous puncture sites occurs, usually developing when graft flow has been reestablished but the
venous stenosis has not yet been dilated. The best treatment is gentle compression over the bleeding site and
angioplasty of the venous outflow. Severe bleeding requiring termination of the procedure or other therapy has
occurred in fewer than 1% of patients undergoing pulsespray thrombolysis.
39
Embolization into the arterial system is also uncommon. If it occurs, it usually can be treated with additional
thrombolytic agent, administered by placing a catheter
into the affected artery and positioning the catheter at
the clot. Alternatively, an occlusion balloon catheter or
Fogarty embolectomy catheter can be placed into the
artery beyond the clot, and the clot is pulled back into the
graft. Aspiration thrombectomy is an additional maneuver that can be used to remove arterial emboli. The best
treatment is prevention; careful guidewire and catheter
manipulations at the arterial anastomosis will minimize
the risk of embolization.
■ Results
The immediate technical results of pulse-spray thrombolysis have been excellent. Time for lysis has been decreased from several hours to fewer than 20 minutes, at
which time flow has been reestablished and angioplasty
can be performed.
10,39
Total procedure times are less
than 2 hours and not uncommonly are only slightly more
than 1 hour. Most importantly, successful lysis can be
achieved in 96% of cases with a clinical success rate of
92%.
Long-term primary patency of thrombosed dialysis
grafts is relatively poor; however, this is true with both
percutaneous and surgical approaches to thrombosed dialysis grafts. Primary patency at 1 year is 11 to 26%,
and secondary patency at 1 year is 51 to 69%.
26,53
27,51,52
Studies
directly comparing surgical thrombectomy with thrombolysis demonstrate similar patency rates.
54,55
■ Conclusion
Hemodialysis access failure is a major cause of morbidity
for patients undergoing hemodialysis. Prevention and
treatment of dialysis graft thrombosis are important but
frustrating clinical problems. The National Kidney Foundation recently formulated Clinical Practice Guidelines for
Vascular Access in an effort to reduce patient morbidity
and improve patient survival and quality of life. Two
primary goals of these guidelines are to encourage the
placement of native arteriovenous fistulae and the detection of access dysfunction prior to access thrombosis.
56
Significant progress has been achieved in the therapy
for thrombosed dialysis grafts. The procedure of graft
declotting has been refined so it takes less time and less
thrombolytic agent, and results in fewer complications.
The pathophysiology underlying venous stenoses is beginning to be understood, and there has been an improvement in the early detection and treatment of the
stenoses. Prevention of the development of neointimal
hyperplasia remains to be solved.
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guidelines for vascular access. Am J Kidney Dis 1997;30 (suppl 3):
150–191.
IndexIndex
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Index
Abdominal aorta, 203, 204f–205f, 205–206
anatomy of, 203, 204f–205f, 205–206
aneurysms in, 225–227, 226f, 227f
coarctation of, 224
and visceral branches
CTA of, 46
indications for, 43, 45
MRA of, 45–46, 46f, 48f
indications for, 43, 45
ABIs (ankle brachial indices), in peripheral
vascular disease, 61
Abscess, percutaneous drainage of, 115–119
appendiceal, 118
complications, 117
diverticular, 118
efficacy of, 117
in empyema and parapneumonic effusions, 118
with enteric communication, 117
follow-up to, 116–117
guidance choices for, 115
hepatic, 117
lung, 118–119
pancreatic, 117–118
pelvic, 118
procedure for, 115–117
renal, 117
retroperitoneal, 117
splenic, 118
subphrenic, 117
Access needles, in catheterization
arterial, 9–10, 9f, 10f
