Technique of peripheral angiogram and complication

Technique of peripheral
angiogram and complication
Parach Sirisriro
22th Aug 2017

JOURNAL
Ye, M., et al. (2013). "Retrograde popliteal approach for challenging occlusions of the
femoral-popliteal arteries." Journal of vascular surgery 58(1): 84-89.
Barbetta, I. and J. C. van den Berg (2014). "Access and hemostasis: femoral and popliteal
approaches and closure devices-why, what, when, and how?" Semin Intervent Radiol 31(4):
353-360.
El-Sayed, H., et al. (2016). "Retrograde Pedal Access and Endovascular Revascularization: A
Safe and Effective Technique for High-Risk Patients with Complex Tibial Vessel Disease."
Ann Vasc Surg 31: 91-98.

OUTLINE
• Operating room and equipment preparation
• Access site selection
• Technique Catheterization of Specific Vessels
• Closure Techniques
• Complication

Equipment preparation
Amplatz
Hydrophilic
guide wire Needle
Sheaths
Balloon Reliant
Diagnostic
catheter

EQUIPMENT
• NEEDLE
• GUIDE WIRES
• SHEATH
• CATHETER
Andros, G. (2011). Arterial Access. Endovascular Surgery: 49-58.

NEEDLE
• Single-wall puncture needles
• Double-wall puncture
needles
Or seldinger needle
two-component systems
containing a blunt-tipped hollow
needle with a beveled solid stylet
that projects out from the end of
the needle
Cronenwett, J. L. and K. W. Johnston (2014). Rutherford's Vascular Surgery E-Book, Elsevier Health Sciences.

NEEDLE
Single-wall puncture technique
Double-wall puncture technique

GUIDE WIRES
• Control and permits access to vasculature
• have the characteristics of pushability and flexibility
–Pushability : characteristics associated with the direct
transfer of forces on the wire from manipulations outside
the patient’s body as they translate to forward advancement
of the wire or device inside the patient.
–Flexibility is a characteristic that usually works in a manner
counter to pushability. The more stiff a wire, or the less
flexible it is, the more pushable it will be
Grant, L. A. and N. Griffin (2013). Grainger & Allison's Diagnostic Radiology Essentials E-Book, Elsevier Health Sciences.

GUIDE WIRES

• Their diameters are measured in inches, with standard sizes on
which current endovascular platforms are based
• 0.035-inch : . For most angiographic procedures and most
aortoiliac interventions
• 0.018-inch and 0.014-inch : : infrageniculate lesions or tight renal
and carotid stenoses
• 0.038-inch wire for passage of a large-diameter sheath or delivery
of an endograft through a tortuous iliac artery
GUIDE WIRES : Diameters

GUIDE WIRES : Length

GUIDE WIRES : Length
Schneider, Peter. Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery, Third Edition (Kindle Locations 578-591). CRC Press. Kindle Edition.

GUIDE WIRES : Tips
Floppy-tip or J tip : no inner
core in its tip and flexible,
reduces the potential for
endoluminal injury by buckling
when it encounters resistance.
Curved or angled : for
selective cannulation and may
be steered into a desired
location.

Steerable
• Hydrophilic guidewires (Terumo, Roadrunner): good torque control ,
have a hydrophilic coating and must be kept wet – their frictionless nature
allows them to cross narrow stenoses
Non-steerable : allows the catheter to be advanced into position
• 3mm J guidewire: this has a 3mm radius to its distal curve – 5, 10
and 15mm curves are also available
• Bentson wire: this has a very floppy atraumatic tip
• Amplatz super stiff: this is a very strong wire to provide support for
introducing stents
GUIDE WIRES : divide into functional
groups

Guidewire handling techniques

SHEATH
• Placed after arterial access
• has a hemostasis valve at the end with a side port for aspiration or
administration of ﬂuids or drugs

- Maintains access to the vessel
- Minimize local trauma
- Decreases blood loss and
hematoma formation
SHEATH

The diameter of the arterial segment

GUIDE
CATHETERS

GUIDE CATHETERS
• Introduced to help direct devices and wires to distal locations
• Inject contrast material distally
• Provide support to keep a vessel ostium engaged
• Intended to be placed through access sheaths and into the
target vessel.

