Peripheral Angiography - Semantic Scholar€¦ · peripheral vascular procedures.9−16 Specialties...

P1: OSO/UKS P2: OSO/UKS QC: OSO/UKS T1: OSO

MCGH052-20 9-780-7817-XXXX-X MCGH052-Dieter-v2 November 7, 2008 13:35

c h a p t e r20Peripheral AngiographySohail Ikram, MD / Massoud Leesar, MD / Ibrahim Fahsah, MD

• PERIPHERAL ANGIOGRAPHY

Peripheral arterial disease (PAD) comprises a host of non-coronary arterial syndromes due to various pathophysio-logical mechanisms resulting in stenosis or aneurysms invarious vascular beds. Atherosclerosis (AS) remains by farthe most common cause of this disease process. Accord-ing to the recently released ACC/AHA guidelines for themanagement of patients with PAD, it is a major cause ofdecrement of functional capacity, quality of life, limb am-putation, and increased risk of death.1

Millions of people worldwide are afflicted with thissyndrome.2,3 While awareness for coronary artery disease(CAD) has significantly increased in the last decade, theawareness, diagnosis, and treatment of PAD remain muchunderappreciated. With improvement in catheter-basedand imaging technology, it was only natural that all special-ties involved in the management of vascular disease wouldinvolve endovascular therapy of this potentially disablingand lethal disorder.4−6

Excellent reviews on PAD are already available in the lit-erature. The ACC/AHA guidelines, Trans Atlantic SocietyConference (TASC) Working Group document,7 the ACCCOCATS-2 Paper,8 provide the basic fundamental mate-rial for a physician interested in the management of pa-tients suffering from PAD. Based on literature review andour own experience at the Washington Hospital Center,Washington, DC, and University of Louisville, Louisville,KY, we have tried to focus in this chapter on the generalprinciples of performing invasive peripheral angiography.We have also briefly described noninvasive imaging modal-ities of computed tomographic angiography (CTA), mag-netic resonance angiography (MRA), and carbon dioxide(CO2) angiography as their utility relates to each vascularbed. The full details of these other modalities are, however,out of the scope of this chapter. We hope that this chapterwill provide the basic understanding in catheter angiog-

raphy to an operator interested in treating patients withPAD.

Training Requirements

There are considerable differences of opinion that ex-ist among various specialties regarding the optimal train-ing required before certifying operators to safely performperipheral vascular procedures.9−16 Specialties includinginterventional cardiology, interventional radiology, vascu-lar surgery, interventional neuroradiology, interventionalnephrology, and interventional neurosurgery all possess ba-sic and unique knowledge that positions them to advancetheir skills into peripheral angiography and interventions.The ACC COCATS-2 (Tables 20-1 and 20-2) providesguidelines for a cardiovascular trainee who wishes to becertified in the performance of such procedures.

A minimum of 12 months of training is required. Com-pletion of 100 diagnostic angiograms and 50 peripheral vas-cular interventions has been recommended for unrestrictedcertification. Fifty percent of such procedures should beperformed as “primary operator” under the guidance of amentor who is certified in peripheral vascular interventions.Prior to the performance of invasive procedures, this physi-cian should be knowledgeable in vascular medicine andnoninvasive modalities in the diagnosis of peripheral vascu-lar disorders. Before signing off the certificate, the mentorshould require the trainee to have exposure in the angiogra-phy of various vascular beds. This should also include casesof vascular thromboses and their treatment. Carotid andvertebral artery angiography is excluded from most gen-eral guidelines and added skills are required in this vascularterritory. The ACC/ACP/SCAI/SVMB/SVS Clinical Com-petent Statement outlines these requirements (Tables 20-3and 20-4).

Restricted certificates can be awarded to physicians whoachieve satisfactory skills in only certain vascular territories.

341



342 • CHAPTER 20

TABLE 20-1. Training in DiagnosticCardiac Catheterization andInterventional Cardiology

Level 1—Trainees who will practice noninvasive

cardiology and whose invasive activities will be

confined to critical care unit procedures.

Level 2—Trainees who will practice diagnostic but

not interventional cardiac catheterization.

Level 3—Trainees who will practice diagnostic and

interventional cardiac catheterization.

Maintenance of certification is also required by continuousmedical education and performance of 25 peripheral vas-cular interventions per year. For full details, the reader mayrefer consensus conference guidelines.17

• NONINVASIVE IMAGING

Noninvasive imaging is improving at a rapid pace and isreplacing routine catheter angiography in many cases.

Magnetic Resonance Angiography

According to the ACC/AHA guidelines, MRA withgadolinium contrast is now a Class I indication (condi-tions for which there is evidence for and/or general agree-ment that a given procedure or treatment is beneficial, use-ful, and effective) and level of evidence A (data derivedfrom multiple randomized trials or meta-analysis) to diag-nose the anatomic location and degree of stenosis in thelower extremity PAD; and to select patients who are candi-dates for endovascular or surgical revascularization. MRAhas Type IIb indication (conditions for which there is con-flicting evidence and/or divergence of opinion about theusefulness/efficacy of a procedure or treatment. Weightof evidence/opinion is in favor of usefulness/efficacy) andlevel of evidence B (data derived from a single random-ized trial or nonrandomized trials) in patients with PADto select surgical sites for surgical bypass and for postsur-gical and postendovascular revascularization surveillance.Gadolinium is less nephrotoxic and there is no exposure to

TABLE 20-3. Formal Training to AchieveCompetence in Peripheral Catheter-BasedInterventions

Training requirements for cardiovascular physicians� Duration of training∗—12 months� Diagnostic coronary angiograms†—300 cases (200

as the primary operator)� Diagnostic peripheral angiograms—100 cases (50

as primary operator)� Peripheral interventional cases§—50 cases (25 as

primary operator)

Training requirements for interventional radiologists� Duration of training‡—12 months� Diagnostic peripheral angiograms—100 cases (50


primary operator)

Training requirements for vascular surgeons� Duration of training—12 months||� Diagnostic peripheral angiograms¶—100 cases (50


primary operator)� Aortic aneurysm endografts—10 cases (5 as

primary operator)

This table is consistent with current Residency Review Committeerequirements.∗After completing 24 months of core cardiovascular training and 8months of cardiac catheterization†Coronary catheterization procedures should be completed prior tointerventional training.‡After completing general radiology training.§The case mix should be evenly distributed among the different vas-cular beds. Supervised cases of thrombus management for limb is-chemia and venous thrombosis, utilizing percutaneous thrombolysisor thrombectomy should be included.‖In addition to 12 months of core vascular surgery training.¶In addition to experience gained during open surgical procedures.

ionizing radiation. Currently utilized techniques of MRAinclude time of flight (TOF), three-dimensional imaging,contrast enhancement with gadolinium subtraction, cardiacgating and bolus chase.18 With the contrast-enhanced MRA(CE MRA), the sensitivity is 90% and specificity 97% in

TABLE 20-2. Summary of Training Requirements for Diagnostic and Interventional CardiacCatheterization

Duration of Cumulative Duration Minimum no. of Procedures Cumulative no. of Examinations

Level Training (mo) of Training (mo) Diagnostic Interventional Diagnostic Interventional

1 4 4 100 0 100 0

2 4 8 200 0 300 0

3 12 20 0 250 300 250

∗Only one level 1, 2, or 3 trainee may claim credit for a procedure. See text for explanation.