organ, 102–103, 103f
Acquisition. See Image acquisition
ACTH (adrenocorticotropic hormone), in venous
sampling for hyperaldosteronism, 435–437
Acute limb ischemia, 220–228
clinical categories of, 220, 221t
nonatherosclerotic causes of, 221, 222f
in peripheral vascular disease
causes of, 57–58
clinical categories of, 59, 60t
physical examination in, 59
in thromboembolic disease, 220–223, 222f–223f
traumatic causes of, 228, 229f–230f, 230
treatment for, 223–224, 224f
Adenocarcinoma, pancreatic ductal, 406–407, 408f
Adenomas
hepatic, 378–379
renal, 277–278, 279f
renin-secreting, 279–280
Adolescent male, asymptomatic varicocele in, 322
Adrenal glands
anatomy of, 435, 436f–437f
hyperaldosteronism. See Hyperaldosteronism
percutaneous needle biopsy in, 115
Adrenal hyperplasia, bilateral, 434
Adrenal veins, anatomy of, 207, 207f
Adrenocorticotropic hormone, in venous sampling
for hyperaldosteronism, 435–437
Age, as peripheral vascular disease risk factor, 55
Aldosterone-producing adenoma, 434
Aldrete scoring system, conscious sedation patients
and, 28
Aliasing artifact, 33, 35f
Alteplase, for thrombolysis, 83
American Society of Anesthesiologists, physical
status classification, 27–28, 28t
Amplatz filter, 249
Amplatz guidewire, 13t
for organ access, 103
Amputation
in acute limb ischemia, 223
in peripheral vascular disease, 212–213
Analgesics, for conscious sedation, 26, 26t
Anastomoses
arterial, 345–346, 346f, 347f
portosystemic, 349
postoperative strictures and, 356
Aneurysm
abdominal aortic, 225–227, 226f, 227f
defined, 225
femoral artery, 227
hepatic artery, 381–382, 382f
lower-extremity, 227–228, 227f
popliteal, 211, 227–228, 227f
and pseudoaneurysms, upper GI bleeding caused
by, 363
pulmonary pseudoaneurysm, traumatic, 158,
158f
Rasmussen, 158
splenic artery, 386, 387f, 388f
thoracic aortic. See Thoracic aortic aneurysms
Aneurysm disease, 225–228
Angiofibroma, juvenile, 195–197
Angiography. See also Computed tomography
angiography; Magnetic resonance angiography
in Buerger’s disease, 183
digital subtraction, 3–4, 20–21, 20f
film-screen (cut-film), 3, 17
of head and neck
contraindications for, 201
indications for, 201
versus other modalities, 201
trauma as indication for, 192–193, 196f
in lower extremity trauma, 228, 229f–230f, 230
for pelvic hemorrhage treatment and diagnosis,
305–310, 306f–310f
embolization in, 298, 299f
in Raynaud’s syndrome, 182, 182f
refractory epistaxis as indication for, 198
of spine
contraindications for, 201
indications for, 199–201
other modalities,
versus
in Takayasu’s arteritis, 183, 183f
for upper GI bleeding, 365f, 367–370, 368f, 368t,
370f
Angiography suite
infection control regulations for, 141–142, 141t
physician health and safety risks in, 137–142
infection, 137–138
postexposure protocols and prophylaxis,
140–141
reduction strategies, 139–140, 139t, 140f
Angioinfarction, renal cell carcinoma and,
282–283, 282f
Angiomyolipoma, 278–279, 279f
Angioplasty. See Percutaneous transluminal
angioplasty
Angled catheters, 13t, 14
Angulation, in percutaneous needle biopsies, 113
Ankle brachial indices, in peripheral vascular
disease, 61
Antegrade puncture, in balloon angioplasty of
superficial femoral and popliteal arteries, 77,
78f
Anticoagulation therapy
contraindication to, 239
for pulmonary deep-vein thrombosis, 236
for recurrent pulmonary embolism, 236
Mobin-Uddin umbrella as adjunct to, 237
Aorta
abdominal. See Abdominal aorta
coarctation of. See Aortic coarctation
congenital diseases of, 174–176, 175f
imaging of, 174–176
treatment of, 175f, 176
dissection of. See Aortic dissection
occlusion of, acute, 215f
pseudocoarctation of, 174, 176
thoracic. See Aortic arch; Thoracic aorta
trauma to. See Aortic trauma
Aortic arch, anatomy of, 147, 148f
congenital variants for, 147, 148t
normal versus variants, prevalence of, 148t
Aortic arteritis syndromes, 171–173, 172f
