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Chapter 13: Radiation-related complications
performing cerebral embolization procedures, special consideration should be given to
the dose to the lens of the eye.
The equipment used for any interventional procedure must be able to estimate and
display cumulative dose in mGy and DA P measurements. Monitoring radiation measurements throughout the procedure helps in reducing exposure to the patient. The radiation
dose level notification helps the interventionalist by allowing him or her to add the previous
radiation dose levels already received by the patient.
If the patient is pregnant, the interventionalist and the medical physicist should evaluate
the potential risk to the embryo or fetus prior to the start of the procedure. Limiting the
dose to the embryo or fetus to no more than 50 mGy should be considered. Avoiding
exposure to the embryo or fetus from the primary beam will greatly reduce exposure. The
dose can be minimized by using a low dose mode, employing narrow beam collimation, and
reducing the number of fluorography images.
The FDA recommends that the patient dose information be recorded in the patient’s
record at the conclusion of each procedure, as this permits estimation of the cumulative
absorbed dose to the skin from all procedures. All patients with estimated skin doses of 3 Gy
should be followed up 10–14 days post exposure. A system to identify repeat procedures
should be set up for managing the dose to the patient.
Radiation protection program
All radiation exposures should be kept As Low As Reasonably Achievable (ALARA). At
times, the interventionalist’s hands are in the primary beam, resulting in high exposure to
the hands. In addition, the operator and the staff in the fluoroscopy procedure room are
exposed to leakage radiation from the X-ray tube, as well as scatter radiation from the
patient. The leakage radiation from the X-ray tube ranges from 0.001 to 0.01 mGy/h at
1 meter. The staff assisting the interventionalist may receive about 0.1% of patient entrance
radiation exposure at 1 meter from the patient. While planning an interventional suite, a
radiation protection program must be established to shield an existing or new facility to
limit the radiation exposure levels to no more than 0.1 mGy/yr, including the control room,
to protect the employees and the public. Each individual present in the interventional
procedure room should receive annual radiation safety training, including some dry runs
of the clinical procedure with appropriate dose reduction techniques.
ICRP and NCRP recommend that the dose to the embryo or fetus of a pregnant
radiation worker should be no more than 0.05 mGy per month. It is very difficult to
estimate the dose to the embryo or fetus, but the ICRP and NCRP recommend approximating it by taking half of the measured dose on the dosimeter inside the lead apron to the
estimate dose to the embryo or fetus.
Based on the recent data, the ICRP
the occupational radiation worker’s lens of the eye to 20 mSv/yr averaged over 5 years and
50 mSv in any single year.
2
recommended limiting the radiation exposure to
Use of dosimeters and personal protective equipment
For measuring occupational radiation exposure and compliance with regulatory agency
requirements, the interventional fluoroscopy operators and staff in the procedure rooms
must wear a collar badge and a whole body badge. A collar badge, worn outside the lead
apron and at the collar level, is used to measure skin and thyroidal doses, whereas the whole
209
Chapter 13: Radiation-related complications
body badge, worn inside the lead apron between the neck and the waist, is used to measure a
whole body effective dose. During the procedure, the operator ’s hands may be exposed to a
primary beam. A ring dosimeter may be used by the operator for measuring the dose to the
fingers and hands.
Employers are responsible for providing radiation protective equipment, including
mobile leaded shields for all employees who have potential to receive radiation exposures
during interve ntional procedures. Evidence demonstrates that staff working within a one
(1) meter distance from the X-ray tube or the patient interventional reference point receive
higher radiation exposure. All personnel present in the endoscopy procedure room, except
the staff behind the mobile leaded shield, must wear a radiation protective garment to shield
them from scatter radiation. The thickness of the radiation protective garment (lead apron)
should be sufficient to attenuate scatter radiation. The lead apron should be of an acceptable
weight; to reduce the weight, a lightweight apron made up of non-lead materials (composite
materials) that have the same attenuation or better may be used. A 0.5 mm lead or leadequivalent material attenuates the incident radiation (scatter X-rays) by approximately 95%.
