1.
Angiography/ Interventional Basics What do we visualize with an angiographic procedure?

2.
Personnel in the Angio Room <ul><li>http://www.heartsite.com/html/cardiac_cath.html </li></ul><ul><li>Radiologist/ Specialist </li></ul><ul><li>Cardiovascular nurse </li></ul><ul><li>2-3 Radiologic Technologists (CV) </li></ul><ul><li>Sometimes Anesthesiologist </li></ul>

3.
Angiography/ Interventional/ Cardiovascular <ul><li>Procedure Room (Suite) </li></ul><ul><ul><li>Room size- 400-600 square feet </li></ul></ul><ul><ul><li>Easily cleaned </li></ul></ul><ul><ul><li>Why? </li></ul></ul><ul><ul><li>Outlets needed for O2, suction, crash cart </li></ul></ul><ul><ul><li>3 means of access to the room (Bushong, p. 374) </li></ul></ul><ul><ul><ul><li>What are they? </li></ul></ul></ul>

4.
<ul><li>Control Room </li></ul><ul><ul><li>100-150 square feet </li></ul></ul><ul><ul><li>Easy access and communication to procedure room </li></ul></ul><ul><ul><li>Computers, monitors and un sterile personnel </li></ul></ul><ul><ul><li>Storage area- guide wires, catheters and needles </li></ul></ul>

5.
Equipment found in all Advanced Procedure Rooms <ul><li>X-ray generators </li></ul><ul><li>Controls </li></ul><ul><li>X-ray Tubes </li></ul><ul><li>System to record events of procedure </li></ul><ul><li>Automatic Injectors </li></ul>

6.
Generator <ul><li>700MA- 1500MA </li></ul><ul><li>Short exposure times </li></ul><ul><li>Able to generate 80- 100 KW power </li></ul><ul><li>Limit motion </li></ul><ul><li>Provide max. contrast </li></ul>

7.
X-Ray Tube Requirements <ul><li>Detail </li></ul><ul><li>Withstand high heat- rapid exposure sequences </li></ul><ul><li>Tube rating charts posted </li></ul><ul><li>Need max. detail for vessels </li></ul><ul><li>Use smallest possible focal spot </li></ul><ul><li>Decrease target angle, p.13…line focus principle </li></ul>

8.
Equipment Requirements <ul><li>High heat load tubes w/ rapid cooling </li></ul><ul><ul><li>Series imaging, intense heat </li></ul></ul><ul><ul><li>SPEED UP THE ANODE RPM </li></ul></ul><ul><li>1-2 Track mounted tubes </li></ul><ul><li>Analog- to- Digital Conversion System </li></ul><ul><li>Programmable digital image acquisition system (rate,sequencing, processing) </li></ul><ul><li>PACS </li></ul>

9.
<ul><li>Electromagnetic Injectors </li></ul><ul><li>Monitoring Equipment- BP & ECG </li></ul><ul><li>Island Tables- access from all sides, height adjustments, floor controls </li></ul><ul><li>Where are the cables? </li></ul><ul><li>Tables do not usually tilt </li></ul>

10.
Digital Acquisition <ul><li>2 types </li></ul><ul><ul><li>1. Analog-to-Digital </li></ul></ul><ul><ul><ul><li>Radiation-pt-intensifier-light-TV-light to electrical signal- analog-to-digital converter- image processor </li></ul></ul></ul><ul><ul><li>2. Flat detectors </li></ul></ul><ul><ul><li>Charged coupled devices (CCD) computer chip </li></ul></ul><ul><ul><li>Direct digital conversion </li></ul></ul>

11.
Charge Coupled Device (CCD) <ul><li>Silicon computer chips </li></ul><ul><li>Converts light to digital image </li></ul><ul><li>Lower noise </li></ul><ul><li>Better contrast </li></ul><ul><li>Lower patient dose </li></ul><ul><li>Advantage to this type system- images produced in low light w/o loss of resolution </li></ul>

