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Digital subtraction angiography

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Digital subtraction angiography

  1. 1. Free Powerpoint Templates Page 1 Digital Subtraction Angiography Subhayan Mandal
  2. 2. Free Powerpoint Templates Page 2 5/22/2014 2 ANGIO? ANGIO means blood vessel And angiography is the radiological study of blood vessel in the body after the introduction of iodinated contrast media. SUBTRACTION? It is simply a technique by which bone structures images are subtracted or canceled out from a film of bones plus opacified vessels, leaving an unobscured image of the vessels.
  3. 3. Free Powerpoint Templates Page 3 5/22/2014 3 DSA-The acquisition of digital fluoroscopic images combined with injection of contrast material and real- time subtraction of pre- and post contrast images to perform angiography is referred to as digital subtraction angiography
  4. 4. Free Powerpoint Templates Page 4 5/22/2014 4 The Portuguese neurologist Egas Moniz,( Nobel Prize winner 1949), in 1927developed the technique of contrast x-ray cerebral angiography to diagnose diseases, such as tumors and arteriovenous malformations. The idea of subtraction images was first proposed by the Dutch radiologist Ziedses des Plantes in the 1935, when he was able to produce subtracted images using plain films. With the introduction of the Seldinger technique in 1953, the procedure became safer as no sharp devices need to remain inside the vascular lumen.
  5. 5. Free Powerpoint Templates Page 5 5/22/2014 5 HISTORICAL DEVELOPMENT CONVENTIONAL SUBTRACTION TECHNIQUE Photographic method used to eliminate unwanted images. No addition of information;only purpose to make diagnostically important information to see. First described by a Dutch radiologist, Zeides des Plantes, 1935. 3 conditions: SCOUT FILM ANGIOGRAM FILM-CONTRAST NO MOTION OF HEAD
  6. 6. Free Powerpoint Templates Page 6 5/22/2014 6 The principles of subtraction are based on the following: The scout film shows the structural details of the skull and the adjacent soft tissue. Angiogram film shows exactly the same anatomic details, if the patient does not move, plus the opacified blood vessels. If all the information in the scout film could be subtracted from the angiogram film, only the opacified vessel pattern would remain visible.
  7. 7. Free Powerpoint Templates Page 7 Basic arrangement
  8. 8. Free Powerpoint Templates Page 8 DSA machines
  9. 9. Free Powerpoint Templates Page 9 Indications • Non traumatic Subarachnoid Hemorrhage (SAH). • Arterial dissection or laceration • Aneurysm • Pseudoaneurysm • Thrombosis. • Arterio-venous malformation (AVM). • Arterio-venous fistula (AVF). • Tumor vascularity • Embolisation • Stenting • Thrombolysis • Thrombectomy Diagnostic Therapeutic
  10. 10. Free Powerpoint Templates Page 10 Contra indications  No absolute contraindication. • Poor renal reserve. • Deranged coagulogram. • Allergic to contrast media.
  11. 11. Free Powerpoint Templates Page 11 5/22/2014 11 Contrast Media Blood vessels are not normally seen in an x-ray image, because of low tissue contrast. To increase image contrast, contrast agents, which are dense fluids with elements of high atomic numbers, such as iodine, are injected into a blood vessel during angiography. Because of its higher density and high atomic number, iodine absorbs photons more than blood and tissue. This creates detailed images of the blood vessels in real time. The first contrast media used for intravascular injection were called high-osmolar contrast media (HOCM). (osmolality is the measure of the particle concentration in a solution.) 11
  12. 12. Free Powerpoint Templates Page 12 5/22/2014 1212 HOCM had osmolarity seven to eight times higher than plasma. This high osmolarity caused adverse effects such as pain, endothelial damage, thrombosis, and increased pressure in the pulmonary circulation. Low-osmolar contrast media (LOCM) were first developed in the 1970's and these helped to reduce these side effects. One of the major risks of modern iodine contrast media is an allergic reaction to iodine.