The thyroid gland is sensitive to radiation, and exposure may lead to radiation-induced
cancer. To protect the thyroid from such stochastic effects, a thyroid collar with 0.5 mm
lead or lead-equivalent material must be worn at all times during the fluoroscopy
procedure.
It is known that high radiation exposure may occur to the eye lens of a physician
performing endovascular procedures. To keep the exposures ALARA, leaded eye glasses,
corrected to prescription, sized, and fitted to the individual’s face, should be worn to protect
the lens of the eye . Where practical, it is advisable to use ceiling-mounted, clear leaded glass
while performing any fluoroscopy procedures. Ceiling-mounted leaded glass provides
protection to the whole head, including the eyes.
Reduction of hand exposure can be achieved using flexible, sterile, radiation-attenuating
surgical gloves during the procedure. Transparent mobile leaded shields are beneficial in
protecting the required anci llary staff present during fluoroscopy procedures. Leaded flaps,
which are mounted at the side of the table, are designed to protect the lower extremities of
the operator and should not be removed from the table.
Techniques to minimize radiation exposure to patient and staff
Increasing the distance between the X-ray tube and the patient skin entrance area greatly
reduces the exposure to the patient and reduces the potential injury to the skin. In addition,
it reduces scatter radiation to the staff. The law that relates to distance is the “inverse squar e
law,” which states that the radiation exposure decreases inversely proportional to the square
of distance. If the distance is doubled between the operator and the source of radiation, the
radiation exposure decreases to a quarter of the original exposure. Since increasing the
distance reduces exposure to staff, the NCRP recommends that personnel stand at least
2 meters away from the X-ray tube, whenever possible. As per the FDA regulations, most
of the fluoroscopy units come with a spacer device which is placed on the X-ray port area to
maintain minimum separation from the skin to the X-ray port area. Radiation exposure
intensity is decreased with spacer use owing to the increase in distance from the patient’s
skin, thereby reducing potential injury to the skin.
A typical fluoroscopic system is equipped with an X-ray “beam-on” foot pedal. Most
units also hav e a beam-on button or a switch that the user can operate by hand. This is
210
Chapter 13: Radiation-related complications
called a “ dead man” switch. When pressure is applied on the “ dead man” switc h, X-rays are
produced. When the operator is not observing the monitor during the procedure, the
pressure on the switch should be released to turn off continuous X-ray production. Using
short taps of the fluoroscopy beam-on control reduces the exposure to the patient. Keeping
the image recepto r as close to the patient as possible not only reduces scatter radiation to
the operator and the staff, but also minimizes the concentration of X-rays at the patient’ s
skin surface. Also, if the collim ator is tightly confined to the area of interest, this reduces
the patient’s total skin entrance exposure, improves the contrast, and decreases the scatter
radiation exposure to the staff. Utilizing the lowest magnification modes consistent with
clinical procedure optimizes the radiation exposure to the patient. Scatter radiation
distorts the image quality. A flat plate called a gr id, which is placed in front of the image
intensifier, improves the image contrast by stopping the scatter radiation. Using low dose
mode or a lower pulse rate when possible minimizes exposure to the patient. Positioning
the X-ray tube underneath the patient table reduces scatter radiation to the operator. For
lateral and oblique projections, posi tion the C-arm so that the X-ray tube is on the
opposite side of the patient from where you are working. This will reduce the scatter
radiation reaching the operator
12
.
Sometimes a physician’s height complicates the procedure and increases the radiation
exposure to the patient. Tall operators can maintain good geometry; however, for the
vertically challenged operator, the tabl e height needs to be lowered. This brings the
patient nearer to the X-ray source and causes a higher radiation dose to the patient.
Using long extension tubing from the manifold to the cathe ter reduces a physician’shand
exposure. Inadvertent use of the biplane system ( by activating both lateral and frontal
X-ray tubes) with exposure to the same skin area, as shown in Figure 13.5,maycause
serious skin injury.