12.
Digital Imaging- Analog VS Digital Concepts <ul><li>Analog- image seen after chemical process </li></ul><ul><li>Digital- image manipulated by software </li></ul><ul><ul><li>Relates to numbers </li></ul></ul><ul><ul><li>Number table called an array </li></ul></ul><ul><ul><li>Information changed through use of computer algorithm </li></ul></ul><ul><li>Advantages of Digital Angiography, p.30 </li></ul>

13.
Digital Subtraction Angiography (DSA) <ul><li>Computer “ subtracts” out all anatomy except contrast-filled vessels </li></ul><ul><li>Looks like a reverse image </li></ul><ul><li>Can be more diagnostic for vessels ( clots, constrictions) </li></ul><ul><li>Imaging systems below now mostly replaced by digital </li></ul><ul><ul><li>Cut Film Changer </li></ul></ul><ul><ul><li>Cine Fluoro( Cardiac Cath Camera) </li></ul></ul>

14.
Electromechanical Injector <ul><li>Used in Angio, CT, MRI </li></ul><ul><li>Overcome arterial pressure + maintains bolus </li></ul><ul><li>Maintains flow rate </li></ul><ul><li>Flow rate affected by </li></ul><ul><ul><li>Viscosity </li></ul></ul><ul><ul><li>Length + diameter catheter </li></ul></ul><ul><ul><li>Injection pressure </li></ul></ul><ul><ul><li>Vessel selected </li></ul></ul>

15.
<ul><li>Components </li></ul><ul><ul><li>Control panel </li></ul></ul><ul><ul><li>Syringe </li></ul></ul><ul><ul><li>Heating Device </li></ul></ul><ul><ul><li>High- pressure mechanism </li></ul></ul><ul><li>Safety Devices </li></ul><ul><ul><li>Acceleration regulators </li></ul></ul><ul><ul><li>Pressure- limiting devices </li></ul></ul><ul><ul><li>MRI- non- ferrous material </li></ul></ul>

16.
Vocabulary Terms <ul><li>Arteriosclerosis- vessels hardened </li></ul><ul><li>Atherosclerosis- plaque like cholesterol </li></ul><ul><li>Thrombus </li></ul><ul><li>Embolus </li></ul><ul><li>Occlusion </li></ul><ul><li>Tumor </li></ul><ul><li>Stenosis </li></ul><ul><li>Angioplasty-angio procedure dilates stenosed vessel </li></ul>

17.
<ul><li>Lithotripsy </li></ul><ul><li>Stent- cage like metal device placed in vessel to maintain blood flow </li></ul><ul><li>Thrombolysis </li></ul><ul><li>Filter </li></ul><ul><li>Embolization- stop bleeding, cease blood flow to site of pathology </li></ul><ul><li>Ante grade </li></ul><ul><li>Retrograde </li></ul>

18.
Seldinger Technique <ul><li>Method for catheterization of vessels </li></ul><ul><li>Developed 1950’s still popular today </li></ul><ul><li>Percutaneous (through the skin) </li></ul><ul><li>3 vessels considered: </li></ul><ul><ul><li>Femoral –preferred site for arterial (size + accessibility) </li></ul></ul><ul><ul><li>Brachial </li></ul></ul><ul><ul><li>Axillary </li></ul></ul>

20.
<ul><li>Selection based on strong pulse w/ absence of disease </li></ul><ul><li>Site cleaned, area draped, local given </li></ul>

21.
Seldinger Technique ( step-by-step) <ul><li>Insertion of needle </li></ul><ul><li>Placement of needle in lumen </li></ul><ul><li>Insertion Guide wire- thru needle, advance 10 cm </li></ul><ul><li>Removal of Needle- guide wire in position </li></ul><ul><li>Threading of catheter to area of Interest- fluoro used </li></ul><ul><li>Removal of guide wire- catheter remains in place </li></ul>

22.
SELDINGER TECHNIQUE

23.
<ul><li>Two less common methods used </li></ul><ul><ul><li>Cut down- minor surgical procedure to expose vessel of interest </li></ul></ul><ul><ul><li>Translumbar- patient prone, long needle passed thru T12- L2 into aorta </li></ul></ul>

