Angiography
Definition
Angiography refers to the radiographic examination of vessels after
injection of a contrast media.
Components of the circulatory system
The circulatory system consists of:
1- Cardiovascular system, include the heart, blood and vessels that
transport the blood.
2- Lymphatic system, include lymph, lymph nodes and lymphatic
vessels.
Function of cardiovascular system
1- Transporting of oxygen, nutrients, hormones and chemicals
necessary for normal body activity.
2- Removal of waste products through the kidneys and lungs.
3- Maintenance of body temperature and water and electrolyte
balance.
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Blood Components
- Red blood cells or erythrocytes are produced in the red marrow of
certain bones and transport oxygen by the protein to the body tissues .
- White blood cells or leukocytes are formed in bone marrow and
lymph tissue and defend the body against infection and disease .
- Platelets, also originating from bone marrow repair tear in blood
vessels and promote blood-clotting.
- Plasma, the liquid portion of the blood, consist of 92% water and
about 7% plasma protein and salt, nutrients, and oxygen.
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The Blood Vessels
The cardiovascular system has three types of blood vessels:
- Arteries (and arterioles) – carry blood away from the heart
- Capillaries – where nutrient and gas exchange occur
- Veins (and venules) – carry blood toward the heart.
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Blood vessels
The Vascular Pathways
The cardiovascular system includes two circuits:
1- Pulmonary circuit which circulates blood through the lungs.
2- Systemic circuit which circulates blood to the rest of the body.
Both circuits are vital to homeostasis.
The Pulmonary Circuit
The pulmonary circuit begins with the pulmonary trunk from the right
ventricle which branches into two pulmonary arteries that take
oxygen-poor blood to the lungs.
In the lungs, oxygen diffuses into the blood, and carbon dioxide
diffuses out of the blood to be expelled by the lungs.
Four pulmonary veins return oxygen-rich blood to the left atrium.
The Systemic Circuit
The systemic circuit starts with the aorta carrying O2-rich blood from
the left ventricle.
The aorta branches with an artery going to each specific organ.
The vein that takes blood to the vena cava often has the same name as
the artery that delivered blood to the organ.
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In the adult systemic circuit, arteries carry blood that is relatively high
in oxygen and relatively low in carbon dioxide, and veins carry blood
that is relatively low in oxygen and relatively high in carbon dioxide.
This is the reverse of the pulmonary circuit.
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Major arteries and veins of the systemic circuit
The Heart
The heart is a cone-shaped, muscular organ located between the lungs
behind the sternum.
The heart has four chambers: two upper, thin-walled atria, and two
lower, thick-walled ventricles.
External heart anatomy
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Cerebral Arteries:
The four major arteries supplying the brain are as following:
1- Right common carotid artery.
2- Left common carotid artery.
3- Right vertebral artery.
4- Left vertebral artery.
Branches of the aortic arch
- Brachiocephalic artery
- Left common carotid artery.
- Left subclavian artery.
The brachiocephalic artery bifurcates into:
- Right common carotid artery.
- Right subclavian artery.
Neck and Head Arteries
- Common carotid artery
- External carotid artery
- Internal carotid artery.
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External Carotid Artery Branches:
- Facial artery.
- Maxillary artery.
- Superficial temporal artery.
- Occipital artery.
Internal Carotid Artery Branches
- Anterior cerebral arteries.
- Middle cerebral arteries.
Circle of Willis
The posterior brain circulation communicates with the anterior
circulation along the base of the brain in the arterial circulation or
circle of Willis.
The five arteries or branches that make up the circle of Willis
are:
- Anterior communicating artery.
- Anterior cerebral arteries.
- Branches of the internal carotid arteries
- Posterior communicating artery.
- Posterior cerebral artery.
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Cerebral Veins
The three pairs of major veins draining the head, face, and neck are:
- Right and Left internal jugular veins.
- Right and left external jugular veins.
- Right and left vertebral veins.
Each internal jugular veins passes caudad to eventually become the
brachiocephalic vein on each side. The right and left brachiocephalic
veins join to form the superior vena cava.
Each external jugular vein joins the respective subclavian vein.
Each vertebral descends to enter the subclavian vein.
Thoracic Arteries
The aorta and pulmonary arteries are the major arteries located within
the chest.
The aorta extends from the heart to about fourth lumbar vertebra and
divided into thoracic and lumbar section.