Figure 13.5 Biplane system – cause of injury.
211
Chapter 13: Radiation-related complications
Summary
An operator’s body and lens of the eye receive high radiation exposures from scatter
radiation. Hands in the primary beam also receive a large radiation dose. In addition, the
patient receives hi gher radiation exposure at the X-ray beam entrance site. These procedures require the operator to wear and use protective devices. Careful manipulation of the
equipment is required to reduce exposure to the patient and the staff. At each institution, a
committee that includes physicians, technologists, medical physicists, and administrators
should be formed to discuss problems that complicate procedures and corrective actions
to prevent such complications. Neurointerventionalists should adhere to basic radiation
protection ALARA principles to achieve the desired safety parameters.
References
1. Miller DL. Overview of contemporary
interventional fluoroscopy procedures.
Health Phys 2008;95:638–44.
2. The 2007 Recommendations of the
International Commission on Radiological
Protection. ICRP publication 103. Ann
ICRP 2007;37:1–332.
3. Walsh SR, Cousins C, Tang TY, Gaunt ME,
Boyle JR. Ionizing radiation in
endovascular interventions. J Endovasc
Ther 2008;15:680–7.
4. Mooney RB, McKinstry CS, Kamel HA.
Absorbed dose and deterministic effects to
patients from interventional
neuroradiology. Br J Radiol 2000;73:745–51.
5. Miller DL, Balter S, Cole PE, et al.
Radiation doses in interventional radiology
procedures: the RAD-IR study. Part II: skin
dose. J Vasc Interv Radiol 2003;14:977–90.
6. Miller DL, Balter S, Cole PE, et al.
Radiation doses in interventional radiology
procedures: the RAD-IR study. Part I:
overall measures of dose. J Vasc Interv
Radiol 2003;14:711–27.
7. Panuccio G, Greenberg RK, Wunderle K,
et al. Comparison of indirect radiation dose
estimates with directly measured radiation
dose for patients and operators during
complex endovascular procedures. J Vasc
Surg 2011;53:885–94 e1; discussion 94.
8. Stecker MS, Balter S, Towbin RB, et al.
Guidelines for patient radiation dose
management. J Vasc Interv Radiol 2009;20:
S263–73.
9. McParland BJ. A study of patient radiation
doses in interventional radiological
procedures. Br J Radiol 1998;71:175–85.
10. Linton OW. The National Council on
Radiation Protection and Measurements: a
growing structure. Radiology 2014;271:1–4.
11. Balter S, Schueler BA, Miller DL, et al.
Radiation doses in interventional radiology
procedures: the RAD-IR Study. Part III:
Dosimetric performance of the
interventional fluoroscopy units. J Vasc
Interv Radiol 2004;15:919–26.
12. Haqqani OP, Agarwal PK, Halin NM,
Iafrati MD. Minimizing radiation exposure
to the vascular surgeon. J Vasc Surg
2012;55:799–805.