24.
Contents of Procedure Tray <ul><li>Variety items 3 basic groups of equipment </li></ul><ul><ul><li>Prep Group </li></ul></ul><ul><ul><li>Anesthetic Group </li></ul></ul><ul><ul><li>Insertion and removal Contrast </li></ul></ul><ul><li>Accessories </li></ul><ul><ul><li>Adaptors </li></ul></ul><ul><ul><li>Connectors </li></ul></ul><ul><ul><li>Manifolds, Stopcocks </li></ul></ul>

25.
Let’s Look at Needles, Guide wires and Catheters <ul><li>Cannula </li></ul><ul><li>stilette </li></ul><ul><li>connecting hub (luer lock) </li></ul><ul><li>baseplate </li></ul><ul><li>two or three-way stopcock </li></ul><ul><li>transparent tubing </li></ul>

26.
Guidewires <ul><li>Guide catheter for placement in vessel </li></ul><ul><li>Diameter large enough so blood can not flow back for too long a time </li></ul><ul><li>Tips at the end of GW </li></ul><ul><ul><li>Straight </li></ul></ul><ul><ul><li>J- tipped </li></ul></ul><ul><li>longer G.W. for selective angio vessels </li></ul><ul><li>Short used for shorter direct vascular approach </li></ul>

27.
CATHETERS <ul><ul><li>Straight </li></ul></ul><ul><ul><li>Pigtail </li></ul></ul><ul><ul><li>Sidewinder </li></ul></ul><ul><ul><li>Cobra </li></ul></ul>

28.
<ul><li>The more holes at the end / the more contrast / large vessels </li></ul><ul><li>Catheter with only end hole/ smaller vessels/ carotid </li></ul><ul><li>Combo end and side holes reduce risk of trauma to vessel, enhances contrast </li></ul>

29.
Vascular/ Non- Vascular Studies <ul><li>Embolization pg 711, Bontrager </li></ul><ul><li>Stent Placements </li></ul><ul><li>PTA pg 712 , Bontrager </li></ul><ul><li>Vena Cava Filters </li></ul><ul><li>Thrombolysis </li></ul><ul><li>Biopsies </li></ul><ul><li>Fluid Drainage </li></ul><ul><li>Injection of Medicines </li></ul><ul><li>Tube Placement in Organs or Cavities </li></ul><ul><ul><li>Bontrager, pg 716 </li></ul></ul>

30.
Interventional Imaging Procedures <ul><li>Intervene w/ disease, provide therapeutic outcome </li></ul><ul><li>Purpose/ benefits </li></ul><ul><ul><li>Lower risk compared to surgery </li></ul></ul><ul><ul><li>Less $ </li></ul></ul><ul><ul><li>Shorter hospital stay and recovery </li></ul></ul><ul><ul><li>Alternative for non surgical patient </li></ul></ul>

31.
Post Procedure Care <ul><li>Catheter removed – compression </li></ul><ul><li>Bed rest- min 4 hrs/ head up 30 degrees </li></ul><ul><li>Vital signs </li></ul><ul><li>Extremity watch </li></ul><ul><li>Some angiographic procedures: angioplasty, venography, angiocardiography, lymphography </li></ul>

32.
Radiation Protection <ul><li>Proximity to patient </li></ul><ul><li>Radiation protection devices </li></ul><ul><li>Leaded glasses pulled into place </li></ul><ul><li>Minimal fluoro use </li></ul><ul><li>Collimation </li></ul><ul><li>Wear badges and ring monitors </li></ul>

33.
Risks/ Complications <ul><li>Bleeding at puncture site </li></ul><ul><li>Thrombus formation </li></ul><ul><li>Embolus formation –plaque dislodged </li></ul><ul><li>Dissection of vessel </li></ul><ul><li>Puncture site infection ( contaminated sterile field) </li></ul><ul><li>Contrast reaction </li></ul>