The thoracic section of aorta is divided into the following segments:
- Aorta bulb.
- Ascending aorta.
- Aortic arch.
- Descending aorta.
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Thoracic Veins
The major veins within the chest are:
- Superior vena cava.
- Pulmonary veins.
- Azygos vein.
Abdominal Arteries
The abdominal aorta is the continuation of the thoracic aorta.
Major branches of the abdominal aorta are:
- Celiac axis artery.
- Superior mesenteric artery
- Left renal artery.
- Right renal artery.
- Inferior mesenteric artery.
Abdominal veins
Blood is return from structures below the diaphragm to right atrium
of the heart by the inferior vena cava.
Portal System
The portal system includes all the veins that drain blood from the
abdominal digestive tract and from spleen, colon, and small intestine.
From these organs, this blood is conveyed to the liver through the
portal vein to filter and returned to the inferior vena cava.
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Upper Limb Arteries
- Axillary arteries.
- Brachial arteries.
- Ulnar arteries.
- Radial arteries.
- Deep palmar arch.
- Superficial palmar arch.
Upper Limb Veins
- Deep and superficial palmar arches.
- Ulnar vein.
- Radial vein.
- Brachial veins.
- Axillary vein.
- Median cubital vein.
- Cephalic and basilic veins.
- Subclavian veins.
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Lower Limb Arteries
- External iliac artery.
- Common femoral artery.
- Deep femoral artery.
- Femoral artery.
- Popliteal artery.
- Anterior and posterior tibial arteries.
- Peroneal arteries.
- Dorsalis pedis artery.
Lower Limb Vein
- Anterior and posterior tibial veins.
- Peroneal vein.
- Popliteal vein.
- Femoral vein.
- Deep femoral vein.
- Great saphenous vein.
- External iliac vein.
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Angiographies divide into:
1- Arteriorgraphy.
2- Venography.
3- Angiocardiography.
4- Lymphography.
The Angiography Team:
1- Radiologist.
2- Nurse that assists with sterile and catheterization procedure.
3- Radiographic technologist.
Consent and preprocedural patient care:
1- Medical history should be obtained before the procedure.
2- A detail explanation of the procedure will be given to the patient.
3- Solid food is withheld for approximately 8 hours before the
procedure to reduce the risk for aspiration.
4- Insure that the patient is well hydrate to reduce the risk of contrast.
5- Premedication is given to patients before the procedure to help
them relax.
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Three vessels are typically considered for catheterization:
1- Femoral.
2- Brachial.
3- Axillary.
* Femoral artery & vein are the preferred sites for an arterial and venous
puncture because of its size and easy acceptable location.
Seldinger Technique:
1- Step 1 - Insertion of needle.
2- Step 2 - Placement of needle in lumen vessel and removing the
inner cannula slowly.
3- Step 3 - Insertion of guide wire.
4- Step 4 - Removal of needle.
5- Step 5 - Threading of catheter to area of interest.
6- Step 6 - Removal of guide wire.
Contrast Media:
- Water-soluble, nonionic iodinated substance. Because of its low
osmolality reduce risk for allergic reaction.
- The amount required depends on the vessel under examination.
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Contraindication:
1- Contrast media allergy.
2- Impaired renal function.
3- Blood clotting disorders or taking anticoagulant medication.
4- Unstable cardiopulmonary/ neurologic status.
Risks / Complications:
1- Bleeding at the puncture site.
2- Thrombus formation.
3- Embolus formation.
4- Dissection of a vessel.
5- Infection of puncture site.
6- Contrast media reaction.
Post procedure care:
1- The catheter is removed and compression is applied to the puncture
site.
2- The patient remains on bed for a minimum 4 hours.
3- Head of the bed may be elevated approximately 30 degrees.
4- During this time check vital signs of the patient.
5- Oral fluid are given and analgesics are provided if require.
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Angiographic Imaging Equipment:
Equipment Requirements:
1- An island-type table that provides access to the patient all side.
2- An analog -to –digital conversion fluoroscopy imaging system.
3- Programmable digital image acquestion system.
4- Specialized x-ray tube.
5- Electromechanical injector.
6- Physiologic monitoring equipment.
Specific Angiographic procedures:
1- Cerebral angiography
2- Thoracic angiography.
3- Angiocardiography.
