Presentation about angiography for medical students

1. AKHIL S RAJ
Technical Assistant, IS &IR
SCTIMST

2.  To understand Catheter angiography
 Essential equipments and their setup
 Essential hard-wares
 Imaging positions and projections
 Basics of physiological monitoring
 Filming / archiving
 Documentation
 Radiation protection tips

3. Angiography is the imaging of vascular
structures of the body like arteries, veins etc.
 Angiography can be performed using:
1. X-rays and Catheters (DSA)
2. Computed Tomography (CT)
3. Magnetic Resonance Imaging (MRI)

4. CTA, MRA DSA( Cath- angio)
 Non/ minimally invasive Invasive
 Non selective Selective/ Super selective
 No dynamic information Dynamic study
 Not good for very small vessels Small vessel information
available
 3D Available 3D available
 Cross circulation studies Cross circulation studies
 not possible possible

5. Advanced angiographic imaging
technique to produce images of
contrast filled vessels in isolation
from other structures
implementing subtraction.

6. Mask subtraction is the most commonly used method in DSA systems.
 A mask or pre contrast image is taken first
 A series of contrast images are obtained with contrast injection
 The mask image is subtracted pixel by pixel digitally from the contrast
containing images
 The resulting image shows only contrast filled vessel
Mask
1 2 3 4 5
2-1 5-1
4-1
3-1

7. 78 45 8 57
33
92
89 82 38
25
70 82 18 87
79
36
99 44 28
55
66 2 94 35 65
78 45 8 57
33
62
89 12 38
25
70 82 18 23
79
36
28 44 28
55
66 2 14 35 65
0 0 0 0
0
32
0 70 0
0
0 0 0 64
0
0
71 0 0
0
0 0 80 0 0
0 = WHITE
100 =BLACK
MASK -1
FRAME 4
4-1
30
70
64
71
80
FINAL DISPLAY

9.  A good quality well equipped DSA suite – single/biplane.
 Radiologist / Interventionist
 Various hardware to perform the angiography.
 An expert Technologist.
 A trained Staff Nurse.

10. Always follow the institute protocols
Prepare a check list for each procedure and follow that strictly.
 Blood investigations
Hb., TC, DC, ESR, PT, INR, Electrolytes, Urea, Creatinine
 Hypertension, Diabetes etc.
 Local body part preparation.
 Informed consent.

11. Before taking the patient inside the DSA lab.
 Check patient’s identity
 Blood reports.
 Informed Consent
 Materials required for the study
 The study required
 Clinical diagnosis
CHECK……
Emergency Medicines
Defibrillator
O2 Supply

12.  Position the patient as per the study
requirement ( make sure that pt. is comfortable )
 Connect physiology monitor
 Check vitals like BP, HR, SPO2, RR etc
 Explain the procedure briefly to the patient
 A technologist must know the operation of the physiological monitors
 Notify any changes in the physiological parameters.

13.  Whenever possible keep the neck of the patient neutral
position or little flexed..
 If it is hyper-extented , it is difficult get proper cranial
angulations during Townes view.
 If positioning for ante-grade puncture with feet first,
provide a hardboard box to facilitate easy breathing for
the patient.

14.  NBP- non invasive BP
There is settings to measure the NBP- either manually or automatically
repeating mode.
 Use the appropriate cuff size as per patient.
 Note down the value after connecting the patient.
 If possible keep the BP cuff on the arm free of any
IV infusions connected.

15.  It is measured by connecting an arterial line to a transducer via a
pressure dome.
 All technologist should be aware of preparing the transducer and
connecting it to the patient.
 After preparing the transducer it should be zeroed and a proper scale
to be selected for obtaining the correct tracing.
 For Zeroing – open the transducer to Atmosphere and zero the
monitor reading.
 Flush the line if there is damping of the waveform.

16.  We can select a number of (6 leads ) ECG tracings
 Select a good tracing and set the Heart rate measurement from the
same lead.
 Keep the ECG tone on- so that any change in rate can be detected
easily.
 Set the speed as 25mm/sec.
 Adjust the gain of the trace for proper interpretation.
 Make sure that the ECG cables are away from the imaging area.

17. Strictly follow sterile techniques
Before local anesthesia fluoro the puncture site area to make sure
the position of the femoral head
Puncture needles
 Arterial needles are 16 to 20G
 18 gauge being the standard.
 WIRE NEEDLE COMPATIBILITY
SELDINGER TECHNIQUE

18. Femoral
Brachiel
Radial
16-18 G needle , up to 10-12F sheath
18-20 G needle , up to 6F sheath
Micro puncture set ( 22G )
Guide-wire puncture needle compatibility Length of the needle

19.  Size ranges from 3F-22F size.
 Various length and pre shaped curved sheaths available.
 Color coding is available for different sizes.

20.  35cm, 55/60cm, 90cm etc.
 Tortuous anatomy.
 Less Stability of guiding catheters during interventions.
 Guiding catheter ID limitations.
 Balkin sheaths. - Used for entry to opposite
iliac artery
 Other sheaths are Ansel / mullin etc.