PERIPHERAL ANGIOGRAPHY • 343

TABLE 20-4. Alternative Routes to Achieving Competence in Peripheral Catheter-BasedIntervention∗

1. Common requirements

a. Completion of required training within 24-month period

b. Training under proctorship of formally trained vascular interventionalist competent to perform full range of procedures

described in this document

c. Written curriculum with goals and objectives

d. Regular written evaluations by proctor

e. Documentation of procedures and outcomes

f. Supervised experience in inpatient and outpatient vascular consultation settings

g. Supervised experience in a noninvasive vascular laboratory

2. Procedural requirements for competency in all areas

a. Diagnostic peripheral angiograms—100 cases (50 as primary operator)

b. Peripheral interventions—50 cases (25 as primary operator)

c. No fewer than 20 diagnostic/10 interventional cases in each area, excluding extracranial cerebral arteries†

d. Extracranial cerebral (carotid/vertebral) arteries—30 diagnostic (15 as primary operator)/25 interventional (13 as

primary operator)

e. Percutaneous thrombolysis/thrombectomy—5 cases

3. Requirements for competency in subset of areas (up to 3, excluding carotid/vertebral arteries)

a. Diagnostic peripheral angiograms per area—30 cases (15 as primary operator)

b. Peripheral interventions per area—15 cases (8 as primary operator)

c. Must include aortoiliac arteries as initial area of competency

∗The fulfillment of requirements via an alternative pathway is only appropriate if the candidate physician has the cognitive and technical skills outlined inTable 20-4 and is competent to perform either coronary intervention, interventional radiology, or vascular surgery. These alternative routes for achievingcompetency are available for up to 5 years following publication of this document.†Vascular areas are (1) aortoiliac and brachiocephalic arteries, (2) abdominal visceral and renal arteries, and (3) infrainguinal arteries.Reproduced, with permission, from Creager MA, Goldstone J, Hirshfeld JW Jr, et al. ACC/ACP/SCAI/SVMB/SVS clinical competence statement on vascu-lar medicine and catheter-based peripheral vascular interventions: a report of the American College of Cardiology/American Heart Association/AmericanCollege of Physician Task Force on Clinical Competence (ACC/ACP/SCAI/SVMB/SVS Writing Committee to develop a clinical competence statementon peripheral vascular disease. J Am Coll Cardiol. 2004;44(4):941-957.

lower extremities PAD as compared to digital subtractionangiography (DSA).19−21 Runoff vessels may, in fact, bebetter visualized with MRA than DSA.22,23 In the patientsdiagnosed with critical limb ischemia (CLI), with intra-operative angiography as the standard, MRA had compara-ble accuracy to standard catheter angiography. Sensitivityand specificity for patent vessels was 81% and 85%, re-spectively. For the identification of segments suitable forbypass grafting, the sensitivity of contrast angiography wasless than MRA (77% vs. 82%), but the specificity was bet-ter (92% vs. 84%).24 A meta-analysis of MRA compared tocatheter angiography for stenoses >50% showed that thesensitivity and specificity were 90% to 100%, especiallywhen gadolinium was used.25 Recent studies also showan agreement of 91% to 97% between MRA and catheterangiography.26

MRA, however, tends to overestimate the degree ofstenosis and occlusions. It might also be inaccurate in as-sessing lesions with stents. Another limitation is in patientswho have been implanted with automatic defibrillators,permanent pacemakers or who have intracranial coils orclips.27,28 In these patients, MRA is generally contraindi-cated. Gadolinium is generally considered nonnephrotoxic,but one study reported nephrotoxicity in patients withbaseline renal dysfunction.29 A significant number of pa-

tients are also severely claustrophobic during imaging andrequire alternative testing.

Computed Tomographic Angiography

CTA is considered by ACC-AHA guideline committee tomerit a Type IIb indication (usefulness/efficacy is less wellestablished by evidence/opinion) and level of evidence B fordiagnosing the anatomic location and presence of stenosesin patients with lower extremity PAD. It is considered as asubstitute for MRA in patients who have contraindicationto MRA.30−34

This technique was first started in 1992. Image acqui-sition is very rapid. Images can be rotated in three di-mensions, thus bringing into view eccentric lesions thatmight be missed by two-dimensional catheter angiogra-phy. Older scanners had a single detector that acquiredone cross-sectional image at a time and was very time-consuming. It also required more contrast load and therewas overheating of the X-ray tube. The currently availablemultidetector CT (MDCT) scanners can acquire 64 slicessimultaneously.34−39 Abdominal aorta and the entire lowerextremity can be imaged in less than 1 minute.40 One hun-dred to one hundred eighty milliliters of iodinated contrastis injected at 1 to 3 mL per minute via a peripheral venous



344 • CHAPTER 20

line. The radiation exposure is typically one-quarter of thatin catheter angiography.

With the single detector scanners, the sensitivity for oc-clusions was 94% and specificity was 100%. For stenosesgreater than 75%, the sensitivity and specificity droppedsignificantly to 36% and 58%, respectively, when maxi-mum intensity projection was used and improved to 73% to88% when each slice was individually analyzed. With theMDCT, the sensitivity for stenoses greater than 50% was89% to 100% and the specificity was 92% to 100%.

CTA is useful in selecting patients who are candidates forendovascular or surgical revascularization. It also providesuseful information about associated soft tissue structuresthat may affect decision making in the optimal endovascu-lar treatment of PAD, e.g., vascular aneurysms. In one study,it showed that popliteal artery stenosis and occlusions oc-curred because of aneurysms, cystic adventitial disease, orentrapment.41 Other advantages are patient comfort, andcompared to DSA, it is noninvasive, less expensive, deliv-ers less radiation (approximately one-fourth) and has bettercontrast resolution.42

The major limitation of CTA is the risk of contrast-induced nephropathy (CIN). Other drawbacks include lackof accuracy with single detector scanners, lower spatial res-olution than DSA, venous filling obscuring arterial imag-ing, decreased accuracy in calcified vessels, and asymmetri-cal opacification of legs. The accuracy and effectiveness ofCTA is not as well delineated as that of an MRA. Treatmentplans based on CTA have not been compared with those ofcontrast angiography in lower extremity PAD.

Carbon Dioxide Angiography

CO2 angiography is not available in most centers and gener-ally reserved for patients with history of contrast allergy orrenal dysfunction with creatinine clearance less than 20 mLper minute. The use is generally limited to arteries belowthe diaphragm to minimize the risk of cerebral embolism.DSA equipment is required for CO2 angiography.43−50

• CONTRAST ANGIOGRAPHY

In spite of tremendous improvements in noninvasive imag-ing, catheter-based invasive iodine contrast catheter an-giography remains the gold standard for the diagnosis ofPAD in patients considered for endovascular intervention.It is the most widely available modality for the imaging ofthe vasculature. It is the only universally accepted technol-ogy for guiding percutaneous peripheral vascular interven-tions. Millions of angiographic procedures have been per-formed worldwide since William Forssman in 1929 passeda catheter from his own arm vein into his right atrium.51

In the early period, direct punctures of the vessels of inter-est were performed.52 This technique has essentially beenabandoned and replaced by percutaneous needle access.Safe and good quality angiography requires adequate equip-ment, well-trained team of staff, and strict adherence towell-established principles.

Catheter angiography has a Class I ACC/AHA indica-tion for delineating the anatomy in patients who requirerevascularization. Modern technology has permitted theuse of smaller diameter sheaths and catheters, less toxiccontrast agents, better imaging equipment in angiographicsuites requiring less contrast load, thus decreasing the risksto the patient for adverse effects. Invasive angiography pro-cedures, however, are still associated with rare but poten-tially devastating complications. The risk of severe contrastinduced reaction is 0.1%.53,54 There is significant risk ofCIN in patients with baseline renal dysfunction, patientswith diabetes mellitus, those with low cardiac output statesor those who are dehydrated. Any combination of these ismore adverse than an individual risk factor.

Informed consents should be obtained prior to the proce-dure from all patients after fully explaining all the risks, ben-efits, and alternatives. History of contrast-related allergicreactions should be documented and appropriate pretreat-ment should be administered. Decisions regarding revascu-larization should be made with complete anatomic assess-ment of the affected arterial territory including imaging ofthe occlusive lesion as well as of the inflow and outflow ves-sels. Noninvasive imaging techniques should be combinedwith vascular imaging for the information. DSA should beused to eliminate dense background tissues. Selective andsuperselective catheter placement should be done for betterenhancement of vasculature and to reduce the contrast loadand radiation exposure. Imaging should be done in multi-ple angulations to uncover vessel overlap, and transstenoticpressure gradients be measured in ambiguous lesions. In pa-tients with renal dysfunction, appropriate hydration shouldbe given prior to the procedure. Patients should be followedup within 2 weeks of the procedure to assess their renalfunction, the access site, and to make sure that they havenot suffered adverse effects like atheroembolism.

