Arteriography and interventional radiology by Dr. Crystal KC

1. Arteriography and Interventional
Angiography
By Dr Crystal K C
2nd Year Resident
NAMS

2. Introduction
• Angiography: Is the general term that
describes the radiologic examination of
vascular structures within the body after the
introduction of an iodinated contrast medium
or gas.
• Arteriography is the study of the arteries
• Venography is the study of veins.

3. Current Techniques for Imaging
Arteries
• Non-invasive and radiation free-Ultrasound
and MRI.
• Mildly invasive and radiation free-MRI with IV
gadolinium(CE MRI)
• Mildly invasive plus radiation-Multislice spiral
CT with IV contrast.
• Invasive with radiation- Percutaneous
catheterisation

4. Puncture Needles
Used to cannulate or puncture the
artery.
Usual Sizes include
18 g, 19 g , 20g, 21 g.
The selection of the Size depends
on the guide wire going to be
inserted through that needle port.

5. •They are the stainless steel metallic structures that guides
the catheter through the blood vessels for placement.
•Guide wires are relatively simple spring type wires that
provides necessary firmness and the control to the site
where Angiogram will be taken.
•They are Made of Stainless steel or other metallic Alloys.
Guide Wires

6. Guide Wires
There are two tip configurations
Guide Wires :
The Straight tip
The J-shaped tip
Guide Wire Length varies from 30 to 260
cm. The shorter Guide wires (30 to 50 cm )
are usually used for percutanous or direct
vascular puncture.
Diameter= 0.014” (0.35mm) to 0.052”
(1.32mm).Most commonly used is 0.035”

7. Catheters
A catheter is a hollow flexible tube that can be inserted
into a body cavity, duct or vessel. Catheters thereby allow
drainage or injection of fluids ,and distend a passageway.
The process of inserting a catheter is catheterization.
Materials:
•Polyethylene (PE)
•Fluoropolomers (PTFE)
(TEFLON)
•Polyurethane (PUR)
•Silicone (SI)
•Polyvinylchloride (PVC

8. Types of catheters
• Diagnostic Angiographic Catheters.
• Micro catheters.
• Drainage Catheters.
• Balloon Catheters.
• Central Venous Catheters.

9. Direct Arteriography
• Two basic techniques :
1. Direct needle puncture: speed and
simplicity but less versatile.
2. Direct catheterization.
Based on the work of
Seldinger in Stockholm .

10. Techniques of Percutaneous
Catheterization

11. Anaesthesia
• Local anaesthesia, basal sedation with
pethidine may be required.
• General anaesthesia
 Children
 Nervous patients
 Uncooperative patients.

12. Contrast Media
• Low osmolar non ionic contrast media :
Ultravist (iopromide)
Others
Isovist ( Iotrolan), Visipaque (iodixanol) Tomeron (Iomeprol)

13. Dosage
Dosage of the contrast medium injected depends upon the
flow rate in the vessels being injected.

14. Complications
A. General
1. Contrast reactions
a. Severe life-threatening
b. Intermediate
c. Minor
2. Embolus
a. Catheter clot
b. Cholesterol
c. Cotton fibre
d. Air
3. Septicaemia
4. Vagal inhibition
B. Local
1. Puncture site
a. Haemorrhage and haematoma
b. False aneurysm
c. Arteriovenous fistula
d. Perivascular or subintimal
contrast injection
e. Local thrombosis
f. Local infection
g. Damage to adjacent nerves

15. 2. Damage to target or other organs due to
a. Excess of contrast
b. Catheter clot embolus
3. Fracture and loss of guide-wire tip
4. Knot formation in catheters
5. Embolisation accidents

16. Contrast Reactions

17. Complications
Damage to arteries:
o Result from traumatic needle or catheter
puncture.
o May lead to actual occlusion and thrombosis
in small vessels.
Precaution:
• Use of short bevelled needles.
• Skill and experienced radiologist.

18. Thrombosis of arteries
Causes:
• Trauma to the arterial wall
• Formation of clot at the end of a catheter.
• Severer hypotensive reaction.
Risk factors :
Cardiovascular insuffienciency
Severely atheromatous vessels.
Precautions:
Systemic heparinization:3000 units
of heparin.
Reversal: Protamine sulfate10mg/1000 unit
of heparin used.

19. Hypotension
• Arteriographic procedure (mainly complex or
prolonged procedure) may lead to
hypotension.
• Hypotension may lead to the arterial
thrombosis.
Precautions
Regular blood pressure monitoring during and
after the procedure in the ward.

