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Ростовский Государственный Медицинский Университет

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115

Relevant Anatomy

Where does

the common

femoral artery

begin? What

is the ideal

position to

access the

femoral artery?

The common femoral artery (CFA) begins

inferior to the inguinal ligament. It is

important to avoid accessing the CFA above

and below the inguinal ligament to decrease

the risk of retroperitoneal hemorrhage and

thigh hematoma, respectively. The ideal

location to access the femoral artery is the

inferomedial margin of the femoral head. This

allows for utilization of the femoral head to

aid with manual compression of the vessel

above the arteriotomy site to achieve arterial

hemostasis following sheath removal.

When does

the superficial

femoral artery

become the

popliteal artery?

What are the

branches of the

popliteal artery?

As the superficial femoral artery (SFA)

courses through the adductor hiatus, it

becomes the popliteal artery. The branches

of the popliteal artery are the geniculate and

sural arteries, which supplies some of the

structures in the knee and calf. The popliteal

artery also gives rise to the anterior tibial

artery and the tibioperoneal trunk.

When accessing

the upper

extremity for

an abdominal

aorta or lower

extremity

procedure,

which arm

should be used?

Why?

The left upper extremity should be used

because this allows the catheter to only cross

one cerebral artery, the left vertebral artery.

Where does the

brachial artery

divide? What

arteries does it

divide into?

The brachial artery divides near the

antecubital fossa. It divides into the radial and

ulnar arteries, which course distally to form the

deep and superficial palmar arches.

(continued)

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What tests are

used to ensure

adequate

perfusion

to the hand

before radial or

brachial access?

The modified Allen test and Barbeau test are

used to ensure preservation of flow to the

hand.

What are

common

variations of the

hepatic arterial

supply?

Commonly encountered variants are replaced

or accessory left hepatic artery originating

from the SMA, replaced or accessory left

hepatic artery originating from the left gastric

artery, and replaced common hepatic artery

originating from the SMA.

What upper

extremity veins

are considered

a part of the

superficial

venous system?

The basilic and cephalic veins are a part of the

superficial venous system. The veins connect

in the antecubital fossa via the median cubital

vein.

What lower

extremity veins

are considered a

part of the deep

venous system?

Anterior tibial, posterior tibial, peroneal,

popliteal, and deep femoral and common

femoral veins are considered a part of the deep

venous system of the lower extremity.

Relevant Materials

What types

of needles

are used

for vascular

access?

Needles provide a central channel for

introduction of a guidewire. Double wall

needles consist of a metal cannula, stylet, and

hub. The double wall needles are typically 18G

or 19G.Single wall needles consist of beveled

cannula and hub. They are typically 18G or 21G.

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117

What are

the inner

workings of a

guidewire?

A guidewire consists of three parts: coil spring,

mandrel, and wire guide. The outer portion

of the guidewire is the coil spring. It is tightly

coiled wire made of stainless steel. The mandrel,

core of the guidewire, gives the guidewire

its characteristics. The wire guide runs the

length of the coil spring and prevents it from

unraveling. Stainless steel wires are more prone

to kinking, and nitinol wires are more flexible

with less support, though wires can be made

with combined materials. Larger core wires

provide more support and torque, and can also

aid in straightening of your equipment and the

vessel. Smaller core diameter wires provide more

flexibility and trackability, though are better

suited for more tortuous vessels.

What is the

difference

between the

core and the

taper?

The “grind” is the constant diameter of the wire.

Wires taper a certain distance from the constant

diameter, which can either be broad (improved

wire tracking) or short (greater tendency to

prolapse, less atraumatic). From taper to grind

(core-to-tip), there is a change in stiffness, which

contributes to differences in steerability and

tactile feedback.

What is the

penetration

power of a

wire?

Penetration power is the tip stiffness divided

over the area of the wire tip. Core-to-tip design

incorporating high tip load with a reduced

tip diameter generates higher tip pressure for

any tip stiffness. Steerability refers to stiffness

in the rotational axis and competes with

softness (flexibility in bending/low tip loading).

Corrugated core-to-tip designs contribute to

rotational axis rigidity, which translates tactile

feedback to the operator.

Guidewires

are accepted

through what

needle gauge

sizes?

The commonly used wire sizes are 0.038, 0.035,

0.018, and 0.014cm. A 21-G needle accepts

0.018–0.021-cm wires. An 18G needle accepts

0.035–0.038-cm wires.

(continued)

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What are

catheters sized

as?