DIAGNOSTIC CATHETERS
• Aid in target vessel selection
• Catheters may have hydrophilic coatings, radiopaque tips, or marker
bands and have braiding to increase pushability and kink resistance
• peripheral indications range from 4F to 6F and typically
have inner diameters of 0.035 or 0.038 inch.
• Microcatheters are small 2F to 3F catheters that can be advanced through
the lumen of standard diagnostic catheters for superselective
cannulation of smaller vessels

Nonselective Catheters
• Or “ﬂush” catheters are used for aortic and vena cava injections or injections where
displacement of a large volume of blood with contrast material is necessary to fill
the entire lumen
• The catheter has an endhole and multiple, much smaller sideholes extending down
onto the distal 1–2 cm of the shaft.
• The distribution of sideholes produces a homogeneous contrast bolus

• Selective catheters are end-hole catheters with tips in a variety of
shapes to facilitate vessel cannulation
• Power injection settings must be adjusted when end-hole catheters
are used in smaller vessels to avoid intimal injury by uplifting plaque
SELECTIVE CATHETERS

Top selective catheters
Cobra
Simmons ‘Sidewinder’

• These are typically straight and tend to have more
body or
stiffness to allow pushability in crossing vessel
stenoses or
total occlusions.
• They also can come with single curves at the
end to aid in directing the wire.
Crossing Catheters

Access : Principle
1. Choose the puncture site with the individual patient’s needs in mind.
2. Determine the likelihood of performing an endovascular intervention during the
angiogram procedure and take that into account when choosing a puncture
site.
3. Pick the access site that is far enough from the lesion so that a sheath may be
placed without encountering the lesion itself.
4. Feel the artery intended for puncture so you know what to expect. Is it soft or
hard and what is the quality of the pulse?
5. Palpate the anatomic landmarks
6. Visualize the artery and its relationship to anatomic landmarks before skin
puncture.

7. Standardize your technique.
8. Use fluoroscopy for guidance.
9. Do not be afraid to abandon the access and puncture elsewhere if the
risk is too high.
10. No one gets in every single time.
11. If there is a problem, hold pressure for a few minutes and start again.
12. It is rare to have any significant damage to the access artery from the
needle alone. Larger problems occur when a poor puncture placement is
not recognized and larger devices are placed through that site.
Access : Principle

• A bone or bone prominence
• Avoid diseased areas
• Away from side branches, bifurcations, or
crossing veins.
• The size of
the artery vs the desired sheath;
the body location to be imaged;
the stenoses or occlusion
• The length of
diagnostic catheters,
sheaths, balloons, wires, and interventional
devices
Access : Choice of Site
Cronenwett, Jack L.; Johnston, K. Wayne. Rutherford's Vascular Surgery E-Book (Rutherfords Vascular Surgery) (Kindle Locations 74440-74441). Elsevier Health Sciences. Kindle Edition.

Access Options
• The most common : The common femoral artery (CFA)
• Alternative sites include : axillary artery, brachial and radial
artery access
• Alternative access for infrageniculate interventions can be
distally through the popliteal arteries or tibial arteries
• when other access sites are not available : Carotid and
subclavian artery two sites are associated with a higher risk of
hemorrhage

Common Femoral Artery landmark

Common Femoral Artery
Retrograde femoral access Antegrade femoral access

Common Femoral Artery
Jackson, J. E. and J. F. Meaney (2015). "Angiography: Principles, Techniques." Grainger and Allison's Diagnostic Radiology: Interventional Imaging: 2.

Puncturing the
Pulseless
Femoral Artery

With the patient prone, use ultrasound guidance to puncture the artery at the level of the patella medial to
the popliteal vein and tibial nerve
Popliteal Artery landmark
Kessel, D. and I. Robertson (2016). Interventional Radiology: A Survival Guide E-Book, Elsevier Health Sciences.

Ye, M., et al. (2013). "Retrograde popliteal approach for challenging occlusions of the femoral-popliteal arteries." Journal of vascular surgery 58(1): 84-89.

Tibial Artery appraoch
ATA landmarkPTA landmark

Anterior tibial artery approach
El-Sayed, H., et al. (2016). "Retrograde Pedal Access and Endovascular Revascularization: A Safe and Effective Technique for High-Risk Patients with Complex Tibial Vessel Disease." Ann Vasc Surg 31: 91-98.