  13. 13. Free Powerpoint Templates Page 13 5/22/2014 13 Non ionic Iso-osmolar contrast media. 30-40% dilution with normal saline. 50 ml of diluted contrast media is enough to do a standard cerebral angiogram with total 8 projections. Approx. 5-8 ml diluted contrast / injection. 13
  14. 14. Free Powerpoint Templates Page 14 5/22/2014 14 Materials used Catheters Arterial sheath Medicut Guidewires Contrast Connector/100 cm.tubing Surgical blade 14 Saline Disposable syringes Local anesthesia Heparin Surgical gloves Elastoplast
  15. 15. Free Powerpoint Templates Page 15 5/22/2014 1515 Picard Pigtail Sim-1 Cathetars
  16. 16. Free Powerpoint Templates Page 16 5/22/2014 16 16 VASCULAR SHEATH MEDICUT GUIDE WIRES ELASTOPLAST STRIPS
  17. 17. Free Powerpoint Templates Page 17 5/22/2014 17 CONTRAST ANESTHESIA ANTICOAGULANT PVA-PARTICLESGEL FOAM
  18. 18. Free Powerpoint Templates Page 18 5/22/2014 18 PREPARATION Appointment time Nil orally 4-6 hrs. On trolley In hospital gown Groin shave Records PTI 18 Should be well hydrated. Should void before procedure. Peripheral pulses marked. I.V line in place. INFORMED CONSENT MUST
  19. 19. Free Powerpoint Templates Page 20 5/22/2014 20 PROCEDURE Gaining arterial access. Selective arterial catheterization. Image acquisition. Closure of arterial access. Post processing Hard copy 20
  20. 20. Free Powerpoint Templates Page 21 5/22/2014 2121
  21. 21. Free Powerpoint Templates Page 22 5/22/2014 22 During angiography, patients may be sedated to reduce anxiety. Their heart rate and rhythm, breathing, and oxygen saturation are monitored throughout the procedure. Patient clean draped . A local anesthetic is usually used in the area where the catheter is to be inserted, most commonly the femoral artery. First, a small incision given, medicut is inserted into the artery. fluoroscopy is used to guide the needle to the proper position . The needle is then removed after placing guide wire in the artery and vascular sheath is inserted over the guide wire . The catheter is then inserted along the guide wire through the sheath. 22
  22. 22. Free Powerpoint Templates Page 23 5/22/2014 23 When the catheter is in the correct position, the wire is pulled out and dye is injected through the catheter. Images are acquired during contrast injection. Injections can be made directly into the artery of interest (selective arteriography) Complications from an arteriogram are very rare, but there is some risk. Most problems that occur can be detected at the time of the procedure or immediately after the procedure. The artery may be injured at the puncture site or along the artery where the catheter is passed. 23
  23. 23. Free Powerpoint Templates Page 24 5/22/2014 24 COMPLICATIONS • 0.16% major complication rate. • Local complications: hematoma, vessel laceration, dissection, peudoaneurysm, AV fistula. • Systemic complications: contrast reactions, fever, sepsis, dehydration, death. • CNS complication: aggravation of preexisting complaints, neurological deficit. 24
  24. 24. Free Powerpoint Templates Page 25 5/22/2014 25 POSTPROCEDURAL CARE After the catheter is removed compression is applied to the puncture site. The patient is asked for bed rest for a minimum of 4 hours During rest patient is monitored and vital sign like peripheral pulse like distal to Puncture are regularly The extremity is also checked for warmth, color, numbness to ensure circulation has not been disrupted.
  25. 25. Free Powerpoint Templates Page 26 5/22/2014 26 Oral fluid is given and analgesics are given if required. Special care should be given in case of children and geriatric patient since additional Patience is required. They have given warming blanket to keep the body temp. Normal. Geriatric patient also frequently feel nervous and afraid of falling off the Table ,reassurance and additional care from the technologist will enable the Patient to feel secure and comfortable.
  26. 26. Free Powerpoint Templates Page 27 Cerebro-vascular anatomy as appreciated in DSA Identification 1.Common Carotid Artery. 2.Internal Carotid Artery. 3.Ascending pharyngeal Artery. 4.Occipital Artery. 5.Superficial Temporal Artery. 6.Middle cerebral Artery. 7.Anterior cerebral Artery. 8.Middle meningeal Artery. 9.Maxillary artery. 10.Facial artery. 11.Lingual artery. 12.External carotid artery. 13.Superior thyroid artery.
  27. 27. Free Powerpoint Templates Page 28
  28. 28. Free Powerpoint Templates Page 29
  29. 29. Free Powerpoint Templates Page 30
  30. 30. Free Powerpoint Templates Page 31 Diagnostic usage • Acom aneurysm
  31. 31. Free Powerpoint Templates Page 32 Diagnostic usage • ACA aneurysm
  32. 32. Free Powerpoint Templates Page 33 Diagnostic usage • MCA aneurysm
  33. 33. Free Powerpoint Templates Page 34 Diagnostic usage • Pcom aneurysm
  34. 34. Free Powerpoint Templates Page 35 Diagnostic usage • Basilar tip aneurysm
  35. 35. Free Powerpoint Templates Page 36 Diagnostic usage • ICA aneurysm
  36. 36. Free Powerpoint Templates Page 37 Diagnostic usage • Arterio-venous malformation
  37. 37. Free Powerpoint Templates Page 38 Diagnostic usage • Arterio-venous fistula
  38. 38. Free Powerpoint Templates Page 39 Diagnostic usage • Tumour vascularity
  39. 39. Free Powerpoint Templates Page 40 Coiling of cerebral aneurysms Therapeutic usage
  40. 40. Free Powerpoint Templates Page 41 Therapeutic usage • Lead pipe embolization
  41. 41. Free Powerpoint Templates Page 42 Therapeutic usage • Gel embolization • Particle embolization
  42. 42. Free Powerpoint Templates Page 43 Therapeutic usage • Onyx embolization Onyx HD500 is comprised of 20% EVOH (ethylene vinyl alcohol) copolymer dissolved in DMSO (dimethyl sulfoxide), and suspended micronized tantalum powder to provide contrast for visualization under fluoroscopy. Onyx HD500 (20% EVOH) is an HDE device for the treatment of intracranial, saccular, sidewall aneurysms that present with a wide neck (≥ 4mm) or with a dome-to-neck ratio < 2 that are not amenable to treatment with surgical clipping. Onyx HD500 can also be used in adjunctive therapy with Axium coils and stents.
  43. 43. Free Powerpoint Templates Page 44 Therapeutic usage • Stenting of ICA stenosis
  44. 44. Free Powerpoint Templates Page 45 Therapeutic usage • Thrombolysis
  45. 45. Free Powerpoint Templates Page 46 Therapeutic usage • Thrombectomy
  46. 46. Free Powerpoint Templates Page 47 In nutshell
  47. 47. Free Powerpoint Templates Page 48
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