imaging modalities for, 172
treatment of, 172–173
Aortic coarctation
abdominal, 224
congenital, 174–176, 175f
pseudocoarctation, 174, 176
Aortic dissection, 163–168, 164f–167f
clinical features of, 167
imaging modalities for, 164f, 166f, 167–168
201
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Aortic dissection (continued)
treatment of, 168
Aortic trauma, 169–171
clinical features of, 169–170
imaging modalities for, 170–171
penetrating, 171
treatment for, 171
Aortitis terminalis (of Leriche), 3
Aortoenteric fistula, upper GI bleeding and, 364
Aortofemoral arteriography, 21–22
Aortoiliac angioplasty, 72–76, 72f–76f
Appendiceal abscess, percutaneous drainage of,
118
Aprons, protective, 133
Arrow-Trerotola percutaneous thrombolytic device,
465
Arterial anatomy. See also specific arteries
above diaphragm, 147, 148f, 148t
anastomotic, 345–346, 346f, 347f
below diaphragm, 203, 204f–206f, 205–207
of gastrointestinal tract, 339–345.340f
Arterial plug, in hemodialysis access graft,
treatment of, 466, 467f
Arterial spasm, during upper-extremity
arteriography, 179
in Raynaud’s phenomenon, 182
Arterial stimulation and venous sampling, for
pancreatic endocrine tumors, 434
Arterial thoracic outlet syndrome, 184–185, 185f
Arteriography
aortofemoral, 21–22
bronchial, 158–160, 158f–160f
diagnostic, 71
digital subtraction, intraarterial, 20
in hyperparathyroidism, 427–430, 427f, 428f,
430f
in lower GI bleeding, 412, 413f
in pancreatic carcinoma, for preoperative
evaluation, 407, 408f
pancreatic/hepatic, 433–434, 433f
pudendal, 314–315, 315f
pulmonary. See Pulmonary arteriography
in Raynaud’s phenomenon, 182, 182f
in renal artery disease, 270, 274–275, 275f
splenic injury and, 385
upper-extremity, techniques of, 179–180, 179f
in upper GI bleeding, 364–366, 365f–367f
Arteriomegaly, 225
Arteriosclerosis obliterans, 211–220
Arteriovenous fistulae, 94, 304–305, 305f
Arteriovenous graft, for hemodialysis access, 459.
See also Hemodialysis access grafts
Arteriovenous malformations, 197–198, 304, 304f
embolization for, 94, 95f
gastroduodenal
lower GI bleeding and, 412–415, 414f
upper GI bleeding and, 364
pulmonary, 156, 157f, 158
spinal angiography for, 199
Arteritis
aortic. See Aortic arteritis syndromes
Takayasu’s, 171–172, 183, 183f, 192, 194f
ASA (American Society of Anesthesiologists),
physical status classification, 27–28, 28t
Aspiration of fluid, 102
drainage catheters for, 103–104, 104f
in percutaneous abscess drainage, 115–116
Aspiration thrombectomy, percutaneous, 224
Aspirin, upper GI bleeding and, 359
ASVS (arterial stimulation and venous sampling),
for pancreatic endocrine tumors, 434
Atheroocclusive disease, chronic. See Chronic
occlusive disease
Atherosclerosis
of arteries of neck, 191, 193f
arteriography in, 211, 212f
diagnostic arteriography for, 211, 212f
peripheral, PTA for, 72
renovascular hypertension and, 267, 268f
surgical procedures in, 211, 212t
of upper extremities, 180, 180f, 181f
AVFs (arteriovenous fistulae), 94, 304–305, 305f
AVG (arteriovenous graft), for hemodialysis access,
459
AVMs. See Arteriovenous malformations
Axillary arter y
access to, 11
anatomy of, 147, 149f
Axillosubclavian vein obstruction, 185, 186f
Azygos vein, anatomy of, 150f, 151
Balloon-occlusion catheters, for embolization, 89
Balloons
detachable. See Detachable balloons, varicocele
occlusion with
in gastrostomy tube placement, 129
percutaneous dilation, of nonmalignant biliary
strictures, 402, 403f
method of, 402, 403f
in thrombectomy, hemodialysis access grafts
and, 464
Barkow, arc of, 345–346
Barrett’s esophagus, upper GI bleeding and, 362
ic veins
Basil
anatomy
of, 150f, 151
central venous access port in, 445–446, 448f
BCV (brachiocephalic vein), anatomy of, 150f, 151
Bentson guidewire, 13t
Benzodiazepines, for conscious sedation, 26, 26t
Berenstein catheters, 13t, 14