Posterior tibial artery approach
El-Sayed, H., et al. (2016). "Retrograde Pedal Access and Endovascular Revascularization: A Safe and Effective Technique for High-Risk Patients with Complex Tibial Vessel Disease." Ann Vasc Surg 31: 91-98.

Brachial Artery
approach
With the arm abducted 60 to 90 degrees, the pulse is palpated in the antecubital fossa and access is obtained
just proximal to the crease of the elbow
Kessel, D. and I. Robertson (2016). Interventional Radiology: A Survival Guide E-Book, Elsevier Health Sciences.

The arm needs to be abducted at 90 degrees and externally rotated, with a towel roll placed under the
axilla. Alternatively, the axillary region may be exposed by ﬂexing the arm at the elbow and placing the
hand behind or just above the head. A micropuncture needle access kit is recommended for access.
Axillary Artery approach

Subclavian Artery
approach

Radial Artery appraoch

Procedure
• Adequately anaesthesia
• 5–10 mL of 0.5–1% lidocaine is infltrated around the artery. if the
puncture site is inadequately anaesthetised arterial spasm and
make selective catheterisation very difficult
• Small scalpel incision is made in the skin
• Ultrasound is also recommended to help select the
most appropriate site of puncture, avoiding atherosclerotic
plaques, and is also used to guide needle entry.

Technique

Procedure
Inside the OR: Peripheral Angiogram ProcedureBon Secours St. Francis Health System

Access : preparation artery
puncture site and needle
Sheath preparation
Hydrophilic guidewire
Selected Diagnostic Catheter
Contrast injection
And Closure Techniques

Digital subtraction angiography
• The basic concept behind DSA involves a recording technique by
which the captured ﬂuoroscopic image is amplifed and digitized.
• With advanced computer data processing capability,multiple
manipulations of the stored data can be performed to optimize image
quality.

Roadmap
Used particularly to navigate strictures and avoid branch vessels

Rotational Arteriography

Closure technique
• Manual Compression
Venous punctures require 5 to 10 minutes
Arterial puncture : This compression should not require total
occlusion of distal ﬂow. When possible, simultaneous palpation of the
pulse distal to the compression location is recommended.
a general guideline of 3 minutes per French size has been used.
Typically, manual pressure will not reliably obtain hemostasis for
sheaths larger than 8F.

Closure Devices
• The devices can be divided into groups as
Intravascular and extravascular plugs
Suture mediated/mechanical
Compressive assistance.

Intravascular and extravascular plugs

Closure Devices
Extravascular Plugs : Angio-Seal

Closure Devices : Extravascular Plugs
Exoseal MynxGrip and Mynx
Cadence

Closure Devices : Suture mediated/mechanical

Compressive Assistance
Catalyst III

These devices are
placed over the puncture site
and adjusted with a
circumferential strap, followed
by pressure bag inﬂation
Compressive Assistance
Femostop

Systemic Complication
• Contrast-induced acute renal failure

• Groin haematoma : minimized by adequate post-procedure
puncture site compression
• False aneurysm formation: inadequate haemostasis and is more
likely to occur with a low CFA puncture where the artery
cannot be compressed against the femoral head ▶ the treatment
options include US-guided compression, thrombin injection and
surgical repair
• Arteriovenous fistula formation: this is uncommon with a CFA
puncture but is more likely with a SFA puncture (as the femoral vein
lies deep to it)
Local Complication

• Thrombosis: this is more likely if the artery is severely diseased at the
puncture site
• Arterial dissection : this usually occurs with an antegrade approach ▶
retrograde dissections are usually self-limiting
• Distal microembolization: this follows thrombus or
atheroma breaking off from the vessel wall
Local Complication

Conclusion
Access : most common site : Rt. CFA
Needle : Single wall > Double wall
Sheath and catheter size
CFA : 5-6 Fr
Brachial : 5-6 Fr
Hydrophilic guidewire : MC diameter 0.035-inch
Length 50–80 cm : Retrograde femoral catheterization
for ipsilateral femoral arteriogram
145–150 cm : General arteriography and
antegrade approach to infrainguinal arteries
180 – 210 cm : contralateral infrainguinal
interventions, subclavian interventions
And Closure Techniques : Compression 3 minutes per
French size

Technique of peripheral angiogram and complication

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