Radiological Equipment

Peripheral angiography frequently requires imaging of largeareas, which in the absence of a large field of view, will re-quire multiple injections and significant contrast load. A14-inches (36-cm) image intensifier is recommended (Fig-ure 20-1). Cineangiography at 15 to 30 frames per sec-ond (FPS) is excellent for imaging of the moving beat-ing heart.55 Imaging of static structures with radioopaquebones in the background, e.g., blood vessels, especially thesmaller branches will be suboptimal with this technique.Therefore, the technique of DSA should be utilized forperipheral angiography. In this technique, the patient isrequired to stay motionless during images; otherwise theimage will be distorted. In carotid angiography, the pa-tient should also be instructed not to swallow to preventmotion. In modern angiographic suites, ability to acquireDSA images has cut down on the contrast and radiationexposure. In DSA, a precontrast “mask” image is first ob-tained. Following contrast injection, subtraction of this im-age allows enhanced filling of the vasculature with mask-ing of nonvascular structures like bones, air, and calcium.




41 2

3

5

6

7

• FIGURE 20-1. Peripheral angiography suite at University

of Louisville, Louisville, KY. (1) Fifteen-inch image intensifier;

(2) live monitor; (3) reference monitor; (4) hemodynamic

monitor; (5) equipment adjustment monitor; (6) fractional flow

reserve (FFR) (RADI Sweden) monitor; (7) long patient bed.

Gadolinium or CO2 angiography should be done in lab-oratories equipped with DSA; otherwise, the image qual-ity is likely to be poor. “Road mapping,” also called “tracesubtract fluoroscopy,” is usually available in catheter labo-ratories equipped with DSA capability. This is a very use-ful technique during interventional procedures. This canbe conceptualized as fluoroscopy without the radioopaquebackground. A small amount of contrast is first injected tofill the vessel and the image is stored in memory as a mask.When the catheter is advanced under normal fluoroscopy,this mask is subtracted, thus allowing visualization of boththe moving catheter and the vessel. The image in road map-ping will appear white in contrast to DSA, where it will beblack. Additional software, enabling quantitative angiogra-phy to measure lesion length and diameter should also beideally available in current angiographic suites.

Examination Console

Highest kilovoltage peak (KVP) is required for cerebral andabdominal angiography, lowest for the extremities, and in-termediate for the thorax. Frame rate is generally 2 to 3 FPSfor arterial imaging. It is decreased for venous imaging dueto long cine runs. Frame rate is increased for cases requiringgadolinium contrast. Newer laboratories will typically havethe settings on the console that can be adjusted to optimizeadequate imaging of each vascular bed.

In the imaging of the legs 12- to 15-inch image intensi-fier is required. A longer table is also desirable. Where theseare not available, the patient can be positioned in reversewith feet facing the head end of the table. Multiple injec-tions maybe required in the legs to image all the arteries.Depending on the operator and the staff experience, eithera “stepped mode” method, which requires contrast bolusat each imaging site, or an “interactive” method where asingle bolus of contrast is given in the abdominal aorta and

the table is automatically set to “chase” down the bolus allthe way to the feet are utilized for angiography. In our ownexperience, the stepped mode technique produces betterimages with the flexibility of changing the amount of con-trast and angles during imaging. It may however requireslightly larger contrast load and exposes operators to moreradiation.

In the “interactive” method, after the bolus is given, aDSA run of both the lower extremities is obtained followedby a “dry run” used for subtraction. This technique is some-times limited by unequal visualization of both legs in largerpatients or in the patients who have flow-limiting lesionsin a segment of the vessel causing delayed filling distally.Patients may also be unable to lie motionless or hold theirbreath for the entire duration of the time required for imag-ing of all the segments. If free movement of the table is notconfirmed prior to the automatic runs, there is a dangerof pulling out of the imaging catheter and the sheath. Werecommend suturing the sheath if using this method.

Radiation Exposure

Peripheral angiography procedures are typically more timeconsuming than coronary procedures. Frustration can easilyset in during a difficult case especially if the staff is not com-pletely familiar with the equipment and trouble shootingof the modalities commonly used, e.g., DSA, road map-ping, bolus chase etc. Also, many laboratories have traineefellows and less experienced operators trying to learn thisincreasingly popular skill. Basic principles to prevent radi-ation exposure can thus be overlooked.

Maximizing distance from the X-ray source is the bestway to reduce exposure. Most procedures by the right-handed individuals are done from the right side of the table.Right anterior oblique (RAO) angulation moves the X-raytube away from the operators, thus exposing them to lessradiation than left anterior oblique (LAO) angles. Protec-tive lead shields, good-quality lightweight aprons, thyroidcollars, and leaded eyeglasses should be used as a habit. Useof DSA and road mapping will further cut down on flouro-time. Radiation badges should monitor radiation exposureof each operator and staff.

Intravenous Contrast Agents

All current contrast agents are iodine-based. The highatomic number and chemical versatility of iodine makes itideal for vessel opacification.56 They are classified as ionic ornonionic and further differentiated into high-osmolar, iso-osmolar, and low-osmolar based on their osmolality. Low-and iso-osmolar agents cause fewer side effects, e.g., hy-potension, bradycardia, angina, nausea, and vomiting. Theyalso cause less heat sensation and are better tolerated inperipheral angiography. The nonionic agents cause less al-lergic side-effects and may also be less nephrotoxic. Thenonionic, hypo-osmolar and iso-osmolar agents are moreexpensive.57−60 Some patients maybe intolerant to pain andheat sensation even with the iso-osmolar agents. A 50:50mixture with saline using DSA imaging can be used in such



346 • CHAPTER 20

cases. Many agents are commercially available in the mar-ket based on their ratio of iodine to ions and concentrationof sodium (that determines their osmolality).

High-osmolar ionic ratio 1.5 agents contain three atomsof iodine for every two ions, e.g., Renografin (Bracco), Hy-paque (Nycomed), and Angiovist (Berlex). Their sodiumconcentration is roughly equal to that of blood, makingtheir osmolality very high (>1500 mosm/kg). They causesignificant pain and are generally not tolerated well by pa-tients undergoing peripheral angiography.

Low-osmolar ionic ratio-3 agents have three atoms ofiodine for every one ion and are low osmolality agents. Theirosmolality is roughly twice that of blood, e.g., Ioxaglate(Hexabrix, Mallinckrodt).

Low-osmolar nonionic ratio-3 agents are water-solubleand do not have any ions, e.g., Iopamidol (Isovue, Bracco),Iohexol (Omnipaque, Nycomed), Ioversol (optiray, Mallin-ckrodt). Their osmolality is also twice that of blood andcause burning in many patients.

Iso-osmolar nonionic ratio-6 agents have osmolalityequal to that of blood (290 mosm/kg). They are very welltolerated by patients. Most commonly used is Iodixinol(Visipaque, Nycomed). It has fewer incidences of allergic

reactions than Ioxaglate and has shown no major increase inadverse coronary events like intravascular thrombosis, ves-sel closure, or perioperative myocardial infarction.61 Thereis also some data suggesting less nephrotoxicity with them.

In all patients with renal dysfunction, intravenous hy-dration with normal saline at 1 mL/kg/h along with N-acetylcysteine (mucomyst) 600 mg orally twice a dayshould ideally be started 12 to 24 hours prior to the proce-dure. Gadolinium contrast or CO2 angiography is anotheroption in such patients.

Diagnostic Catheters and Guide Wires

Vascular access is commonly obtained with an 18-gaugeneedle that will accommodate most 0.038 inch or smallerwires. A smaller 21-gauge needle with a 0.018-inch wire isavailable in “micropuncture kit” (Cook, Bloomington, IN)that can be used for difficult femoral, brachial, radial, orantegrade femoral approaches (Figure 20-2). For a nonpal-pable pulse Doppler, integrated needle (smart needle) canbe used. Wires are available in 0.012 to 0.052 inch in di-ameter. Most commonly used are wires of 0.035 and 0.038inch. In a standard guide wire, a stainless steel coil surrounds

• FIGURE 20-2. Micropuncture kit.




• FIGURE 20-3. Angiography selective catheters.

a tapered inner core. A central safety wire filament is incor-porated to prevent separation in case of fracture. Typicallythey are 100 to 120 cm in length but can also be 260 to300 cm. Wires are available when wire position needs tobe maintained for catheter exchanges. Long wires are fre-quently required in peripheral angiography, more so than incoronary angiography and their use is encouraged when indoubt.