Beta-blockers, for aortic dissection treatment, 168
Biliary stents, 102, 104, 106f
Carey-Coons, 104, 106–107
expandable metal, 400–401, 401f
percutaneous-endoscopic team approach, 400
percutaneous transhepatic placement, 400
plastic, 400
Biliary strictures, nonmalignant, percutaneous
balloon dilation of, 402, 403f
Biliary tree, 391
cholangiographic findings in, 392, 394f, 395t
interventional procedures in, 393–395
balloon dilation of nonmalignant biliary
strictures, 402, 403f
percutaneous biliary drainage, 395–397, 398f,
399f
percutaneous cholecystostomy, 402–404, 404f
stent placement, 399–400
obstruction in
causes of, 102
therapeutic relief of, 102
radiological evaluation in, 391–392, 392f
stent placement in, 106
stricture etiology and, 392–393, 395f–397f, 395t
vascular anatomy in, 349–350, 350f
Biopsy
fine-needle aspiration, 110, 111f, 113
percutaneous organ access for, 102. See also
Percutaneous needle biopsy
Bird’s nest filter, 243–244, 244f
Bismuth numbering system, in liver anatomy,
349
Bleeding
active, embolization for, 90–91, 93
bronchial artery, 158–159, 159f
duodenal, 368, 369, 370f
lower GI. See Lower gastrointestinal bleeding
upper GI. See Upper gastrointestinal bleeding
Blood pressure, monitoring during conscious
sedation, 27
Blood testing, following pathogen exposure, 140,
140t
Blood urea nitrogen levels. See BUN (blood urea
nitrogen) levels
Bloodborne pathogens, 137–138
OSHA (1992) standard, 141–142
Blue toe syndrome, 57, 57f, 214
Blunt trauma
aortic. See Aortic trauma
renal. See Renal trauma
upper-extremity arteriography in, 181
BOCs (balloon-occlusion catheters), for
embolization, 89
Body cavity, percutaneous access to. See Organ
access, percutaneous
“Bolus chasing” techniques, 21
Bougienage, for esophageal strictures, 353–354
Brachial artery
access to, 11
anatomy of, 147, 149f
Brachiocephalic vein, anatomy of, 150f, 151
Brescia-Cimino fistula, for hemodialysis access, 460
Bronchial arteriography, 158–160, 158f–160f
materials and equipment in, 159–160
Bronchial artery
bleeding from, 158–159, 159f
embolization of, 158–159, 158f, 160, 160f
in hemoptysis management, 158–160
spinal branch from, 159, 160f
Buckled aorta, 174, 176
Budd-Chiari syndrome, 381, 381f
Buehler, arc of, 345, 346f
Buerger’s disease, 225, 225f
upper-extremity arteriography in, 182–183
BUN (blood urea nitrogen) levels
in obstructive uropathy and renal calculus
disease, 287
in upper GI bleeding diagnosis, 360–361
Cancer patients
gastric, upper GI bleeding and, 362–363
vena cava filter placement in, 239–240
Cannulation, pyloric and duodenal, in gastrostomy
tube placement, 126–127, 127f
Capnography, during conscious sedation, 27
CAQ (Certificate of Added Qualifications), 4
Carbon dioxide, as contrast agent, 23–24
Carcinoma. See Cancer patients; specific types of cancer
Cardiac catheterization, for giant cell arteritis, 173,
173f
Cardiovascular and Interventional Radiologic
Carey-Coons biliary stents, 104, 106–107
Carotid arteries
Catheter-related thrombosis, 455–456
Catheter systems, for embolization, 89
Catheterization
Catheters, 12–15
Cavernous hemangioma, hepatic, 378, 378f
CBD (common bile duct), 393, 396f
Celiac artery, anatomy of, 203, 204f, 339, 441f–342f
Central venous access
of Europe,
Society
anatomy of, 189, 190f, 191f
extracranial, CTA and MRA of, 52
noninvasive studies of, 52
catheters for, 12–15. See also Catheters
guidewires in, 12, 13t
pulmonary arter y, 154
sheaths and dilators in, 10
vascular access in, 7–9, 8f
femoral artery, 10–11
needles for, 9–10, 9f
translumbar, 11–12
upper extremity, 11
balloon-occlusion, for embolization, 89
in bronchial arteriography, 159
characteristics of, 14
common types, 13t
custom versus preformed, 13–14
displacement of, as gastrostomy tube placement
complication, 456
parts of, 14
for percutaneous organ access, 103–104,
104f–106f
abscess drainage, 116
removal, 117