4- Abdominal angiography.
5- Peripheral angiography.
6- Lymphography
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Cerebral angiography
Cerebral angiography Is a radiographic study of the blood vessels
of the brain.
Pathologic Indications:
1- Vascular stenosis and occlusions.
2- Aneurysms.
3- Trauma.
4- Arteriovenous malformation.
5- Neoplastic disease.
Catheterization:
The femoral approach is preferred for the catheter insertion. The
catheter is advanced to the aortic arch, and the vessel to be imaged is
selected. Vessels commonly selected for cerebral angiography
include:
- Common carotid artery
- Internal carotid artery
- External carotid artery
- Vertebral artery
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Contrast media:
The amount of contrast required depends on which vessel is being
examined, but it usually ranges from 5 to 10 ml.
Imaging:
Biplane equipment is preferred for cerebral angiography. The
imaging sequences selected must be include all phases of the
circulation – arterial, capillary and venous – and will typically be 8 to
10 seconds long.
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Thoracic Angiography
Thoracic Aortagraphy:
Is an angiography study of the ascending aorta, the arch, the
descending portion of the thoracic aorta, and the major branches.
Pulmonary Arteriorgraphy:
Is an angiography study of the pulmonary vessels usually done to
investigate pulmonary embolus.
Pathologic Indications:
1- Vascular stenosis and occlusions.
2- Aneurysms.
3- Trauma.
4- Congenital abnormalities.
5- Embolus.
Catheterization:
The femoral approach is preferred for the catheter insertion. The
catheter is advanced to the desired location in the thoracic aorta.
Because of the location of the pulmonary artery, the femoral vein is
the preferred site for catheter insertion.
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Contrast media:
The amount of contrast required depends on which vessel is being
examined, however, an average amount for thoracic angiography is
30 to 50 ml. for pulmonary angiography, and the average amount is
25 to 35 ml.
Imaging
Serial imaging for thoracic angiography are acquired over several
seconds. The imaging rate and sequences depend on many factors
including vessel size, patient history, and physician preference.
Respiration is suspended during acquisition.
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Angiocardiography
Purpose:
Angiocardiography refers especially to radiologic imaging of the
heart and associated structures. Coronary Arteriorgraphy is typically
performed at the same time to visualize the coronary arteries.
Pathologic indications:
- Coronary artery disease and angina
- Myocardial infarct
- Valvular disease
- Atypical chest pain
- Congenital heart anomaly
Catheterization:
As for other angiograms, the femoral artery is the preferred site to
catheterize. The catheter is advanced to the aorta and along its length
into the left ventricle. A pigtail catheter is used because a large
volume of contrast media will be injected. For the coronary
arteriogram, the catheter is changed.
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Contrast media:
Approximately 40 to 50 ml of nonionic, low-osmolar, watersoluble iodinated contrast media is injected for the cardiogram. The
coronary arteries typical require 7 to 10 ml of contrast media per
injection.
Imaging:
The imaging rate for Angiocardiography is very rapid, in the range
of 15 to 30 frames per seconds and higher for pediatric patients.
If biplane equipment is available, RAO and LAO images will be
obtained. If equipment is single plane, 30 degrees RAO will be
obtained.
A series of oblique images is obtained to fully visualize the
coronary arteries. Routinely six views of the left coronary artery are
obtained, and two views of right coronary artery are obtained
(because in most people left coronary artery and its branches supply
blood to the majority of the heart).
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Abdominal Angiography
Purpose
Abdominal angiography demonstrates the contour and integrity of
abdominal vasculature.
Aortography
Refers to an angiographic study of the aorta, and selective studies refer to
catheterization of a specific vessel.
Venacavography
Demonstrates the superior and/or inferior vena cava
Pathologic Indication
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Aneurysm
Congenital abnormality
GI bleeding
Stenosis or occlusion
Trauma
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Catheterization
For an aortagram, the aorta is typically accessed by the femoral artery. The
type and size of catheter require depend on structure, but a pigtail catheter is
usually used because a large amount of contrast media be delivered such as
needed for an abdominal aortagram.
Selective angiographic studies require the use of especially shaped catheter
to access the vessel of interest. Common selective studies performed include the
celiac axis, the renal arteries, and superior and inferior mesenteric arteries,
which are selected when investigating a GI bleed. A superselective study
involves selecting a branch of a vessel. A common example of this is selection
of the hepatic or splenic artery, which are two of the branches of the celiac axis.