212
Index
abciximab, 191
adenosine diphosphate (ADP)
inhibitors, 190
adrenocorticotropin hormone,
central to peripheral
ratio, 141
Alberta Stroke Program Early
CT Score (ASPECTS),
69
albuterol, 194
allergy, 163–164
anaphylactic reaction, 161
contrast media, 163, 193–195
heparin, 164
local anesthetic reactions,
181
alteplase, 191
analgesia, 180–181
anaphylactic reaction, 161
anesthetics, 154
local, 181
aneurysms. See intracranial
aneurysms
angioplasty. See intracranial
angioplasty; carotid
angioplasty and
stenting (CAS)
anticoagulants, 184–190
cessation following intra-
arterial stroke
treatment, 70–71
oral agents, 184–187
parenteral agents, 187–190
anticonvulsants, 182–184
antihypertensive medications,
155
antiplatelet agents, 190–191
antithrombotics, 184–187
intra-arterial stroke
treatment, 67
intracranial aneurysm
treatment, 12–13, 21
aorta, abdominal, translumbar
access, 8
aortobifemoral bypass graft, 2
access complications, 2
apixaban, 184
argatroban, 187
arrhythmias, 156–157
arterial dissection
external carotid artery, 125
femoral artery, 2–3
innominate artery, 114
intracranial angioplasty and,
60–61
stroke intra-aterial treatment
and, 72–74
vertebral artery, 110
arteriovenous fistula (AVF), 6
case study, 45
dural AVF, 45
recurrence, 56
spinal cord (SCAVF), 46–47
treatment principles, 45
arteriovenous malformations
(AVMs)
intracranial, 44–45
post-embolization
complications, 55–56
AVM recurrence, 56
intracerebral hemorrhage
(ICH), 55–56
spinal cord (SCAVM), 47–48
technical complications,
78–82
arterial feeder related
complications, 49
arterial obliteration
without nidus
obliteration, 21–22
case study, 50
distant venous
embolization, 55
inadequate obliteration of
AVM nivus, 54–55
inadequate obliteration of
pre-nidal aneurysm,
49–53
invisible artery
appearance, 51–52
microcatheter adhesion
within embolic material,
52–53
microcatheter rupture, 53
reflux into feeding pedicle
and parent artery, 49–50
venous drainage channel
obliteration with or
without nidus
obliteration, 55
treatment principles, 44–45
aspiration of gastric contents,
152
aspirin, 190
axillary artery access, 7
balloon remodeling technique,
wide neck intracranial
aneurysms, 25–26
balloon test occlusion (BTO),
132–135
classical approach, 133–146
complications, 134–135
false and incomplete tests,
133–134
benzodiazepines, 182, 196
bivalirudin, 188
blood pressure monitoring,
149
brachial artery access, 7
bradycardia, 156
brain code protocol, 158
brain death, 158
bronchospasm, 194
calcium channel blockers,
192–193
cardiac monitoring, 149
cardiovascular complications,
153–157
arrhythmias, 156–157
hypertension, 153–155
hypotension, 156
local anesthetic effects, 181
carotid angioplasty and
stenting (CAS),
84
adverse hemodynamic event
management, 96–97
approaching and crossing the
lesion, 91–94
difficulty crossing distal
embolic protection
device, 93–
high grade and irregular
stenosis, 92–93
basic technique, 84–88
94
213
Index
carotid angioplasty and
stenting (CAS) (cont.)
cerebral hyperperfusion
syndrome, 101
distal embolic protection
device retrieval, 95–96
device overload with
embolic debris, 96
difficulty, 95–96
extension wires, 98
extracranial carotid
pseudoaneurysms, 101
guide catheter instability, 97
perforation of external carotid
artery branches, 97
stent deployment, 94
difficulty with stent
delivery system
removal, 94–95
thromboembolic
complications, 98–101
trapping of a wire by the
stent, 97
unexpected thrombus/
foreign body
management, 98
vascular access, 89
aorto-iliac occlusion, 90
distal CCA stenosis, 89
ECA occlusion, 89
with unfavorable aortic
arch, 89
vs carotid endarterectomy
(CEA), 104
carotid endarterectomy (CEA),
84
vs carotid angioplasty and
stenting (CAS), 104
cerebral arteriovenous
malformations. See
arteriovenous