20. Catheter clot embolus
Clot may form in and around the tip of a catheter,
particularly during a prolonged procedure
Risk carrying procedures:
• Left ventriculography,
• Coronary arteriography,
• Arch aortography
• `Headhunter' catheterisation of the
cerebral and subclavian vessels
Precautions :
Small catheters
Speedy and skilled angiography.
Systemic heparinization.

21. Cholesterol embolisation:
Occur after surgery
Occasionally by arterial catheterisation.
A large shower of cholesterol crystals can produce disastrous results in
vitals organs.
Air embolus:
Risk factors:
• Large steel syringes
• If the nozzle is horizontal or pointing upwards.
Precautions:
• Translucent plastic syringes
• Not to include air when loading with contrast medium or saline solution,
• Injections should be made with the nozzle pointing down.

22. Haematomas and false aneurysms
• Relatively uncommon as small needles are used and the tips
of larger catheters are well tapered.
• Most frequently with hypertensive patients.
Precautions:
• History: Anticoagulants drugs used.
• Investigations: PT/INR 0.9- 1.5
• Firm manual pressure through gauze swabs should be
maintained on the puncture site after arterial puncture.
• The puncture site should also be inspected before the patient
leaves the department.

23. Damage to nerves
Injury to brachial plexus:
• Seen in transaxillary
catheterisation leading to
severe disability.
Cause :
• Direct needle injury
• Compression due to hematoma or false
aneurysm.
Femoral nerve palsy is a much rarer complication
of femoral artery puncture

24. Vagal inhibition
• May occur after a contrast medium injection.
• Characterised by collapse of the patient with
bradycardia.
• In case of circulatory collapse in acute allergy,
which is usually associated with tachycardia.
• In vagal inhibition atropine is the drug of
choice.
• Allergic condition treated with epinephrine
(adrenaline).

25. Damage to organs
Targets :Vital organs
• Heart, brain, kidneys and bowel
Causes:
Arterial thrombosis
Excessive dose of contrast medium.
Spinal cord damage is a rare and tragic complication
of arteriography.
Usually due to an excessive dose of contrast medium
entering a main artery of supply to the spinal cord from
injection of the artery of Adamkewicz which supplies
the cord from T8 downward and arises from one of the
upper lumbar or lower intercostal arteries.

26. Indications For Arteriography
I. Congenital
2. Aneurysms
3. Stenoses and thromboses
4. Arteritis
5. Trauma
6. Embolus
7. Angiomatous malformation
8. Arteriovenous fistula
9. Haemorrhage
10. Masses and tumours.

27. Congenital
• The brachial artery occasionally divides into its radial and
ulnar branches at a high level and this had some practical
importance when brachial arteriography was more widely
practised.
• Persistent primitive sciatic artery.

28. Congenital anomalies of the
renal supply are very common,
and
some 25% of kidneys have an
accessory artery supplying
them. For this reason
arteriography is performed on
live renal donors to check that
the proposed kidney is
suitable for grafting.
Bilateral accessory artery may
be seen in 10-15% of cases.
Fig: MRA showing bilateral
accessory renal arteries

29. Aneurysms
• Congenital
• Infective
• Traumatic
• Poststenotic
• Degenerative
• Dissecting
• Necrotizing vasculitis

30. Dissecting Aneurysm

31. Stenoses and thrombosis
Congenital stenoses:
Coarctation of the
thoracic aorta is
commonly seen.
However abdominal
coarctation involving
the origin of the
splanchnic and the
renal arteries may be
seen.

32. • Extrinsic pressure: Pressure from tumours, cysts or
other masses,localised compression due to fibrous
band (in thoracic outlet syndrome),anomalous tendon
(obstruct popliteal artery.
• Arteritis: Takayasu’s arteritis.
• Atheroma:mainly seen in
1. Internal carotid and vertebral origin
2. Coronary artery lesions causing cardiac ischaemia
3. Renal arteries, with resulting hypertension
4. The abdominal aorta
5. Iliac and femoral arteries.

33. Leriche’s Syndrome
Clinical triad of impotence,
pelvis and thigh
claudication, and absence
of the femoral pulses.
Aetiology
arteriosclerosis
vasculitis
Thrombosis
CT angiography
It allows direct anatomical
visualisation of the location
of the stenosis and
occlusion of the aortoiliac
arteries and the collaterals
associated.

34. Buerger's disease
Age:young group than
typical atheromatous
vascular disease.
Sex:Male
Strong association in heavy
smokers.
The typical angiographic
appearance : Healthy
femoral and popliteal
arteries, with the calf
vessels largely occluded
and replaced by tiny
collaterals .