Catheterization for Venacavography is obtained by a femoral vein puncture.
Contrast Media
An average amount of contrast media for aortagram and a venacavogram
is 30 to 40 ml. The amount of contrast media for selective studies varies
depending on the vessel under examination. As for other angiographic
procedure, the contrast media of choice is nonionic water-soluble, and
iodinated, with low osmolity.
Imaging
Imaging is done with patient in the supine position; any obliquity require is
obtained manipulation the C-arm.
Before performing any arterial selective studies an abdominal angiogram
will generally be obtained
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Peripheral Angiography
Purpose
Peripheral angiography is a radiographic examination of the peripheral
vasculature after the injection of contrast media. Peripheral angiography may be
an arteriogram, in which the injection is by a catheter in an artery, or a
venogram, in which the injection is into a vein of the extremity being examined.
Pathological Indication
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Atherosclerotic disease
Vessel occlusion and stenosis
Trauma
Neoplasm
Embolus and thrombus
Catheterization
The seldinger technique is used to access the femoral, or an alternate injection
site for a peripheral arteriogram.
Contrast Media
The average amount of contrast media required for an upper limb arteriogram is
much less than for a lower limb arteriogram. This is because of the difference in
part size and the fact the upper limb exam is unilateral, whereas the lower limb
exam is bilateral.
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Imaging lower limb
Because variance in blood flow through both lower limbs exists as a result of
vessel patency and occlusion, the time of circulation must be determined to
ensure contrast is visible in the in the vessels during imaging. Different methods
can be used to time the imaging. It can be manually by controlling the speed of
table movement during acquisition or it can be programmed into the computer.
Respiration is suspended for the image acquisition.
Imaging Upper limb
Upper limb imaging also requires timing of the blood flow, and a technique
similar to the one described previously may be used. The primary different
between upper and lower limb imaging is that the imaging is unilateral for
upper limb, not bilateral as for lower limb.
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Interventional Imaging Procedure
Definition and purpose:
Interventional Imaging Procedure are radiologic procedure that intervene in a
disease process, providing a therapeutic out-come. Simply stated, interventional
procedures use angiographic techniques for the treatment of disease in addition
to providing certain diagnostic information.
The purposes of these procedures include the following:
 Techniques that are minimally invasive and lower-risk compared with
traditional surgical procedures
 Procedures that are less expensive than traditional medical and surgical
procedure
 Shorter hospital stays for the patient
 Shorter recovery time because of a safer, less invasive procedure
 Alternative for patients who are not candidates for surgery
Interventional procedure may be categorized as vascular or nonvascular
procedures
Vascular Intervention Procedures
1- Embolization
Transcatheter embolization is a procedure that uses an angiography approach to
create an embolus in a vessel, thus restricting blood flow.
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Clinical indication
o Stop blood flow to a site of pathology
o Reduce blood flow to a highly vascular structure and tumor before
surgery
o Stop active bleeding at a specific site
o Deliver a chemotherapeutic agent
2- Percutaneous Transluminal Angioplasty (PTA)
Uses an angiographic approach and specialize catheters to dilate a stenosis
vessel.
A catheter with a deflated balloon is advanced to the vessel of interest.
Hemodynamic pressures proximal and distal to stenosis are obtained, and a
preangioplasty angiogram is performed. The balloon portion to the catheter is
placed at the vessel stenosis, and the balloon is *. The pressure of the inflation
is monitored by a pressure gauge to prevent vessel rupture, and more than one
inflation may be required. The duration of the inflations are carefully timed to
eliminate damage to distal tissue because the blood supply is temporarily
occluded.
The final steps to the procedures include obtaining arterial pressures proximal
and distal to the dilated portion of the vessel and a post angioplasty angiogram.
This allows the effectiveness of the procedure to be assessed.
Risk and complications
o
o
o
o
o
Vessel rupture
Perforation
Embolus
Vessel occlusion
dissection
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Non Vascular Interventional Procedures
1- Percutaneous Vertebroplasty Kyphoplasty
2- Enteric stenting
3- Nephrostomy
4- Percutaneous Biliary Drainage
5- Percutaneous Abdominal Abscess Drainage
6- Percutaneous Gastrostomy
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