Angiography Interventional Basics

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Angiography/ Interventional Basics

• What do we visualize with an angiographic
  procedure?

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Angiography/ Interventional/ Cardiovascular

• Procedure Room (Suite)
• Room size- 500 square feet
• Easily cleaned (floors, wall, etc.)
• Why?
• Outlets needed for O2, suction, crash cart
• 3 means of access to the room (Bushong, p. 374)
• What are they?

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• Control Room
• 100 square feet
• Easy access and communication to procedure room
• Computers, monitors and un sterile personnel
• Storage area- guide wires, catheters and needles
• Generators with 1000 MA

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Equipment Requirements

• 1-2 Track mounted x-ray tubes ( C-arm or L- arm)
• Anode has small target angle
• Why?
• Focal Spot Size 0.3mm or smaller ( needed for
  magnification radiography)
• Vessels must be bigger than FS blur to be seen on
  the study) Bushong, p. 376

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• High heat load tubes w/ rapid cooling
• Series imaging, intense heat
• SPEED UP THE ANODE RPM
• Analog-to -Digital Conversion System
• Programmable digital image acquisition system
  (rate, sequence, processing)
• PACS

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• Electromagnetic Injectors
• Monitoring Equipment- BP ECG
• Island Tables- access from all sides, height
  adjustments, floor controls
• Where are the cables?
• Tables do not usually tilt
• Tables should have stepping capabilities

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Digital Acquisition

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

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Lets talk about Charge Coupled Device (CCD)

• Replaces vidicom / plumbicon
• Silicon chips
• Converts light to digital image
• Lower noise
• Better contrast
• Lower patient dose
• Can image very dim or very bright objects

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Digital Subtraction Angiography (DSA)

• Computer subtracts out all anatomy except
  contrast-filled vessels
• Looks like a reverse image
• Can be more diagnostic for vessels ( clots,
  constrictions)
• Imaging systems below now mostly replaced by
  digital
• Cut Film Changer
• Cine Fluoro( Cardiac Cath Camera)

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Electromechanical Injector

• Used in Angio, CT, MRI
• Overcome arterial pressure maintains bolus
• Maintains flow rate
• Flow rate affected by
• Viscosity
• Length diameter catheter
• Injection pressure
• Vessel selected

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Safety Features

• Reliable flow rate settings
• Ready light
• Slow or manual control ( air bubble removal)
• Controls to prevent inadvertent injection,
  excessive pressure, volume injection
• Pressure limit control- prevents catheter
  whipping or breakage
• Mechanical stop

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Personnel in the Angio Room

• Radiologist ( or other specialist)
• Cardiovascular nurse
• 2-3 Radiologic Technologists (CV)
• Sometimes Anesthesiologist depending on the
  procedure

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Vocabulary Terms

• Arteriosclerosis- vessels hardened
• Atherosclerosis- plaque like cholesterol
• Thrombus
• Embolus
• Occlusion
• Tumor
• Stenosis
• Angioplasty-angio procedure dilates stenosed
  vessel

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• Lithotripsy
• Stent- cage like metal device placed in vessel to
  maintain blood flow
• Thrombolysis
• Filter
• Embolization- stop bleeding, cease blood flow to
  site of pathology
• Ante grade
• Retrograde

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• Technologic advances allow CT, MRI, US to replace
  angio for some diagnostic procedures
• Angiography now for interventional or therapeutic
  procedures

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Technologist Responsibilities

• Prepare Room/ consent forms
• Provide radiographic positioning / Dr Assistance
• Knowledge of exam, anatomy, pathology
• Prepare sterile tray, prep patient
• Knowledge of catheters and guide wires
• Know sterile technique/ safe clean up
• Monitor ECG pressure
• Patient care skills

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Medical History

• Anti coagulants- what do these do?
• Consent form
• NPO 8 hours
• Pre- medication (benadryl steroid)
• Lab tests- what ones to test kidney function?
• Vessels accessed by catheters

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Seldinger Technique

• Method for catheterization of vessels
• Developed 1950s still popular today
• Percutaneous (through the skin) technique for
  arterial and venous access
• 3 vessels considered
• Femoral preferred site for arterial (size
  accessibility)
• Brachial
• Axillary