35. Fibromuscular hyperplasia
Unusual congenital arterial disease first described in the renal arteries
as a rare cause of renal artery stenosis and occurring mainly in
young women.
Angiography: irregular beaded appearance of the affected artery.The
lumen of the artery, when examined pathologically, exhibits
both stenoses and sacculations, and the latter may become aneurysmal.

36. Arteritis
• Takayasu’s arteritis:
• Rare condition first described in Japan in 1908
• Age 20-30 yrs
• Sex: Female
• Granulomatous inflammation of the media of aorta
proceeding to fibrosis and atheroma like changes
involving the branches.
• Angiography shows a surprising irregularity of the
aorta, which resembles that of an elderly
atheromatous person, together with stenoses or
occlusions of the origins of the major branches.

37. Giant cell arteritis
Giant cell arteritis typically
involves
Medium and large sized
arteries supplying the
head (temporal arteritis, neck
carotid arteries
and arm brachial ateries.
Age :more than 60 yrs
Sex: Female
Angiography :Areas of smooth
long segment
Narrowing of the axillary and/
or bachial arteries.

38. Embolus
Angiography shows a sharp
cut-off at the point of
occlusion
with sometimes a
characteristic convex upper
margin
(meniscus sign). Larger
emboli affecting the
aortic, iliac or femoral
bifurcation are usually
removed surgically
with a Fogarty balloon
catheter.

39. Embolus
• Major embolus to the systemic arterial system is
most commonly cardiac in origin, being seen in
patients with atrial fibrillation and intra-atrial clot, or
following clot formation in the left ventricle after
cardiac infarction.
• Another cardiac cause is clot forming on prosthetic
valves after cardiac surgery.
• Embolus may also follow clot formation in a large
aneurysm,which is then detached and carried
distally.

40. Angiomatous malformations
• Referred to as angiomas and congenital arteriovenous
fistulas, represent direct communications between
arterioles and venules without the interposition of a
capillary bed.
• Congenital, present in adults.
• common in the cerebral circulation but can present
anywhere in the body
• There are hypertrophied arteries leading to the lesion and
hypertrophied veins draining it, their size depending on the
degree of shunt present.
• Both arteries and veins fill rapidly, and before contrast
medium has passed through normal capillaries in the
adjacent regions.

42. Arteriovenous fistula
• This term is best limited to the condition
where there is a single communication
between an artery and a vein, and is mainly of
traumatic origin, particularly following
gunshot or other penetrating trauma.
• Occassionally may result from the closed
injury.
• Traumatic fistulas may occur anywhere in the
body.

44. Haemorrhage
Arteriography can be extremely useful in the
diagnosis and treatment of internal haemorrhage.
Causes
• Trauma,
• Peptic ulceration
• Ruptured aneurysms
• Neoplasms or inflammatory lesions.
Percutaneous catheterisation and embolisation offers
a simpler and safer alternative to surgery.

45. Upper gastrointestinal tract
haemorrhage
Common causes
• Oesophageal varices,
• Mallory-Weiss tears
• Gastritis,
• Gastric ulcer
• Duodenal ulcer
• Others jejunal diverticulum, Meckel's diverticulum, neoplasms
and typhoid enteritis
Endoscopy is now widely used for both diagnosis and
treatment, and angiography and embolisation have played a
diminishing role in recent years.
Scintigraphy, as described below, may be useful in
demonstrating the site.

46. Lower gastrointestinal tract
haemorrhage
• Radionuclide scintigraphy is the technique of
choice for the investigation of acute lower
gastrointestinal tract bleeding.
• Diverticulosis is the commonest cause and,
Site : Ascending colon.
• Most common site of diverticulosis is
Descending /Sigmoid colon.
• Angiodysplasia is the second most common
cause and site is ascending colon/ caecum.

47. Hemorrhage
Colonoscopy is less
successful in identifying
these lesions than
arteriography, which is
often necessary.
Medical management with
vasopressine may be useful
but usually temporary.
Alternative emergency
colectomy carries high
mortality.
Embolisation with
superselective
catheterization is usually
required.