21. SHEATHS AND CATHETERS DIAMETER IS MEASURED IN FRENCH UNIT
1Fr = 0.003 ‘
3Fr = 1mm

22.  A Catheter is a hollow flexible tube that can be inserted in to a blood
vessel
 Poly vinyl chloride (PVC)
• Polyurethane (PUR)
• Polyethylene (PE)
• Fluropolymers (PTFE) (TEFLON)
• Silicone
Ideal characteristics of catheters
 Better torque control
• Strength and Radio-opacity
• Flexibility
• Atraumatic Tip
• Low surface friction resistance

23. Metallic reinforcement
• Stainless steel
• Beryllium
• Copper
• Silver
• Monofilament polymers
The benefits of braided catheter shaft are its
high torque control and kink resistance.

24. Catheter Classification criteria
• End hole / side hole
• Shape of the tip
• Std. size or micro catheters
• Balloon catheters
• Flow guided
• Diagnostic catheters
• Guiding catheters

25.  Diagnostic and Guiding catheters are basically named according to
their tip shape/ curve and the part where it is used.
 The curves are Primary curve, secondary curve, tertiary curve etc.
JR – Right Coronary
JL – Left Coronary
Pigtail Catheter-
End hole & side holes

27. • Increase the ease and safety of catheter placement in vascular
system.
• Basiclly two types - Metallic guidewire and hydrophilic
guidewire
Outer shell of flexible spring like material Central core- stiffens GW
Basic structure of metallic guidewire
Teflon outer coat - decreases
thrombogenicity
- Increases trackablity.

28. 28
Gold – Good radiopaque property
Nitinol – Nickel Titanium alloy, has exceptional shape
memory,limited rigidity, used in tandem with rigid
substances.
Platinum – radiopaque
Stainless steel
Stainless steel with nickel
Titanium core
Tungsten

29. Hydrophilic guide wire:
• Central core made of very flexible alloy- Nitinol
• Outer envelope-polyurethane to which a hydrophilic
polymer is bonded.

30. Tip Configuration -Straight , Curved , Angled
Length of guide wires ranges from 150 - 300cm
A 150 cm guide wire is called a standard wire
A double length( 260-300cm) is called exchange wire
Guide wire diameters vary from 0.007 inch to 0.038 inch
Micro guide wires - 0.007, 0.010, 0.014 etc.
Macro guide wires - 0.018, 0.025, 0.032, 0.035, 0.038.
Based on stiffness
Standard , stiff , super stiff, ultra stiff etc.

31.  A non- ionic contrast media is the best
choice - 300-370mgI/ml
 A 1:1 dilution in DSA
 An iso-osmolar contrast for patients with
impaired renal function.
 A pressure injector is used when fast
injection of contrast media - Aortography,
3D angio etc.

32. Region Volume - ml Rate - ml /sec Pressure/psi
ARCH 30-35 15-18 500-650
DTA 30 15 600
ABD. 35 16 650
ILIACS 25 15 500
3D- CAROTIDS 21 3 300-350
3D-VERTEBRAL 21 2.5 250

33.  A fair knowledge of the vascular anatomy is must for working in an
angiographic suit.
 A 3D idea should be there for proper selection of catheters.
 Should be able to identify vessels in all orthogonal planes when doing
3D imaging and MPR images.

36. There are standard projections for each vessels in angiography
Cerebral angio
Carotids
AP cranial ( AP CRA) Lateral ( LAT) Oblique
20-25o RAO/ LAO
(Ipsilateral)

37. Vertebral arteries
AP Caudal Townes Lateral

38.  Take projections for better anatomical views
 Make sure that the image rotation is applied according to
the patient position( head first/ feet first etc.)
 Apply zoom for better visualization.
 Give angulations in lower limb angios for exact anatomical
positions.

39. Indications
A –com aneurysm, ICA aneurysms, intracranial tumors encasing main branches,
CCF, etc.
Palpate and compress the carotid artery with three fingers in between the
lateral aspect of trachea and medial aspect of sterno-cleido mastoid muscle at
the level of thyroid cartilage
Apply the pressure gently so that the patients head should not
move
Explain the patient that you are going to compress in the neck

40.  The images are recorded in particular frames per second.
 Follow the preset protocols for each study / pathology / part , the FPS vary
 FPS is a factor which help in radiation protection.
 FPS of 2-4 is enough normally for cerebral angios.
 In AVM /AVF etc. fps can be the maximum possible.
 In Coronary angio an fps of 12- 15 is enough for adult patient. But can
increase in pediatric cardiac studies.

41. Arterial phase Capillary Venous
Segment parameters can be edited as per the pathology

42.  Always use all radiation shields like lead aprons, thyroid shields, other
lead shields, lead goggles etc. while inside the lab.
 Keep away from x-ray tube as possible.
 Adjust the fluoro and acquisition FPS only minimum for the study
requirement.
 Wear radiation badges and send it for analysis regularly.
 Avoid unwanted views and acquisitions.
 Collimate the fields properly.
 Always give attention to the Fluoro alarms.
 Instruct the patient so that un- wanted repetitions due to patient
movements can be avoided.
 Insist the service personals to do Quality assurance check and
calibrations periodically.
 In difficult anatomy use wire and roadmap.