A catheter’s outer diameter is measured in

French (Fr). One Fr equals 0.33mm or 3 Fr

equals 1mm.

What are flush

catheters and

what are their

uses?

They are nonselective catheters used to

deliver large boluses of contrast to the large

vessels of the body. They can have different tip

configurations (pigtail, omni, and straight) to

allow the interventionalist more control and

options in directing flow of the contrast.

What is

the size of

microcatheters

and what

are their

purposes?

Microcatheters are 1.5–3-Fr catheters. They are

used in super selective interventions.

What are the

characteristics

of contrast

agents?

Acceptable contrast agents should be relatively

inert and soluble in blood and provide adequate

opacification.

Iodinated agents may be ionic or nonionic:

Ionic agents are high-osmolar and less viscous/

more reactive.

Nonionic agents are more inert and more

viscous/less reactive:

Visipaque is based on the nonionic dimer,

iodixanol, and is isoosmotic to blood plasma.

Omnipaque is based on the nonionic

monomer, iohexol, and has an osmolality

about twice that of plasma.

General Step by Step

What are some

general guidelines

for selecting an

arterial access?

In selecting an arterial access, one should

ensure a patent artery, a superficial location

over the bone, healthy overlying skin, and

communication with the artery of interest.

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119

What is the

short-axis view

(longitudinal

approach) and

the long-axis

view (transverse

approach) during

an ultrasound-

guided vascular

access?

In a short-axis view, the image plane is

perpendicular to the course of the vessel and

to the needle (needle is “out of plane”). The

vessel should appear as an anechoic circle

on the screen with the needle visualized as a

hyperechoic point in cross section. In a long-

axis view, the image plane is parallel to the

course of the vessel (needle is “in plane”).

The image should show the course of the

vessel across the screen and the shaft and

point of the needle as it is advanced.

Describe the

Seldinger

technique.

The Seldinger technique consists of

percutaneous puncture of a blood vessel

with a hollow needle at a 45° angle. Once

blood return is visualized, an atraumatic

guidewire is introduced through the needle.

The needle is then removed while the

guidewire remains in place. An angiographic

catheter is advanced into the vessel over the

guidewire. Once the catheter is in the vessel,

the guidewire is gently pulled out.

What is the

terminology for

injection rates?

What are the

typical injection

rates?

“a for b” where “a” is rate of injection in

mL/s and “b” is volume of injection

Thoracic aorta 20mL/s

Abdominal aorta 15mL/s

Abdominal aortic bifurcation/iliac

arteries

5–10mL/s

Femoropopliteal arteries 4–6mL/s

Celiac/SMA 4–6mL/s

Main pulmonary artery 20mL/s

(continued)

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Selective right or left pulmonary

artery

10mL/s

IVC 10–20mL/s

When would a longer

injection time be ideal?

Longer injections are ideal when

studying a larger vascular bed, detecting

a small or peripheral bleed, and

studying the venous outflow of an

organ.

What are the key steps

for pulmonary artery

angiography?

Before embarking on a pulmonary

artery angiogram, a baseline EKG

should be performed to assess for heart

block. Insertion of a catheter or sheath

can introduce a right bundle branch

block. Patients with a left bundle branch

block should have immediate access to

pacing. Imaging during the angiography

should be performed on full inspiration.

An angled pigtail catheter or flow-

directed balloon catheter should be

used to quickly negotiate the right

ventricle outflow tract and minimize

contact and irritation with the right

atrium and ventricle. Once in the main

pulmonary artery, the intravascular

pressure is measured. Normal pressure

is roughly 25/10.

What is DSA? Digital subtraction angiography refers

to a process in which the radiologist

attempts to acquire maximal diagnostic

opacification of vessels, using the least

amount of injected contrast material

as possible. DSA removes, from the

projection, non-opacified structures

that are present on the pre- and post-

contrast images (stationary anatomy).

Body and organ movement results in

misregistration artifact and incomplete

subtraction of tissues.

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Why do individuals

leave the angiosuite

during a “run?”

Air kerma used in digital subtraction

angiography is higher than air kerma

used in conventional digital fluoroscopy

to reduce quantum mottle. This is

because images to be subtracted

must be imaged (in order to identify

stationary anatomy), as well as the

structures opacified by the contrast. The

subtracted image has approximate 40%

more noise than the non-subtracted

image and therefore requires a

considerable increase in dose.