The tip of the wires can be straight, angled, or J-shaped.Some wires have the capability of increasing their floppytip by having a movable inner core. Varying degrees of shaftstiffness, e.g., extra support, to provide a strong rail to ad-vance catheters in tortuous anatomy versus extremely slickhydrophilic with low friction for complex anatomy havemade peripheral vascular angiography and interventions aviable and many times a preferred treatment of PAD.

Every angiographic suite should have an inventory ofsuch wires. The 0.035-inch wires used in our laboratoryare standard J-shaped, Wholey, Straight and Angled Glide,Amplatz Super Stiff, and Supracore. Among the 0.018-inchwires inventory are the Steel Core and V18 Control. Inaddition to 0.014-inch coronary wires, we frequently useSparta Core wire in renal and other peripheral vascularinterventions. Glide wire (Terumo wire) is very useful in

tracking most vessels but carries the risks of vessel dissectionand perforation. It should not be used to traverse needlesbecause of the potential of shearing.

Numerous catheters are available (Figures 20-3 to 20-5)and every operator should develop his own skill and “feel”of catheters he uses in peripheral angiography. An “idealcatheter” should be able to sustain high-pressure injections,to track well, be nonthrombogenic, have good memory, andshould torque well.62 Catheters are made of polyurethane,polyethylene, Teflon or nylon. They have a wire braid in thewall to impart torquibility and strength. They are availablein different diameters and lengths. They can have an endhole, side holes, or both end and side holes. When usingthe femoral approach, short-length catheters (60–80 cm)are adequate for angiography of the structures belowthe diaphragm, whereas long catheters (100–120 cm)are needed for carotid artery, subclavian artery, or arm an-giography. Five- to six-French catherter (1-F catheter =0.333 mm) diameter catheters are most commonly used.Three- to four-French catheters are used for smaller ves-sels. Side-hole catheters are safe and allow large volumeof contrast at a rapid rate with power injectors, e.g. pigtail,Omniflush, Grollman. They are commonly used for angiog-raphy of ascending aorta, aortic arch, and abdominal aorta.



348 • CHAPTER 20


End-hole catheters are very useful in selective angiographyusing manual hand injections. For DSA, 5-F catheters aresufficient.

Omniflush catheter can be advanced over the wire be-yond the aortic bifurcation and then pulled back to engagethe contralateral common iliac artery for selective angiog-raphy of the leg. For type-1 aortic arch, a 5 F JR4 willbe adequate for carotid, vertebral, subclavian artery an-giography, and for nonangulated renal arteries. Simmons,Vitek, SOS, and Amplatz catheters are very useful in cer-tain situations but require added skills and careful manipu-

lation. Heparin should be used with the use of these lattercatheters. Simple curved catheters, e.g., Berenstein, Cobra,and Headhunter, are also useful in angulated renal arteriesand vertebrals.

Vascular Access

Meticulous technique to achieve vascular access is essentialfor a successful angiographic procedure. In patients withPAD, the success or failure of a procedure will significantlydepend on the correct choice of access site. Every effort





should be made to learn the vascular anatomy and direc-tion of blood flow if the patient had previous bypass graft.Prior noninvasive studies like MRA, CTA, and Duplex ul-trasonography (US) should be reviewed prior to the an-giography. Peripheral bypass grafts in general should not bepunctured for 6 to 12 months after surgery.

Most common vascular sites are common femoral artery(CFA) and brachial artery (BA).63,64 Fluoroscopy should beroutinely used to identify bony landmarks to avoid punc-turing the artery too low or too high.

Femoral Approach

CFA is ideally suited because of its large caliber that canaccommodate up to 14-F sheaths percutaneously and itscentral location, enabling access to all vascular territories.When compared to the arm approach, there is less radiationexposure but more incidence of bleeding and delayed am-bulation. Both retrograde (toward the abdomen) and ante-grade (toward the feet) CFA punctures are routinely done.For the antegrade approach, micropuncture technique us-ing 21-gauge needle with 0.018-inch wire is recommended.It should always be done under fluoroscopy and should not

be done in very obese patients. It limits arteriography to theipsilateral leg, but provides a better platform for interven-tions if needed. Patients are typically placed in reverse withthe feet facing the head-end of the table, allowing max-imum mobility of the image intensifier around the limbs.The skin puncture is made at the top of the femoral head. Aless acute, less than 45-degree angle is usually required forsmooth insertion of the sheath and catheters. Long taperedintroducer-sheath instruments are sometimes needed. Ashort 4- to 5-F sheath should be introduced first and acine angiogram performed to confirm access in the CFA,and wire position in the superficial femoral artery (SFA)before inserting the larger and longer sheaths and initia-tion of anticoagulation65 (Figure 20-6). An ipsilateral 30 to50 degrees angulation will open up the superficial and deepfemoral artery (DFA) bifurcation. Anticoagulation can bereversed at the end of the procedure for early removal ofsheath and to decrease the incidence of bleeding.

Brachial and Radial Approach

For radial artery (RA) and 5- to 6-F sheaths and forbrachial artery 5- to 7-F sheaths can be used. The biggest



350 • CHAPTER 20

A B

• FIGURE 20-6. (A) Antegrade femoral artery access technique under direct

flouroscopy using micro puncture needle and wire. The wire is in the deep femoral artery.

(B) The wire is directed under flouroscopy into the superficial femoral artery.

advantage with these approaches is less bleeding andearly ambulation.66−68 There are however more ischemiccomplications.69 These approaches require crossing thegreat vessels of aorta and great care should be exercisedto avoid causing embolic strokes.

For BA approach, the arm is abducted and the punctureis made at the site of maximum pulsation. Micropuncturetechnique is recommended. When using this approach, oneshould be aware of the need for longer length catheters ifangiography and intervention of the lower extremities isanticipated. Left brachial approach has approximately 100mm greater reach than the right brachial approach. Wholeywire, glide wire, and other soft wires should be used withthese approaches to minimize trauma and spasm of thevessels.

For RA approach,70 more skill is required. RA is super-ficial and lies against the bone. It has no major veins ornerves in the vicinity. Its smaller size, however, limits theuse of some devices and larger stents. Hydrophilic sheathsand guiding catheters of upto 6- to 7-F are now availableand can be used with this approach. They can accommo-date most current balloons and stents. There is approx-imately a 3% incidence of RA occlusion postprocedure.Allen’s test71 should be performed prior to cannulating RAto confirm the ulnar artery patency (Figure 20-7). There is,however, some controversy regarding the absolute value ofAllen’s test. The success rate of this approach is 95%.72 The

wrist is extended and the arm abducted in supine position.Using micropuncture technique, puncture is made 1 to 2cm proximal to the wrist crease. After sheath insertion,the arm is brought back in the adducted neutral position.Right arm is preferred to preserve left RA for future bypasssurgery if needed. Minimal local anesthesia is administered.Five F long hydrophilic sheath is a good choice. Heparin2500 to 5000 units should be given directly in the sheath.Radial arteries are very prone to spasm and vasodilatorsshould be used. Nitroglycerin 100 to 200 mg and Vera-pamil 1 to 2 mg is directly given through the sheath. Ashort cineangiogram should be performed to look for any

Ulnar artery

Radial artery

• FIGURE 20-7. Atretic ulnar artery in a patient with

equivocal Allen’s test.




anomalous arteries. One should look for radial recurrentartery. The sheath should be removed immediately after theprocedure. Activated clotting time (ACT) check is not nec-essary. Compression straps, e.g., Hemoband (HemobandCorp., Portland, OR) are placed directly over the puncturesite. Pressure is maintained for approximately 90 minutesfor diagnostic and 180 minutes for interventional proce-dures. Access site complications are very uncommon.

Other Vascular Access Sites

PA is uncommonly accessed. The patient has to lie prone.Puncture is performed under fluoroscopy and micropunc-ture technique is recommended. Axillary approach is morepopular among interventional radiologists. Left axillaryartery is preferred. The patient needs very close monitoringfor bleeding after axillary artery puncture because even amedium-sized hematoma can cause nerve compression. BAcut down is very uncommon now. It is used in less than 10%of cases and should be performed only by experienced op-erators. Lumbar aortic punctures are again sometimes usedby radiologists in patients who have extensive PAD.73 Pa-tient is placed prone. This site is only used as a last resortbecause in case of bleeding complications direct pressurecannot be applied and patient will likely require open sur-gical repair of the bleeding vessel.