malformations (AVMs)
cerebral hyperperfusion
syndrome (CHS),
101
cervical anastomosis, 118
clopidogrel, 190
coagulopathy complications,
159–161, See also
thromboembolic
complications
Cobb’s syndrome, 47
coils, 48, See also primary coil
embolization
conscious sedation failure,
153–154
contrast media
allergy, 163,
properties, 167–168
contrast-induced nephropathy
clinical course, 172
clinical evaluation, 171
definition, 166
gadolinium-based contrast
incidence, 167
iodinated contrast media,
pathogenesis, 170
preventive strategies,
hemodialysis and
hydration, 173
N-acetylcysteine (NAC),
risk assessment, 169
risk factors, 169
corticotropin releasing hormone
cranial nerve blood supply, 116
cranial nerve palsies, 116
Cushing’ssyndrome,135, 137,
cyanoacrylates, 48
dabigatran, 185
dalteparin, 190
desmopressin, 142
dobutamine, 197
dopamine, 197
embolic agents, 48–49
coils, 48
liquid, 28, 48
solid, 48
enoxaparin, 189
epinephrine, 194, 197
eptifibatide, 191
erythema, 194
external carotid artery (ECA)
arterial dissection, 125
arterial rupture, 125
arterial spasm,
embolization. See head and
occlusion, 89
extracranial–intracranial
193–195
(CIN), 166–178
agents, 176
166–172
172–175
hemofiltration, 174
174
(CRH), 141
See also inferior petrosal
sinus sampling
118
neck embolization
anastomotic pathways,
118–119
cervical anastomosis,
118–124
orbital region anastomosis,
119–124
petrous-cavernous region
anastomosis, 119
femoral artery access, 1–2
femoral artery dissection, 2–3
fentanyl, 180
flow diverters, wide neck
intracranial aneurysms,
28–31
complications, 30
deployment in collapsed
form, 29
difficulty in release of distal
end, 29
loss of distal access, 30
misalignment of deployed
system, 29
flumazenil, 183
fluoroscopy system, 205–207
fondaparinux, 188
fosphenytoin, 183
gadolinium-based contrast
agents (GBCAs)
nephrogenic systemic
fibrosis relationship,
176–178
nephropathy, 176
properties, 176
gastric contents aspiration, 152
glycoprotein IIb/IIIa inhibitors,
191
groin complications
alternative access routes, 7–8
following percutaneous
access, 2–8
acute lower extremity
ischemia, 4–7
arterial pseudoaneurysm
at access site, 4–5
arteriovenous fistula
formation, 4–
femoral arterial dissection,
2–3
hematoma, 3–4
vascular closure device
related complications,
5–6
risk factors for access site
complications, 1–2
aortobifemoral bypass
graft access, 2
6
214
Index
pulseless femoral region
access, 1–2
Guglielmi detachable coil
(GDC), 13
head and neck embolization
complications, 116–118,
123–127
arterial dissection and
thrombosis, 125
arterial rupture, 125
arterial spasm, 118
distal vasculature ischemic
injury, 126
inadvertent embolization
of extracranial arteries,
126
inadvertent embolization of
intracranial arteries, 126
direct tumor puncture, 119
indications, 116
standard vascular access,
119–121
head and neck trauma, 121–123
trauma dissection, 123–124
flow restoration, 123
large vessel occlusion, 123
trauma hemorrhage, 121–123
flow restoration, 123
large vessel occlusion, 122
small vessel occlusion, 121
hematoma, groin access
complications, 3–4
hemodialysis, contrast-induced
nephropathy
prevention, 174
hemofiltration, contrast-
induced nephropathy
prevention, 174
heparin, 189
allergy, 164
intra-arterial stroke
treatment, 67
thrombosis prevention, 8, 21
high-osmolality contrast media
(HOCM), 167
hives, 194
hypertension, 153–155
hypoglycemia, 194
hypotension, 156,
hypotension challenge, 133
hypoventilation, 152
hypoxemia, 152
inferior petrosal sinus
sampling, 135, 137–139
194
central to peripheral
adrenocorticotropin
hormone ratio, 141
complications, 145
corticotropin releasing
hormone (CRH), 141
desmopressin, 142
false negative results, 142
false positive results, 142
intraprocedural heparin, 144
preprocedure assessment,
143