What is a roadmap? A roadmap utilizes a single DSA

reference image as a fluoroscopic

“mask,” which the fluoroscopy unit

stores digitally. Live fluoroscopy images

are then subtracted from projected

mask, which allows the radiologist to

detect the location of live catheters and

wires with respect to the previously

visualized opacified vessels (seen in the

mask).

What is a fluoroscopic

fade?

A roadmap utilizes a single DSA

reference image from a prior

angiographic “run” to serve as a mask

for live fluoroscopy images. Therefore, it

avoids repeat double exposure required

for repeat DSA, as well as the need to

administer additional contrast material.

What is the best DSA

projection for imaging

certain vessels?

The abdominal aorta is best seen via an

AP projection. The internal iliac artery

division is best seen via contralateral

oblique projection. The internal iliac

artery anterior division is best seen via

the ipsilateral oblique projection. The

femoral and popliteal/tibioperoneal

bifurcations are best viewed via the

ipsilateral oblique projection. The pedal

vessels are best viewed in the lateral or

contralateral oblique projection.

(continued)

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What are some ways

dose can be reduced

during angiography?

Limiting use of magnification and DSA

Increasing the source-to-image distance

Utilizing pulsed fluoroscopy or

decreased frame rates

Decreasing FOV and use of collimation

and filters

Complications

What are the

complications of

vascular access?

Hematoma, pseudoaneurysm, thrombosis,

arterial dissection, retroperitoneal hemorrhage,

and arteriovenous fistula are complications of

arterial vascular punctures.

What is the

management for

the above-stated

complications?

If a hematoma develops, it is outlined with a

marking pen and inspected at regular intervals

to ensure no expansion. If the hematoma is

massive and expanding, surgical evacuation

may be required.

If an arterial dissection is not flow-limiting,

it is managed with imaging surveillance. If it

is flow-

limiting, it is managed with balloon

inflation across the dissection to reattach the

dissected intima with the vessel media.

Nonocclusive thrombosis is managed with

antiplatelet therapy. Occlusive thrombus is

typically treated with surgical thrombectomy.

Retroperitoneal hemorrhage occurs when the

CFA is accessed above the inguinal ligament or

when primary hemostasis is not achieved with

an appropriately placed puncture. Standard of

therapy is surgical repair. If the patient is not

a surgical candidate, a covered stent can be

placed across the vascular injury.

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123

What is the

management of a

pseudoaneurysm?

The options for management of a

pseudoaneurysm include observation,

ultrasound-guided compression, ultrasound-

guided thrombin injection, and surgery. Small

pseudoaneurysms that are less than 2cm can

be observed with weekly duplex ultrasound

until thrombosis occurs. They can also be

managed with ultrasound-guided compression

or ultrasound-guided thrombin injection. If a

pseudoaneurysm is >2cm, has a short (<4mm)

neck width, is enlarging, or is associated

with significant pain, surgical repair may be

necessary.

What are the

complications of

venous punctures?

Venous complications include perforation of

vein, thrombosis of puncture site, hematoma,

and inadvertent arterial injury. In the jugular

and thoracic veins, complications include

pneumothorax, hemothorax, and air embolism.

What is the

management of

central venous air

embolism?

Control source, turn patient to left decubitus

position, administer oxygen, and aspirate air

from the heart with catheter.

How is wire- or

catheter- induced

vasospasm

managed?

Nitroglycerin can be directly injected. It is

typically provided as a bolus between 50 and

300 mcg and has a nearly immediate onset.

Nitroglycerin must be used with caution in

patients taking PDE5 inhibitors. Intra-arterial

verapamil can also be used. It is typically given

as a 2.5–5-mg bolus. Its onset of action is within

a few minutes and lasts 20minutes.

Landmark Research

1. Irani F, Kumar S, Colyer WR Jr. Common femoral artery

access techniques: a review. J Cardiovasc Med (Hagerstown).

2009;10(7):517–22.

19 Angiography

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124

2. Kalish J, Eslami M, Gillespie D, Schermerhorn M, Rybin D,

Doros G, etal. Routine use of ultrasound guidance in fem-

oral arterial access for peripheral vascular intervention

decreases groin hematoma rates. J Vasc Surg.

2015;61(5):1231–8.

3. Campeau L.Percutaneous radial artery approach for coro-

nary angiography. Catheter Cardiovasc Diagn.

1989;16(1):3–7.

4. Fischman AM, Swinburne NC, Patel RSA.Technical guide

describing the use of Transradial access technique for

endovascular interventions. Tech Vasc Interv Radiol.

2015;18(2):58–65.