Local Vascular Complications

Society for Cardiac Angiography and Interventions (SCAI)has reported an incidence of 0.5% to 0.6% local vascularcomplications. These complications comprise vessel throm-bosis, dissection (Figure 20-8), bleeding, which can befree hemorrhage, retroperitoneal bleeding, or access sitehematoma, arteriovenous fistula (Figure 20-9), distal em-bolization, or false aneurysm (pseudo aneurysm).

The operator should be well versed in the diagnosis andmanagement of these complications. Adequate specialtycare should be readily available at the facility where suchprocedures are performed.

Thoracic Aorta and Aortic Arch Angiography

Noninvasive modalities like MRA and three-dimensionalCTA should be performed if available prior to invasiveimaging. Angiography provides 2D imaging and may un-derestimate the tortuosity of various vessels (Figure 20-10).CTA and MRA will also provide information about the typeof aortic arch, and anomalous origin of any vessel from thearch (Figure 20-11).

Thoracic Aorta

Commonly approached via right CFA utilizing 4- to 6-Fsheath and diagnostic catheters. Pigtail or tennis racquetcatheter is advanced over a soft J-tip guidewire under flu-oroscopy. In cases of coarctation of the aorta, anteropos-terior and lateral views are obtained with the contrast

• FIGURE 20-8. Catheter-induced abdominal aortic

dissection.

injected proximal to the coarctation. For cases of patentductus arteriosus, selective aortic angiography is very sensi-tive in demonstrating small shunts and supercedes the sen-sitivity of right heart catheterization with stepwise oxime-try. In cases of thoracic aortic aneurysms (TAA), MRA andCTA are again very useful initial tools (Figure 20-12), butcatheter angiography is still considered essential to delin-eate the aneurysm and its relationship to the branches inthe chest and abdomen. If endovascular thoracic aneurysmrepair (ETAR) or open surgical repair is planned, thencoronary, brachiocephalic, visceral, and renal arteriographyshould also be performed. For the diagnosis of thoracicaneurysms, angiography is performed in the ascending tho-racic aorta above the aortic valve using 30 to 40 mL of iodi-nated contrast at 15 to 20 mL/s using power injection. TAAis less common than abdominal aortic aneurysm (AAA) butthe incidence is increasing as the median age of the pop-ulation is also increasing. It also has a higher incidence ofrupture than AAA. Untreated, the mortality is greater than70% within 5 years of diagnosis.74 Open surgical repair hasa mortality of 10% to 30%, spinal cord injury 5% to 15%,respiratory failure 25% to 45%, myocardial infarction 7% to



352 • CHAPTER 20

A B

• FIGURE 20-9. (A) Arteriovenous fistula between left CFA and vein. (B) Repair of

arteriovenous fistula with a covered stent.

20%, and renal dysfunction 8% to 30%.75 Chronic obstruc-tive pulmonary disease (COPD) and renal failure are strongpredictors of rupture. In one series,76 the rupture rate washigh for aneurysms greater than 6 cm. In another series, norupture was reported in aneurysms less than 5 cm. Meansize for rupture was 5.8 cm. With ETAR, the mortality andthe morbidity has been reported to be much less.77

In cases of thoracic aortic dissection, angiography hasa sensitivity of 80% and specificity of 95%. Noninvasivemodalities like CTA, MRA, and transesophageal echocar-diography have taken over as the initial diagnostic tools;however, cardiothoracic surgeons will still require an an-giogram for additional information about coronary andbranch vessel involvement and the competence of the aor-tic valve prior to aortic repair. A pigtail or tennis racquetcatheter is advanced over a soft wire typically via the rightCFA approach. Most of the aortic tears are at the greater(outer) curve and to avoid entry into the false lumen, thecatheter is used to direct the wire toward the inner curve.Frequent contrast injections should be utilized to check thecatheter position. Entry into the false lumen is not uncom-mon and if that occurs, the catheter should be gently re-tracted and advanced into the true lumen.

Aortic Arch

Catheter angiography is still considered the gold standard,but 3D CTA and MRA are excellent for imaging the aorticarch and should be considered prior to considering arch an-giography. CFA is the most common access site. Brachial or

radial approaches can be used in cases of suspected aorticdissection and in patients with severe ileofemoral or ab-dominal aortic atherosclerotic disease. A pigtail catheter ispositioned above the sinus of valsalva and 40 to 60 mL ofnonionic iso-osmolar contrast at the rate of 20 cc/s is in-jected with a power injector. Both cine and DSA imagingcan be used. For a cine angiogram, 30 FPS and for DSA,4 to 6 FPS are commonly used. LAO at 45 degrees angleopens up the aortic arch and the great vessels in most cases.DSA allows a lower contrast load of 30 mL injected at20 cc/s.

Carotid and Cerebrovascular Angiography

Catheter angiography is the gold standard for aortic arch,cervical, and cerebral angiography. A major drawback forangiography in this territory has been the risk of strokes.There was 1.2% incidence of stroke in the hands of radi-ologists in the ACAS78 trial. In a later study79 performedby cardiologists, the risk was 0.5%. Proper patient selectionand the procedural volumes and the technical skill of theoperator are important predictors of this risk.

Carotid Artery

Many patients with carotid artery disease are asymp-tomatic. History and physical examination are therefore notvery sensitive in detecting carotid artery disease. Carotidduplex ultrasound, CTA, and MRA should be utilized as theinitial diagnostic tools (Figure 20-13). Invasive angiography




• FIGURE 20-10. CTA showing extremely tortuous carotid

arteries making endovascular intervention an undesirable

option in such cases.

Courtesy: Robert Falk MD, 3-DR Louisville, KY.

remains the gold standard in patients considered for carotidartery stenting (CAS). The landmark North AmericanSymptomatic Carotid Endarterectomy Trial (NASCET),European Carotid Artery Surgery (ECAS), and Asymp-tomatic Carotid Artery Stenosis (ACAS)78,80,81 trials wereall based on angiography.

Brachiocephalic (BC) artery arises as the first great vesselfrom the aortic arch and divides into right subclavian (RSC)and right common carotid arteries (RCCA). RCCA almostalways arises from the BC and rarely as a separate branchfrom the aorta. It may come from a single common carotidtrunk that also gives rise to left common carotid artery(LCCA). RCCA further divides into right internal carotidartery (RICA) and right external carotid artery (RECA)at the fourth cervical vertebra. The angle of the mandibleis a good bony landmark for the bifurcation of the CCA.ECA gives numerous branches (Figure 20-10). LCCA arises75% of the time as a separate branch from aorta, 10% to15% of the time as a common origin with the BC, and ap-proximately 10% of the times from the BC (bovine origin)(Figure 20-11). ICA can be divided into four segments82

(Figure 20-11).

a. Prepetrous (cervical). Between the CCA bifurcation andthe petrous bone. This segment does not give rise to any

• FIGURE 20-11. CTA nicely showing a “bovine” aortic

arch. There is also severe stenosis of the left internal carotid

artery and the aortic arch is also “type 3” making carotid artery

stenting an unsuitable option in this case.


• FIGURE 20-12. CTA showing thoracic aortic aneurysm.




354 • CHAPTER 20

• FIGURE 20-13. CTA of carotid arteries showing patent

stent in the right common and internal carotid arteries (arrows).


major branches and is the most common site of carotidstenosis involving the ostial and the proximal portion ofthe artery.

b. Petrous. This segment courses through the petrous boneand makes a 90-degree L-shaped angle on angiogram.

c. Cavernous. This is the part through the cavernous sinus.d. Supraclinoid. This segment gives ophthalmic, posterior

communicating, and anterior choroidal branches beforeterminating as the middle and anterior cerebral arteries.Ophthalmic artery supplies the ipsilateral retina and op-tic nerve and is a source of important collateral route be-tween ICA and ECA. Posterior communicating branchconnects ICA with posterior cerebral artery to providecommunication between the anterior and posterior cir-culation. The area supplied by ACA and MCA is referredto as “carotid territory of the brain.”