sample handling, 144
sinus anatomy, 136
stimulation and sampling
technique, 143
technical aspects of
catheterization,
139–141
vs internal jugular venous
sampling, 141
informed consent,
endovascular
embolization of
intracranial aneurysms,
10–11
innominate artery
post-traumatic
pseudoaneurysm/
dissection, 114
stent placement, 112–114
two-wire technique, 114
inotropic agents, 156
intracerebral hemorrhage
(ICH), postembolization, 55–56
intracranial aneurysms
characterization, 11–28
endovascular embolization,
10
aneurysm recurrence,
36–37
antithrombotic use, 12–13,
21
general anesthesia versus
conscious sedation,
11–12
informed consent, 10–11
postprocedure care, 37
primary coil embolization,
13
–19
thromboembolic
complications, 10,
19–22
intraprocedural aneurysm
rupture, 10, 22–24
general management,
22–25
stages, 23–24
peripheral aneurysms, 34–35
very small aneurysms, 32–33
wide neck aneurysm, 24–31
balloon remodeling
technique, 25–26
flow diversion, 28–31
liquid embolic agents, 28
stent assisted coil
embolization, 26–27
wide neck bifurcation
aneurysms, 35
intracranial angioplasty, 58–59
reported complications,
59–60
arterial dissection, 60–61
reperfusion hemorrhage,
62
vasospasm, 62–63
vessel perforation, 61–62
intracranial pressure elevation,
157
intrapocedural monitoring,
149–150
iodinated contrast media,
166–172, See also
contrast-induced
nephropathy (CIN)
ischemia, lower extremity, 6–7
laryngeal edema, 195
liquid embolic agents, 28, 48
local anesthetics,
lorazepam, 182, 196
low-osmolality contrast media
(LOCM), 167
magnesium sulfate, 195
mannitol, 195
medication errors, 76–78
Merci Concentric retriever, 67
device fracture, 74
midazolam, 182, 196
monitoring during
endovascular
procedures, 149–150
morphine, 180
myocardial ischemia, 157
N-acetylcysteine (NAC),
contrast-induced
nephropathy
prevention, 174
naloxone, 181
181
215
Index
narcotics, 154
nephrogenic systemic fibrosis
(NSF)
clinical manifestations, 178
gadolinium-based contrast
agent relationship,
176–178
prevalence, 176
prevention, 178
risk factors, 176
treatment, 178
neurocritical care
intraprocedural monitoring,
149–150
pre-procedural patient
assessment, 148–149
neurological complications,
157–159
brain death, 158
intracranial pressure
elevation, 157
new neurological deficits,
157
seizures, 159
nicardipine, 192
norepinephrine, 198
Onyx liquid embolic system,
28, 48
orbital region anastomosis,
118–119
osmotic agents, 195
oxygenation, inadequate, 152
patient preparation. See
periprocedural
preparation
Penumbra Neuron MAX
delivery catheter, 78
Penumbra Separator device, 68,
73
device fracture, 74
retrieval problems,
74
percutaneous vascular closure
device related
complications, 5–6
peripheral arterial disease
(PAD), 164–166
periprocedural preparation, 163
allergy, 163–164
contrast-induced
nephropathy (CIN),
166–178
peripheral arterial disease
(PAD), 164–166
preprocedural assessment,
148–
petrous-cavernous region
phenylephrine, 198
Pipeline embolization device
pituitary gland venous
anatomic variants, 136
platinum coils, 48
polyvinyl alcohol (PVA), 48
popliteal artery access, 8
prasugrel, 190
premedication regimens, 164
pre-nidal aneurysms, 53
preprocedural patient
primary coil embolization,
coil misplacement or
coil protrusion and distal
coil stretching, unraveling
coil structure, 13
failure of coil placement, 14
first coil selection, 13
propofol, 183, 197
provocative testing, 129
balloon test occlusion (BTO),
Wada test, 129–132
pseudoaneurysm
carotid, 101
innominate artery, 114
percutaneous access site, 4–5
pulmonary edema, 195
pulse oximetry, 149
radial artery access, 7
radiation
biological effects, 205
complications, 202
dose to patient and operator,
exposure minimization,
fluoroscopy system, 205–207
ionizing vs non-ionizing
149
