Upper & Lower Limb Angiography PDF

UPPER & LOWER LIMB ANGIOGRAPHY Arif Faddilah Mohd Noor UPPER LIMB ANGIOGR...

UPPER & LOWER LIMB ANGIOGRAPHY Arif Faddilah Mohd Noor UPPER LIMB ANGIOGRAPHY Angiography - Preprocedure Vessel access for CM injection 1. Seldinger technique 1. Medical history should be obtained Percutenous technique that can be used for arterial or venous access 2. Detail explanation of the procedure including both benefits and risk 3. NPO 8H b4 procedure 2. 4 vessels for catheterization 4. Premedication is given for pt to relax 1. Femoral – preferred site for artery puncture because its size & easy access 5. Continuous communication and monitoring pt during procedure. 2. Axillary 3. Brachial 4. Radial Vascular Access Angiographic tray  Relatively disease-free, without significant cancer. 1. Hemostats  Over a bony structure, if possible 2. Prep sponges and antiseptic solution  Angle of entry- 30⁰-45⁰ 3. Scalpel blade  If access vessel-small/potentially diseased- micropuncture technique 4. Syringe and needle for LA preferred 5. Basins and medicine cup 6. Sterile drape and towels 7. Band-aids 8. Sterile II cover Contrast media Contraindication 1. CM allergic 1. Water soluble 2. Impaired renal function 2. Non ionic – low osmolality – reduce risk of allergic 3. Blood clotting disorders or taking anticoagulant medication 3. Volume = depends on vessel of exam 4. Unstable cardiopulmonary / neurologic status Risks/complication After care 1. Bleeding at the puncture site 1. Compression is applied to the puncture site 2. Thrombus formation : blood clot 2. Pt remain on bed rest min 4h but head of bed may be elevated approximately 30º. 3. Embolus formation : vessel occlusion/ stroke 3. Monitored vital sign and pulse 4. Dissection of a vessel 4. The extremity is checked for warmth, color, and numbness to ensure circulation is in 5. Infection of puncture site good condition 6. CM reaction 5. Oral fluid are given Upper limb artery 11 Pathologic indication Catheterization 1. Atherosclerotic disease  Femoral artery = for lower limb catheter advanced just superior 2. Vessel occlusion and stenosis to the aortic bifurcation 3. Trauma  For upper limb, catheter 4. Neoplasm advanced along abdominal & 5. Embolus & thrombus thoracic aorta and into subclavian artery Aortogram Catheter Guidewire  Simmons catheter  Straight or J-tip  Angiographic catheter  50 – 145 cm long  Diameter – 0.03 – 0.13cm  Slippery with excellent torque and useful for tortuous vessel Brachial and Axillary Arteriogram Axillary Arteriogram 17 18 1. Radial Artery. 2. Ulnar Artery. 3. Deep Palmar Arch. 4. Common Palmar Digital Artery. 5. Proper Palmar Digital Artery Hand Arteriogram Hand Arteriogram with Occlusion 25 Vessel anatomy LOWER LIMB ANGIOGRAPHY Peripheral angiography – lower limb Vascular Access sites Retrograde Common Femoral Artery (CFA) Access Common access site used for peripheral diagnostic angiography and intervention Prevent injury to the less diseased extremity Vascular access sites Contralateral femoral retrograde access : Contralateral access: Internal iliac stenosis are best treated from a contralateral approach Superficial Femoral Artery (SFA), profunda femoris artery (PFA)- lesions located within the common femoral artery (CFA) / involve superficial femoral artery (SFA) / PFA ostium Proximity to arterial puncture site, Bifurcation anatomy of CFA Also allows treatment bilateral disease with a single arterial puncture Other reasons of catheterizing the contralateral side: Affected leg is ischemic. Scar tissue is present on involved side. Iliac pulse is absent on affected side  Vascular Access site Vascular access sites Antegrade Common Femoral Artery (CFA) Ipsilateral popliteal retrograde access: Access: Useful in SFA occlusion with failure to Required for infrainguinal proceed cross from contralateral or antegrade Approx 3cm CFA lies between Ostial SFA/CFA lesions may also be ligament & Femoral Artery bifurcation approached via PA in acute angled In order to access CFA, skin entry - terminal aortic bifurcation proximal to inguinal ligament. Contraindications - aneurysms of Access too close to Femoral Popliteal Artery, pathology of bifurcation –inadequate working room popliteal fossa- Baker’s cyst to selectively catheterization of SFA Brachial Artery Access Wire selection  Preferred access for visceral arterial [Celiac Artery, SMA] interventions  Many-Teflon/silicone : Some- hydrophilic  Percutaneous approach at Brachial Artery can lead to a ↑complication rate:  Hydro-stenosed / torturous+angle tip – Glidewire  Upper Limb arteries – smaller, prone to spasm and embolism.  Can be used for crossing tight lesions and can be advanced independent of a guidewire  A small hematoma- Could lead to brachial plexopathy  requires > 6F sheaths/smaller pt→ open approach preferred  Left Brachial artery access preferred over Rt- can avoid carotid origin  A micropuncture technique should be used for all PC BA intervention Estimated distances from FA access Omni Flush Angiographic Catheter  Designed as a single catheter to perform flush aortography, Bilateral “run off” studies of lower extremities and to cross aortic bifurcation with ease for Contralateral diagnostics in interventional procedures.  Super-Radiopaque tip  Reforms and maintains shape—even under injection pressure—with less catheter whipping, resulting in less vessel wall injury  Less contrast reflux than other flush catheters, thus resulting in lower total contrast dose Accesses and Selective Guiding Catheters for Some Basic Interventions Superior Femoral Artery 1. First choice—contralateral FA 2. Alternative—ipsilateral retrograde FA for run- off; ipsilateral antegrade for intervention. 3. Selective catheter—Berenstein, Kumpe, Vertebral Tibial Arteries 1. First choice—contralateral FA Kumpe catheter 2. Alternative—ipsilateral retrograde FA for run- off; ipsilateral antegrade for interventions 3. Selective catheter—Kumpe, Vertebral Thanks