Angiography

Angiography is considered to be the gold standard forthe diagnosis of extracranial and intracranial carotid arterydisease. For complete cerebrovascular circulation, carotidangiography should be done in conjunction with aorticarch and selective vertebral angiography. Knowledge ofarch anatomy and presence of proximal AS and tortuos-ity are crucial in the appropriate selection of the cathetersfor selective angiography. For Type-I or Type-II arch, 5 FJR4, Davis, HH (Meditech Watertown, MA), or Beren-stein catheters are adequate. In patients with bovine archVitek catheter is often needed. For Type-III arch (elon-

• FIGURE 20-14. Venous phase of cerebral angiogram.

gated), reverse curve catheters like Simmons (Angiody-namics, Queensbury, NY) or Vitek are often required. Sim-mons catheter can be very useful as it “travels up” thecarotid artery and does not get dislodged. Its use, however,requires more skill.

Meticulous technique and double flushing is recom-mended once the catheter is beyond the aortic arch. Di-luted low- or iso-osmolar contrast is injected at 4 to 6 mL/sfor a total of 8 mL for CCA angiography using DSA at 4 to6 FPS.

Cerebral circulation imaging should be continued intothe venous phase to rule out any venous anomaly (Figure20-14). Multiple projections and angulation are sometimesneeded for optimal visualization. In most cases, a straightAP and lateral or 30 to 40 degrees ipsilateral angle willopen up the bifurcation to assess the lesion (Figures 20-15 and 20-16). RAO projection opens up the bifurcationof the BC artery. In patients who are undergoing carotid orvertebral interventions, cerebral angiography should be per-formed before and after the intervention, for comparison,in the event of suspected embolic stroke. It also provides in-formation about intracranial aneurysms and atheroscleroticdisease. A straight PA cranial view to bring the petrous boneat the base of the orbit (Towne’s view) will nicely outlinethe cerebral circulation in most cases (Figure 20-17).

For assessment of the severity of carotid stenosis, themethodology used by NASCET investigators is most pop-ular. This method compares the stenotic area with the mostnormal appearing artery distal to the stenosis.

Vertebral Artery

Left vertebral artery originates as the first branch of sub-clavian artery. In 3% to 5% of cases, it may arise directlyfrom the aorta between LCCA and LSCA. Very rarely, itmay originate distal to LSCA. Right vertebral artery can




• FIGURE 20-15. Severe stenosis of right internal carotid

artery.

A B

• FIGURE 20-17. (A) Right and (B) and lateral view of cerebral angiography in AP

(Towne’s view).

• FIGURE 20-16. Severe right carotid artery stenosis in a

patient with previous carotid endarterectomy.

Courtesy: John Laird MD, Washington Hospital Center, Washington,

DC.



356 • CHAPTER 20

• FIGURE 20-18. CTA showing “Circle of Willis.”


originate from RCCA and duplication of vertebrals can oc-cur at any level. It originates from the superior and posterioraspect of the RSCA. The two vertebrals converge to formthe basilar artery at the base of the pons (Figure 20-18).

It can be divided into four segments83:

V-1: From the origin to the transverse foramen of thefifth and sixth cervical vertebrae.

V-2: Its course within the vertebra until it exits at C2level.

V-3: Extracranial course between the transverse fora-men of C2 and base of skull where it enters fora-men magnum.

V-4: Intracranial course as it pierces the dura and arach-noid maters at the base of skull and ends as it meetsthe opposite vertebral artery (Figure 20-14).

Intracranial part gives anterior and posterior spinalbranches; penetrating branches and posterior inferior cere-bellar artery (PICA), which gives supply to dorsal medullaand cerebellum. Left vertebral artery is usually dominantand stenosis of the dominant vertebral is likely to causesymptoms.

AS is the dominant pathology involving the ostium andproximal extracranial segment of the VA. Surgical revas-cularization carries significant mortality and morbidity ap-proaching 20%.84 With rapidly improving skills and tech-nology, endovascular revascularization is becoming a veryattractive option for these patients.

Angiography

Subclavian and vertebral artery angiography is commonlyperformed from the CFA approach. For patients with se-vere lower extremity PAD with no femoral access or whohave Type-III aortic arch ipsilateral brachial approach canalso be used. Unfractionated heparin (3000–5000 units)are given when using the brachial approach. RA can alsobe used for angiography and in addition to heparin vasodila-tors should also be given with this approach. AP, RAO, andLAO projections will open up the SCA and VA. RAO cra-nial angle will show the origin of internal memory artery(IMA). JR4 catheter is usually adequate for straight aor-tic arch. For elongated aortic arch, Vitek, Head Hunter,or Simmons 1 or 2 are used (Figure 20-19). For vertebralartery, 3 to 4 mL/s for a total of 6 mL of contrast is gener-ally sufficient. Nonselective angiography with a blood pres-sure cuff inflated on the ipsilateral arm will improve thevisualization of ostial disease. Ostia are also better seen inthe contralateral oblique projections and V2 and V3 seg-ments are better seen in PA and lateral views or ipsilat-eral oblique views. Intracranial segments are best seen insteep 40 degrees PA cranial (Towne’s) view and crosstableview.

1

2

3

4

• FIGURE 20-19. Selective angiography of left subclavian

artery (1) using a Simmons catheter. (2) A normal left

vertebral artery, (3) a small internal mammary artery, and

(4) thyrocervical trunk are also seen.




• FIGURE 20-20. CTA of brachial, radial, and ulnar

arteries.


Subclavian, Brachiocephalic,

and Upper Extremity

This vascular bed constitutes approximately 15% of symp-tomatic extracranial cerebrovascular disease. Right subcla-vian artery (RSCA) arises from BCA on the right and LSCAis the last major branch from the aorta on the left. In 0.5%population, RSCA arises as the terminal branch from thedescending thoracic aorta and courses over to the right to-ward its normal distribution to the right upper extrem-ity. Rarely, RSCA and RCCA may have separate originsfrom the aorta instead of a BCA. It gives vertebral, IMA,and thyrocervical trunk (TCT) from its first segment. TCTgives inferior thyroid, suprascapular, and transverse cervicalbranches. SCA becomes axillary artery at the lateral mar-gin of the first rib that in turn becomes BA at the anatomicneck of the humerus. Opposite to the neck of radius, BAdivides into ulnar and radial arteries (Figure 20-20). In ap-proximately 1.3% of cases, RA originates from the axillaryartery and in 15% to 20% of cases from the upper BA. Ulnarartery helps to form the superficial palmar arch and the RAthe deep palmar arch (Figure 20-21).

Angiography

Angiography is generally needed in patients presenting witharm claudication, and in other causes of arm ischemia, e.g.,blue digit syndrome, severe digital ischemia, and blunt andpenetrating trauma with vascular injury to these vessels.CTA and MRA are useful to delineate arch anatomy. Step-

• FIGURE 20-21. CTA of hand arteries.


wise angiography with iso-osmolar contrast is preferred.Contrast of 5 to 10 mL with hand injection using DSAwill give good visualization of these vessels. JR4 catheteris routinely used (Figures 20-22 and 20-23). Vitek or Sim-mons catheter maybe required depending on the take off ofSCA or BCA. Vitek catheter is advanced under fluoroscopyand positioned in the descending thoracic aorta with thecurve facing the right side of the arch and the tip facingnorth. Catheter is gently advanced and each great vesselis selectively engaged. After completion of the angiogram,the catheter is removed over a wire. Simmons catheter isreshaped in the ascending thoracic aorta and is gently with-drawn to engage each vessel selectively. It is also removedafter straightening with a wire.