48. Neoplasms and Mass lesions
With the advent and constant improvement of
the non-invasive techniques of ultrasound,CT and
MRI Arteriography has become largely obsolete
as a purely diagnostic tool.
Purpose:
• To provide anatomical information to the surgeon
about the vascularity and blood supply of a
tumour,
• In some cases to permit embolisation of
inoperable tumours or of highly vascular tumours
prior to surgery

49. Arteriovenous shunting with early
opacification of drainage veins is a
frequent feature of the more
malignant neoplasms.
Second, the growth of the tumour may
displace and stretch the normal vessels at
its margins, thus enabling less vascular
tumours to be located.
Third, tumours may actually involve
adjacent arteries, leading to `cuffing‘ or
irregular narrowing of the affected
arteries.
Fig: Renal Carcinoma showing pathological vessels.

51. Interventional Vascular Radiology
• Interventional vascular radiology has developed from
the diagnostic angiography.
• Now plays a central role in management of patients
with vascular diseases.
Interventional vascular radiology includes
• Transluminal angioplasty
• Vascular stent insertion,
• Therapeutic embolisation,
• Vascular infusion therapy and
• The insertion and retrieval of intravascular foreign
bodies.

52. Transluminal Angioplasty
• The technique of percutaneous transluminal
angioplasty (PTA) was initially performed in 1964
by Dotter and Judkins.
• Atherosclerosis is by far the commonest cause of
an arterial stenosis or occlusion that is suitable
for treatment by PTA.
• Other pathological conditions such as
fibromuscular dysplasia, arteritis, intimal
hyperplasia, radiation damage and trauma are
also amenable to treatment with PTA.

53. Basic technique of PTA
• Passing a guide-wire and catheter across a
stenosis or through an occlusion in a blood
vessel.
• A balloon catheter is then positioned across
the diseased segment.
• Then dilated up to the same size as the
adjacent lumen, in order to increase the blood
flow through the artery or vein

55. Intravascular stents
• Arterial Stents:
Indications :
• To prevent acute occlusion developing after an
intimal flap has been produced by angioplasty.
• To abolish the pressure gradient across a significant
residual stenosis after angioplasty,
• to treat recurrent stenoses, and stenoses in the
aorta, renal ostea.

57. Arterial Stent

58. IVC filters
Indications
• Recurrent pulmonary emboli in patients despite
good anticoagulation,
• pulmonary emboli or deep vein thrombosis in
patients with a contraindication to
anticoagulation,
• deep vein thrombosis in patients with pulmonary
arterial hypertension
• as prophylaxis against pulmonary emboli in high-
risk patients

59. IVC filters are ideally
positioned below the renal
veins following
catheterisation of the
femoral or internal jugular
vein,
can be positioned in the
suprarenal IVC if there is
thrombus in the renal veins.
Most IVC filters are
permanent insertions, but
the Gunther tulip filter is
retrievable
from the IVC for up to 2
weeks
IVC Filters

60. Therapeutic embolisation
• Involves the injection of embolic material through a
catheter selectively positioned in an artery or vein in
order to deliberately occlude the artery, vein or
vascular bed of an organ by the formation of thrombus
in the blood vessels.
Ideal embolic material
• Thrombogenic but non toxic
• Permanent vascular occlusion.
• Easy to inject through the catheter.
• Available in wide ranhe of shape and sizes.
• Strile and opaque.

61. Embolic agents

62. Metal Coils
• The metal coils are made of stainless steel or
platinum.
• Available in a range of sizes and lengths with a
spiral diameter 1 -20 mm or larger.
• The stainless steel coils have threads of wool, or
Dacron attached to them to increase their
thrombogenicity.
• Metal coils are radiopaque and are delivered by
being pushed through the catheter with a guide
wire.

63. Detachable balloons
• Are made of latex or silicon and are available
in 1-2mm sizes.
• They can be inflated up to 4-8mm.
• The balloons are not radiopaque so should be
filled with contrast media before being
detached from the catheter.

64. Indications of embolisation
• Alternative to the surgical procedure if the
patient is not fit for surgery.
• In combination with surgery to reduce the
blood loss during the operation and thus
shortens the procedure.
• Management of acute hemorrhage
• Managements of tumors
• Treatment of AVM, AV fistulas and aneurysms.

66. Complications
• The complications of embolisation include the
complications of both the arteriography and the use of
contrast media, the embolisation syndrome and the
specific complications of the procedure.
Post embolisation syndrome:
• Occurs within 24-48hours.
• Lasts for 3-7days.
• Characterised by pain nausea vomiting malaise fever,
leucocytosis and raised inflammatory markers.
Precaution :
• Prophylactic antibiotics
• Strict aseptic techniques.

67. Retrieval of Vascular Foreign bodies

68. References
• Text book of Radiology and Imaging – David
Sutton
• Fundamentals of Diagnostic radiology 4e.
• Various internet sources.

69. Thank You