Michael J. Cowley, M.D., FSCAI

Carotid Angiography
Essential Cognitive Knowledge
Indications and contraindications
Non-invasive methods of vascular evaluation and their utility/appropriateness
Potential complications & management
Ability to assess risk / benefit

Carotid Angiography
Essential Cognitive Knowledge
Cerebrovascular pathology:
• Atherosclerosis
Typical disease states and appearance
Unusual forms of disease
• Aneurysms
• AVM’s
• Bleed
• Tumor

Technique
• Vascular Access
• Arch Angiography
• Selective angiography:
• Extracranial vessels
• Intracranial vessels

Technique
• Vascular Access
• Arch Angiography
• Selective angiography:
• Extracranial vessels
• Intracranial vessels

• Femoral approach whenever possible
• Better angle of entry to arch vessels
• Allows forming of complex curve catheters
• Brachial access is possible but:
• requires more advanced skills
• higher complication rates

Technique
• Access
• Arch Angiography
• Selective angiography:
• Extracranial vessels
• Intracranial vessels

Aortic Arch Angiography
• To evaluate access to great vessels
• Identify Type of arch
• Identlfy ; anatomic variants (anomalies)
• 5 or 6F Pigtail catheter
• 30-40 degree LAO view
• Field of view: origin of great vessels extending to the carotid bifurcation
• Patient’s head should be straight with chin turned upward
• Hand or power injection
• 15-20 ml/sec for 2 seconds

Courtesy of Mark Burket, M.D.

Aortic Arch Angiography
Anatomic Features
65-70%: Usual pattern
20-25%: Bovine arch (Left CCA from brachiocephalic)
3%:
5%:
Separate origin of left vertebral
Various patterns, including right subclavian from distal arch

It’s Not Just The Arch That Gets Longer!
Tortuous
Right
Common
Carotid
LEFT

Technique
• Access
• Arch Angiography
• Selective angiography:
• Extracranial vessels
• Intracranial vessels

• Ipsilateral oblique and lateral views
(additional views may be necessary)
• Contralateral carotid (Circle of Willis, collaterals, etc)
• 5 or 6 F with appropriate curve
• Intracranial angiography also important

Key Information for Carotid Stenting
• Site of stenosis
• Bifurcation involvement
• Landing zone for EPD
• Patency of ECA
• Presence of ICA tortuosity
• Presence of ulceration
• Severity of stenosis
• Lesion length
• Degree of calcification
• Presence of thrombus

• Simple Curve Catheters
• Have only a primary (distal) curve
• Do not need to be formed
• May not be adequate in tortuous anatomy
• Complex Curve Catheters
• Have a primary and secondary curve
• Must be formed
• Often will not track over standard wires

Simple Curved
Catheters
‘Coronary catheters’
IMA
Modified AR1
JR 4
Consider using dedicated catheters!!!

• First choice for most selective angiography
• Wide variety of catheters available, chose one and perfect its use
• Glide catheters provide improved tracking over softer wires
• Chose a catheter that will be less traumatic and still allow selection of the arch vessels

H1 or Vertebral Artery Catheter
These catheters work well for flat aortic arches

Simmons 1, 2, and 3 curves
VTK

Simmons Catheter:
A Closer Look
• Ideal for Type II-III arch
• Technique Tip: Re-shape in subclavian artery with an exchange wire to avoid arch manipulations

Vitek, Simmons 1,2,3 Catheters

• Allow for access proximally displaced vessels
(Type 2 & 3 Arch or bovine arch
• Can be formed by placing the primary curve in the left subclavian artery and advancing the secondary curve toward the ascending aorta
• Avoid forming in the ascending aorta whenever possible
• Do not track well over most wires
• May require exchange length wires to change to a simple curve catheter after access is obtained

Right Common Carotid Artery
• Dx catheter engages innominate and road map of carotid bifurcation done
• Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance
• Catheter advanced over guidewire into CCA
• Guidewire removed
• Angio performed in ipsilateral oblique and lateral views (and other views if necessary)

Extracranial:
- Ipsilateral oblique
- Lateral
- AP
Intracranial:
- AP cranial (Townes view)
- Lateral
- Ipsilateral oblique, caudal

• Pass angled guidewire into CCA using road map image
• Avoid advancing wire across diseased segment
• Fix wire and advance catheter over wire
• Position catheter tip in porox 1/3 of CCA
• Remove wire slowly from catheter

Left Carotid Artery
• Using roadmap, retract catheter from Asc
Aorta with clockwise rotation
• Position catheter close to origin of L CCA and turn counter- clockwise to engage CCA
• Pass angled guidewire into CCA using road map image; avoid advancing across diseased segment
• Fix wire and advance catheter over wire
• Position catheter tip in porox 1/3 of CCA
• Remove wire slowly from catheter

Right Common Carotid Artery
• Dx catheter engages innominate and road map of carotid bifurcation done
• Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance
• Catheter advanced over guidewire into CCA
• Guidewire removed

Intracerebral Angiography
• Anterior cerebral circulation viewed by PA cranial
(15-20 degrees) and lateral views
• Important to visualize both arterial and venous phases:
- Intracerebral disease
- Collateral circulation
- Presence of AVM, aneurysm, isolated hemisphere
- Missing arterial phase vessels
(allows identification of embolization post CAS)

Avoiding Complications
• Non-ionic contrast preferred
• Minimize contrast volume used
• Use lower risk catheter curves when possible
• Minimize catheter manipulations

Avoid Excessive catheter manipulation

Complications
• Clinical status: Symptomatic vs Asx
• Technical challenges:
- Duration of catheter dwell time
- Number of catheter exchanges
- Contrast volume, fluoro time
• High risk anatomic features (not high risk clinical features)
Complication Risk determined primarily by case selection

Summary
• High quality baseline angiography is essential for optimal carotid stenting
• Understanding necessary elements and anatomic variations assures quality imaging
• Intracranial and extracranial angiography is essential for pre and post intervention
• Proper catheter selection and careful technique insures safest possible angiography