Orthogonal oblique views will visualize SCA and itsbranches. LAO for RSCA and RAO for LSCA will givegood views of these vessels (Figures 20-24 and 20-25). Pa-tient’s arm should be adducted to the neutral position dur-ing angiography. For axillary artery and BA angiography,catheter is advanced into distal SCA. Usually a long 300 cmWholey, Magic Torque or a Stiff Shaft Angled Glide wire isused to exchange the JR4, Vitek, or Simmons catheter for astraight 4- to 5-F Glide catheter or a multipurpose catheter.Axillary artery is angiographed in adducted arm positionand BA in an abducted position with forearm supine. Forthe forearm and hand angiogram, the diagnostic catheteris further advanced into the distal BA. Forearm should besupine, fingers splayed and thumb abducted. PA projection



358 • CHAPTER 20

5 F JR4

6 F long shuttle sheath

100% occluded left subclavian artery

• FIGURE 20-22. Hundred percent occluded left

subclavian artery. Dual injection technique is demonstrated with

5-F JR4 catheter in the subclavian artery and 6-F long shuttle

sheath in the ascending aorta.


DC.

• FIGURE 20-23. Left subclavian artery widely patent

after stenting.


DC.

• FIGURE 20-24. Critical stenosis of the origin of

innonimate artery seen on angiogram performed via right radial

artery. Aortic arch is not clearly opacified due to the stenosis.

Right common carotid artery is patent (arrow head).


DC.

is adequate. Vasodilators are given intraarterially due to thespasmodic nature of these arteries. For borderline lesions atranslesional gradient can be measured using a 0.014-inchpressure wire or simultaneous measurement of pressure be-tween 4- and 5-F catheter tip placed distal to the lesion andthe side port of a long 6-F sheath positioned in the distalaorta. Vasodilators can be used to augment the gradient. Agradient greater than or equal to 15 mm Hg in SCA andBCA is considered significant.

Abdominal Aorta

Atherosclerotic disease is very common with more involve-ment of the infrarenal abdominal aorta. Abdominal aortastarts at the level of the diaphragm (T12) and continuesanterior to the spine and to the left of inferior vena cava. Itbifurcates at L4 level into the right and left common iliacartery.85 AA is 15 to 25 mm in diameter and larger in malesand older populations.86 It gives rise to the celiac trunk atT12–L1, superior mesenteric artery (SMA) at L1–L2, andinferior mesenteric artery (IMA) at L3–L4 level. Renal ar-teries originate posterolaterally at L1–L2 level below theorigin of the SMA. Four pairs of lumbar arteries originatebelow the renals.

Abdominal aorta is considered to be aneurysmal whenthe anteroposterior diameter is 3 cm. Diagnosis is based




• FIGURE 20-25. Innonimate artery is widely patent after

stenting with opacification of aortic arch.


DC.

on formulas that adjust for age or body surface area or bycalculating the ratio between the normal and dilated aorticsegments.87−90 The prevalence of AAA increases with age.In a necropsy study,91 incidence was 5.9% in men aged 80to 85 years and 4.5% in women who were older than 90years of age. Based on U.S. studies, the prevalence for AAA2.9 to 4.9 cm is 1.3% for men aged 45 to 54 years and up to12.5% for men aged 75 to 84 years. Comparable prevalencefor women is 0% to 5.2%.

Common iliac artery aneurysms are usually also found inassociation with AAA. One-third to one-half are bilateraland 50% to 85% are asymptomatic when diagnosed.92,93

Rupture occurs when they are more than 5 cm.For the diagnosis, a history of abdominal and back pain

and presence of a pulsatile mass are important indicatorsof the presence of AAA. Plain X-ray film of the abdomenmay show curvilinear aortic wall calcification as an inciden-tal finding. US or nuclear scan of abdomen may show AAAas an incidental finding. Similarly, during unrelated arteri-ography, slow or turbulent flow in the aorta may suggestpresence of AAA.

US has a specificity of nearly 100% and sensitivity of 92%to 99% for the diagnosis of infrarenal AAA.87 For suprarenalAAA, the accuracy is much less. CTA and MRA are the

• FIGURE 20-26. CTA of abdominal aorta and iliac

arteries showing infrarenal abdominal aortic aneurysm and

accessory bilateral renal arteries.


current gold standard for the diagnosis of AAA.94 Spiralcontrast-enhanced CTA with 3D reconstruction is now thestandard preop evaluation to look for vessel calcification,thrombus, and anatomy of the aneurysm for optimal stentgraft placement (Figure 20-26). In addition to previouslydescribed limitations, CTA tends to overestimate the di-ameter of the neck and underestimate the length of theneck of the aneurysm. MRA is inferior to spiral contrast-enhanced CTA in spatial resolution and not very good fordetecting vessel wall calcification. MRA is slower than CTAbut not inferior in the diagnosis. It is considered superiorto catheter angiography for defining the proximal extent ofthe AAA, venous anatomy, intraluminal thrombus and iliacaneurysms.95 Renal arteries can also be imaged accuratelywith the new scanners. Standard MRA protocols for AAAare not available everywhere.

Catheter angiography is always done at the time of en-dovascular aneurysm repair (EVAR). Pelvic angiographyis also done at the same time to visualize iliac arteries,which are also frequently involved with abdominal aorticaneurysm. It also helps in the optimal visualization of col-lateral or variant arterial anatomy.96,97 Contrast angiogra-phy, however, is not accurate in estimating the diameterof the AAA due to presence of thrombus that is usuallypresent in the aneurysms. CTA or MRA are thus needed



360 • CHAPTER 20

• FIGURE 20-27. Large abdominal aortic aneurysm

(arrows), only partially visualized on contrast angiogram. The

rest of the sac is filled with thrombus.

in conjunction prior to EVAR (Figures 20-27 and 20-28).Prior to open or endovascular repair the maximum trans-verse diameter of the aneurysm, its relationship to the re-nal arteries, presence of iliac artery or hypogastric arteryaneurysm, stenosis of renal or iliac arteries, and presenceof horse-shoe kidneys, etc., must be defined. The diagnos-tic modality must provide measurement of the neck andbody of the AAA and of the iliac arteries. CTA is also ex-cellent in defining the type of endoleak after EVAR beforeangiography to repair the endoleak (Figure 20-29).

Femoral approach is most common using 4- to 6-F pig-tail or Omniflush catheter. Radial, brachial, or axillary ap-proaches are also used. As a last resort, translumbar punc-ture can be done. For AAA, the pigtail or Omniflushcatheter is positioned such that the tip is at T12-L1 levelso that the side holes are at L1-L2 level. Contrast of 30 to50 cc is injected. For abdominal or thoracic aortic steno-sis, a translesional gradient can be measured as previouslydescribed. A gradient greater than 10 mm Hg is consideredsignificant (Figure 20-17).

Visceral Artery Aneurysms

Open or endovascular repair has a class I indication foraneurysms greater than 2 cm in women of child-bearing ageor in men or women undergoing liver transplant. They haveClass IIa indication in men or in women who are beyondthe child-bearing age. Splenic and hepatic artery aneurysmsare not very common.98,99 Most are found incidentally dur-ing imaging for other reasons. Most are asymptomatic buta rupture in pregnant women carries a very high mortalitythat may approach 70% for the mother and >90% for the

• FIGURE 20-28. CTA of an abdominal aortic aneurysm

showing a large thrombus in the aneurysm not likely to be

visible on a catheter angiogram.


fetus.100 In general population the rupture carries a mortal-ity of 10% to 25%

SMA has 6% to 7% of all visceral aneurysms. Lower ex-tremity aneurysms generally do not rupture but pose a dan-ger of thromboembolism or vessel thrombosis. PA carriesup to 70% of all LE aneurysms. CTA and MRA are the testsof choice.