anastomosis, 119
(PED) complications,
30, See also flow
diverters
drainage, 136
assessment, 148–149
13–19
migration, 15
migration, 15–17
and fracture, 17
132–135
207
dose limits, 207
dose management, 207–209
210–211
radiation, 202
protection program, 204–205
dosimeters and
protective equipment,
209–210
quantities and units, 204–205
X-ray production, 203
reperfusion hemorrhage, 62,
68–70
respiratory complications,
151–153
inadequate oxygenation, 152
inadequate ventilation, 152
retroperitoneal hematoma
groin access complications,
3–4
rivaroxaban, 186
sedation failure, 153–154
sedatives, 154, 196–197
seizures, 159
anticonvulsants, 182–184
local anesthetic reactions,
181
SILK flow diverter
complications, 30, See
also flow diverters
skin necrosis, 116
sodium chloride, 195
Solitaire device, 68
device fracture, 74
spinal cord arteriovenous
fistula (SCAVF), 46–47
conus medullaris, 47
extradural, 46
intradural, 46
spinal cord arteriovenous
malformation
(SPAVM), 47–48
stainless steel coils, 48
stent placement, 58–59, See also
carotid angioplasty and
stenting (CAS)
vertebral artery
angioplasty and
stenting
innominate artery, 112–114
reported complications,
59–60
difficulty in stent delivery,
63
in-stent restenosis, 63
in-stent thrombosis, 61
reperfusion hemorrhage, 62
vasospasm, 62–63
vessel perforation, 61–62
subclavian artery, 112–114
;
216
Index
stent retriever devices, 68
stroke
intra-arterial treatment
complications, 67–68
antiplatelet regimens in
acute stenting, 71–72
antithrombotics, 67
device fracture, 74–77
device stuck, 74–75
distal embolism, 75–76
futile treatment, 72
medication errors, 76–78
reperfusion hemorrhage,
62, 68–70
risk vs benefit of
anticoagulant cessation,
70–71
vessel perforation and
dissection, 72–76
intracranial angioplasty and,
60–61
mechanical thrombectomy
benefits, 67
technical failure in
intervention, 78–82
inability to access
occlusion site, 78–79
tandem stenoses/
occlusions, 81–82
unsuccessful
thrombectomy, 79–80
subarachnoid hemorrhage
(SAH), following intraarterial stroke
treatment, 70
subclavian artery stenting,
112–114
superselective testing
Wada testing, 130–131
pre-embolization
provocative testing, 131
tachycardia, 194
thrombectomy
devices, 67–68
unsuccessful, 79
thromboembolic
complications, 159–161
carotid angioplasty and
stenting, 98–101
endovascular embolization of
intracranial aneurysms,
10, 19–22
intraprocedural
thrombosis with coil
prolapse, 22
intraprocedural
thrombosis without coil
prolapse, 21–22
external carotid artery
intervention, 125
in-stent thrombosis, 61
stroke intra-arterial
treatment, 75–76
vertebral artery angioplasty
and stenting, 110
thrombolytic agents, 191–192
ticagrelor, 190
transcranial Doppler (TCD),
134
Trevo device, 68
vasopressin, 199
vasopressors, 156, 197–199
vasospasm, 62–63
external carotid artery, 118
vertebral artery, 111
venous sampling, 135
ventilation, inadequate,
152
verapamil, 192
vertebral artery angioplasty and
stenting, 105–112
–80
bailout techniques, 109–112
distal embolic protection
device retrieval, 110
ensuring accurate stent
placement, 110
in-stent thrombus, 110
neurological status change,
111
significant proximal
tortuosity, 109, 111
stent herniation
prevention, 110
vertebral artery dissection,
110
vertebral artery spasm,
111
periprocedural management,
108
postprocedural management,
109
potential complications, 109
preprocedural management,
105
vessel perforation
angioplasty and stent
placement, 61–62
external carotid artery
branches, 97
intra-arterial stroke
treatment, 72–76
Wada test, 129–130
complications, 131–132
pre-embolization testing, 131
superselective testing,
130–131
warfarin, 186
Wingspan stent system, 58–59,
See also stent placement
X-ray production, 203
217
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