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• Selection based on strong pulse w/ absence of
  disease
• Site cleaned, area draped, local given

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Seldinger Technique ( step-by-step)

• Insertion of needle
• Placement of needle in lumen
• Insertion Guide wire- thru needle, advance 10 cm
• Removal of Needle- guide wire in position
• Threading of catheter to area of Interest- fluoro
  used
• Removal of guide wire- catheter remains in place

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SELDINGER TECHNIQUE
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• Two less common methods used
• Cut down- minor surgical procedure to expose
  vessel of interest
• Translumbar- patient prone, long needle passed
  thru T12- L2 into aorta

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Contents of Angiographic Tray

• Basic sterile items needed for Seldinger
• Hemostats
• Prep Sponges antiseptic solution
• Scalpel blade
• Syringe needle for local
• Basins medicine cup
• Sterile drapes towels, band-aids
• Sterile image intensifier cover
• Fenestrated Drape- sterile drape w/ window

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Contrast Media

• Water- soluble, non-ionic
• Low osmolarity (no positive-charged cations)
• Reduces risk of reaction
• Amount depends on vessel
• Emergency equipment available
• Electomechanical injector

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Radiation Protection

• gt radiation dose to angio team- fluoro
• Proximity to patient
• Radiation protection devices
• Leaded glasses pulled into place
• Minimal fluoro use as possible
• Collimation
• Angio personnel wear badges and ring monitors

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Contra Indications

• Contrast allergy
• Impaired renal function
• Blood- clotting disorders
• Anti coagulant medication
• Unstable cardio pulmonary/ neurological status

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Risks/ Complications

• Bleeding at puncture site
• Thrombus formation
• Embolus formation plaque dislodged from vessel
  wall by catheter
• Dissection of vessel
• Puncture site infection ( contaminated sterile
  field)
• Contrast reaction

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Post Procedure Care

• Catheter removed compression applied
• Bed rest- min 4 hrs/ head elevated 30 degrees
• Vital signs
• Extremity watch
• Some angiographic procedures angioplasty,
  venography, angiocardiography, lymphography

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Alternative Modalities / Procedures

• Spiral CT
• CTA- CT angiography- provides vascular structures
• Ultrasound and Nuclear Medicine

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Interventional Imaging Procedures

• Intervene w/ disease, provide therapeutic outcome
• Purpose/ benefits
• Lower risk compared to surgery
• Less
• Shorter hospital stay and recovery
• Alternative for non surgical patient

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Special Procedures performed In

• Angio
• GI Suites
• Radiographic Rooms
• CT
• MRI
• Ultrasound

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Vascular/ Non- Vascular Studies

• Embolization pg 711, Bontrager
• Stent Placements
• PTA pg 712 , Bontrager
• Vena Cava Filters
• Thrombolysis

• Biopsies
• Fluid Drainage
• Injection of Medicines
• Tube Placement in Organs or Cavities
• Bontrager, pg 716

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Lets Look at Needles, Guide wires and Catheters

• Cannula
• stilette
• connecting hub (luer lock)
• baseplate
• two or three-way stopcock
• transparent tubing

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Other odds and ends

• Stopcocks
• Vessel dilators
• Manifolds

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Guidewires

• Guide catheter for placement in vessel
• Guide wire diameter be large enough so blood can
  not flow back for too long a time
• Tips at the end of GW
• Straight
• J- tipped
• longer G.W. for selective angio vessels
• Short used for shorter direct vascular approach

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GUIDEWIRES
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• Catheters
• Straight- end hole only
• Pigtail- circular tip w/ multiple side holes to
  reduce whiplash and control contrast
• Sidewinder- curved to facilitate vessel selection
• Cobra- variation in curvature to facilitate
  selection of vessels

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• The more holes at the end / the more contrast
  used/ large vessels
• Catheter with only end hole/ smaller vessels/
  carotid
• Combo end and side holes reduce risk of trauma to
  vessel, enhances contrast

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CATHETERS