for pulmonary arteriography, 154, 155f
shape of, 14–15, 14f
side holes in, 14, 15, 15f
in thrombolysis, 83–84, 84f–85f
catheter management and removal in, 454
complications with, 454–456
infectious, 456
long-term, 455
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mechanical, 455
procedural, 454–455
thrombotic, 455–456
device insertion in, 449t
Hohn catheter, 447
nontunnelled, centrally placed catheters, 447
peripherally inserted central catheter, 449
subcutaneous ports, 449–451, 452f, 453f
tunnelled catheters, 447–449, 450f, 451f
device selection for, 444
devices for, 441–444, 442f, 443t
chest wall catheters, 442–444, 442f
subcutaneous ports, 443f, 444
placement techniques in, 444–447
extremity veins, 445–446, 448f
internal jugular vein, 445, 447f
subclavian/axillary vein, 444–445, 445f, 446f
unconventional sites, 446–447, 449f
venous access, 444
Cephalic veins
anatomy of, 150f, 151
central venous access port in, 445–446
Certificate of Added Qualifications, 4
Cervical stenosis, 333
false passage creation in, 333–334, 334f
CFA. See Common femoral artery
CHD (common hepatic duct), 393, 396f
Chemoembolic therapy (chemoembolization),
97–99, 97f
in hepatocellular carcinoma, 376–377
Chest, percutaneous needle biopsy in, 115
Chest roentgenography
for aortic arteritis syndromes, 172
for aortic trauma, 170–171
for giant cell arteritis, 172f, 173
for thoracic aortic aneurysms, 169, 170f
Chest-wall catheters
insertion technique for, 449–451, 452f, 453f
nontunnelled, 442, 442f
tunnelled, 442–444, 442f
Chiba needle, 102–103
Cholangiocarcinoma, 377, 377f
Cholangiography
of biliary tree, 391–392, 394f, 395t
T-tube, 350f
Cholecystostomy, percutaneous. See Percutaneous
cholecystostomy
Cholescintigraphy, of biliary tree, 391
Chronic occlusive disease
angiographic findings in, 213–214, 214f–215f
in peripheral vascular disease
clinical categories of, 59, 60t
physical examination in, 58
symptoms of, 57
Rutherford criteria in, 211–213, 213t
treatment for, 214, 216–217, 216f–221f, 220
Chronic pancreatitis, 393, 395f
Cine MRA, 30
Cirrhosis, 379, 379f
Budd-Chiari syndrome and, 381, 381f
CIRSE (Cardiovascular and Interventional
Radiologic Society of Europe), 4
Claudication
of foot, 56
in occlusive disease, 212
sites of, 56
vasculogenic versus neurogenic, 56
CNIS (carotid noninvasive studies), 52
Coarctation of aorta. See Aortic coarctation
Coaxial catheter system, for embolization, 89
Cobra catheters, 13t, 15
in bronchial arteriography, 159
Coils, varicocele occlusion with, 327
Colic arteries, anatomy of
ileocolic, 344
left, 344–345, 345f
middle, 344
right, 344
Colon
ischemia of, 420
strictures of, 356–357, 357f
Color Doppler ultrasonography, in peripheral
vascular disease, 67–69, 68f
Common bile duct, 393, 396f
Common femoral artery
in balloon angioplasty of superficial femoral and
popliteal arteries, 77
and infrapopliteal angioplasty, 80
Common hepatic artery, anatomy of, 339–340
Common hepatic duct, 393, 396f
Computed tomography
in abdominal aortic aneurysm evaluation, 226
of biliary tree, 391, 392f
in gastrostomy tube placement, 124, 125
helical. See Helical CT scanning
of kidney, anatomy relevant to, 259f, 260–262,
261f, 262f
in mesenteric ischemia, 417, 417f
in pancreatic carcinoma, 407
of pelvic fractures, 298–300
uroradiographic studies, 300
in percutaneous needle biopsy, 112
principles of, 35
in pulmonary embolism, 153, 156
spiral. See Helical CT scanning
for target localization, 101, 102
technology
Computed tomography angiography
of abdominal aorta and visceral branches, 46
advantages of, 38
contrast-enhanced, of thoracic aorta, 49–50, 49f
of extracranial carotid arteries, 52
image display in, 36
image postprocessing techniques in, 38–39, 40f
limitations of, 38
of lower-extremity arteries, 42–43
of neck, versus angiography, 201
principles of, 36
of pulmonary arteries, 50–51, 51f
in renovascular hypertension, 269–270
source data for, 38–39
technique in, 36, 37f
of thoracic aorta, 49–50, 50f
timing in, 36, 37f
Computed tomography venography
of inferior vena cava, 43
of lower-extremity veins, 43
of mesenteric veins, 48–49
of portal veins, 48–49
of splenic veins, 48–49
of thoracic veins, 52
Conscious sedation
agents for, 26, 26t
ASA physical status classification and, 27–28, 28t
evaluating patient for, 25
monitoring during, 25–26
Continuous wave Doppler instrumentation, in
Contrast agents, 23–24
flow rates, 19t
injection techniques for, 22–23, 22f
Contrast sensitivity, of digital subtraction
Contrast venography, for lower-extremity deep-vein
Coronary arteries, anatomy of, 147, 148f–149f,
Couinaud numbering system, in liver anatomy,
Crossed-catheter approach, to thrombosed graft,
Cruveilhier-Baumgarten syndrome, 348
CT. See Computed tomography
CTA. See Computed tomography angiography
Cut-film (film-screen) angiography, 3, 17
CW (continuous wave) Doppler instrumentation, in
Cystic artery, anatomy of, 340, 342f
Cystic medial necrosis, aortic dissections caused by,
of, 35–36,
electrocardiogram, 27
pulse oximetry, 27
recovery period and, 28
vital signs, 26–27
peripheral vascular disease evaluation, 63–64
angiography, 20–21
thrombosis, 233–234, 234f
148t
349
462–463, 463f, 464t
peripheral vascular disease evaluation, 63–64
163
37f–38f, 38
Declotting procedure, in hemodialysis access grafts,
462–463, 462f, 463t
Deep sedation, 25
Deep-vein thrombosis
diagnosis of, 233–236, 234f, 235f
epidemiology of, 233
medical management of, 236–237
Detachable balloons, varicocele occlusion with,
327–329, 328f
complications with, 329
Diabetic patients, peripheral vascular disease in,
214, 215f
Dialysis. See Hemodialysis
Dialysis sheaths, 467
Diaphragm
vascular anatomy above, 147, 148f–150f, 148t, 151
vascular anatomy below, 203, 204f–208f, 205–209
Dieulafoy’s disease, 363
Digital “road mapping,” 21
in balloon angioplasty of superficial femoral and
popliteal arteries, 277
Digital subtraction angiography, 3–4, 20–21, 20f
advantages and disadvantages of, 21
intravenous, 20, 29, 32
of lower-extremity arteries, 44f
radiation dose and, 134
in upper-extremity imaging, 180
Digital subtraction arteriography
aortofemoral, 21–22
intraarterial, 20
Dilation, in gastrostomy tube placement, 127–128,
128f
Dilators, in catheterization, 10
Distance, radiation protection and, 132, 133
Diverticular abscess, percutaneous drainage of, 118
Diverticulosis, bleeding with, 412, 413f
Doppler ultrasonography
in peripheral vascular disease, 67–69, 68f
waveform analysis, 63–64, 64f, 68
in renovascular hypertension, 268–269
Dotter angioplasty technique, 3
“Dottering,” 3
Double-J ureteral stents, 104, 105f, 106–107
Double-wall needles
for arterial access, 9–10, 9f
in percutaneous interventions, 71
Drainage catheters, 103–104, 104f
placement of, 105–106
Drainage procedures, percutaneous, 105–108, 107f
of abscess, 115–119. See also Abscess,
percutaneous drainage of
of, 102
goal
modalities for, 101–102
imaging
materials for, 102–105
principles of, 105–108, 107f
Droperidol, for conscious sedation, 26, 26t
Drummond, marginal artery of, 346
DSA. See Digital subtraction angiography
Duodenum
bleeding from
following endoscopic sphincterotomy, 369, 370f
ulcer and pyloroduodenal, treatment of, 368
cannulation of, in gastrostomy, 126–127, 127f
and gastric strictures, 356
Duplex ultrasonography
of neck, versus angiography, 201
for penile arterial anatomy evaluation, 313–314,
314f
in peripheral vascular disease, 67, 69
DVT. See Deep-vein thrombosis
Dwight, marginal artery of, 343
Echo times, 29
Eclampsia, HELLP syndrome and hemorrhage in,
302
Effective radiation dose
NCRP recommendations, 131
Webster’s formula for, 132
weighting factors for, 132t
Electrocardiographic monitoring, during conscious
sedation, 27
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