Renal Artery

Renal artery stenosis (RAS) is a very common and progres-sive disease in patients with PAD. It is a relatively uncom-mon cause of hypertension.101−103 A duplex US study ofpatients older than 65 years showed an incidence of 9.1%in men, 5.5% in women, 6.9% in white population, and6.7% in black population.102 In another series of 395 pa-tients with abdominal aortic and ileofemoral disease, theincidence of RAS greater than 50% was 33% to 50%.104

The incidence of significant RAS in patients who were un-dergoing coronary angiography who also underwent renalangiography was approximately 11% to 18%.105−107 Con-versely, the incidence of clinically significant CAD was 58%in patients with atherosclerotic RAS.108 In 24% patients




• FIGURE 20-29. CTA of an abdominal aortic endograft

showing an endoleak via a collateral between Internal iliac and

inferior mesenteric arteries (arrow).


with end-stage renal disease (ESRD) and in need for dialy-sis, there was severe atherosclerotic RAS.109 AS is by far themost common pathophysiological mechanism approaching90% in patients with RAS. Fibromuscular dysplasia is foundin approximately 10% of patients with RAS. There is alsosignificant progression of RAS. In patients with less than60% RAS, progression was 20% per year and in those withgreater than 60% stenosis, there was complete occlusionin 5% cases at 1 year and 11% at 2 years.110−112 Bilat-eral RAS is also common. In six different studies including319 patients, it was found in 44% of cases.113 renal atro-phy and ESRD can develop in patients with RAS and RAocclusion.114−116

Renal arteries arise at L1–L2 level from the posterolat-eral aspect of the abdominal aorta. Right RA typically orig-inates slightly higher than the left. Accessory renal arteriesare also quite common and found in 25% to 35% of thegeneral population. These usually supply the lower polesof the kidneys. They can arise anywhere from suprarenalaorta down to the iliac and are generally smaller in caliber.Main renal artery further branch into segmental, interlobar,arcuate, interlobular, and arterioles.

• FIGURE 20-30. (A and B) MRA of renal and mesenteric

arteries showing normal vessels and abdominal aorta.


Angiography

MRA has an ACC/AHA Class I indication as a screeningtool for RAS (Figure 20-30). Similarly, CTA has Class Iindication in patients with normal renal function. When theclinical suspicion is high and when the noninvasive tests areinconclusive, catheter angiography has Class 1 indicationfor the diagnosis of RAS (Figure 20-18).

MRA with gadolinium compared to catheter angiogra-phy has a sensitivity 90% to 100% and specificity of 76% to94% in atherosclerotic RAS. For patients who have FMD,the accuracy of MRA is less.117 MRA is the most expen-sive test diagnostic tool and other limitations are as dis-cussed before. CTA has a sensitivity of 92% and specificityof 95% when compared to DSA.118 Use of CTA is limitedbecause of a risk of CIN. CTA with the old scanners hada sensitivity of 59% to 96% and specificity of 82% to 99%when compared to catheter angiography.119−124 With thenew scanners, they have improved to 91% to 92% and 99%,respectively.

Currently, catheter angiography is reserved for those pa-tients whose diagnosis is not clear by noninvasive testing. Itis also recommended in patients who are undergoing coro-nary or peripheral angiography in whom there is a highsuspicion of RAS.

For contrast angiography, CFA approach is most com-mon using 5- to 6-F short sheath. In severely tortuous ile-ofemoral vessels, a long 6 F sheath should be used. Brachialapproach is used in patients with poor femoral approachor if the renal arteries are acutely downward angulated.Nonselective angiography is done first with a pigtail or



362 • CHAPTER 20

• FIGURE 20-31. Bilateral renal artery stenoses on flush

angiography of abdominal aorta utilizing pigtail catheter.

Omniflush catheter positioned at L1-L2 level in AP viewto look for ostia of the renal arteries and also to look foraccessory renal arteries. DSA at 4 FPS with 30 mL non-ionic iso-osmolar contrast at the rate of 15 mL/s is usuallyinjected (Figure 20-31). For selective renal angiography 4 to

• FIGURE 20-32. Selective left renal artery angiography

utilizing Judkin’s right coronary catheter showing significant

stenosis.

• FIGURE 20-33. Selective right renal artery angiography

utilizing Cobra catheter.

5 F JR4, renal double curve, Cobra, IMA, SOS, or Hockeystick catheters can be used (Figures 20-32 to 20-34). Fordownward-angulated renals, reverse curve catheters, for ex-ample, Simmons or Omniselective can be utilized fromthe femoral approach or a straight MP catheter from thebrachial approach. Contrast of 5 to 8 mL at 5 mL/s us-ing DSA at 4 FPS will give excellent images. Usually anipsilateral 15 to 30 degree oblique view will display the os-tium and proximal renal artery. Another useful techniqueis to modify the LAO/RAO angulation under fluoroscopywhile the catheter is engaged until the tip of the diagnostic

• FIGURE 20-34. Selective right renal artery angiography

showing in-stent restenosis utilizing Judkin’s right coronary

catheter.




catheter is maximally opened. Cranial and caudal angula-tion can be used to open up the bifurcation lesions. Cinean-giogram is prolonged until the nephrogram phase to assessthe kidney size and regional perfusion of the kidney to op-timize revascularization strategy.

No Touch Technique

Abdominal aorta frequently is severely atherosclerotic andthere is risk of visceral or distal embolization of atheromaduring manipulation of catheters. With this technique, a0.14-inch wire is advanced through the catheter beyond therenal arteries. The catheter is manipulated toward the renalostia without touching them, thus avoiding the scraping ofthe aortic intima.

In borderline lesions, a translesional gradient should bemeasured. A 0.014-inch pressure wire is most accurate. Al-ternatively, a 4 F diagnostic catheter is advanced beyond thelesion and gradient measured between the catheter and a6 F sheath in the aorta. A systolic gradient greater than orequal to 20 mm Hg or a mean gradient of 10 mm Hg is con-sidered significant. Vasodilators, for example, nitroglycerin100 to 300 mg or Papaverine 20 to 30 mg intravenouslycan be used to augment the gradient. Intravascular ultra-sound (IVUS) is also a very useful imaging modality in re-nal arteries to accurately assess the artery size and diseaseinvolvement of the ostia.

CIN is a significant risk and can be as high as 20%to 50% in patients with both chronic kidney disease anddiabetes mellitus.125,126 Iso-osmolar contrast agent Iodix-inol showed less nephrotoxicity than low-osmolar agentIohexol in one randomized trial.127 In patients with creati-nine clearance less than 60 mL/min and serum creatininegreater than 1.2 mg/dL, Mucomyst 600 mg twice a day de-creased the incidence of CIN in patients undergoing coro-nary angiography.128 In patients with renal insufficiency,CO2 angiography can be done injecting 40 to 50 mL ofCO2 delivered by hand injection while the patient is hold-ing breath using DSA. This will allow visualization of renalostia to facilitate selective renal angiography. Gadoliniumcontrast or iodinated contrast in a 50:50 ratio with normalsaline can also be used in patients with renal dysfunction.

Mesenteric Arteries

AS involvement of these arteries is common but mesen-teric ischemia is uncommon. Mesenteric ischemia can alsobe caused by nonobstructive arterial disease in cases of lowflow states. Two-thirds of the patients with intestinal is-chemia are women with a mean age of 70 years and mosthave preexisting CAD.129−131 Postprandial abdominal painis almost always present as a symptom.

Celiac artery arises from the anterior surface of the aortaat T12 level. It travels inferiority for 1 to 3 cm before divid-ing into common hepatic, splenic, and left gastric arteries.SMA arises at the L1–L2 level and gives rise to middle colicand pancreatoduodenal arteries. IMA arises at L3–L4 leveland gives rise to left colic and superior rectal arteries (Figure20-35).

1

2

34

• FIGURE 20-35. Mesenteric vessel arteriogram showing

(1) patent spenic, (2) common hepatic, (3) superior mesenteric,

(4) and right renal arteries. Left renal artery is absent.

These vessels have rich collateral pathways. meander-ing mesenteric artery allows communication between SMAand IMA. Pancreatoduodenal artery communicates be-tween celiac artery and SMA while IMA has collateral com-munications with the EIA. Occlusion of one of these arter-ies generally does not cause intestinal ischemia. Classicalteaching was that severe stenosis or occlusion of two of thethree of these arteries has to be present to cause this syn-drome, but this is not considered entirely true now.132,133

Single vessel disease, virtually always of the SMA, can causeintestinal ischemia (Figure 20-36). Patients in whom col-lateral circulation has been interrupted by prior surgery areespecially prone to intestinal ischemia by single vessel in-volvement.

Duplex ultrasound, CTA, MRA with gadolinium en-hancement, and catheter angiography with lateral abdom-inal aortography where noninvasive testing is not availableor indeterminate, all have Class I indication in the diagno-sis. In many cases, US is not very helpful because of thepresence of bowel gas or patient body habitus. CTA andMRA are good for detecting proximal artery lesions. CTA,however, requires intravenous contrast. In case of acute in-testinal ischemia, catheter angiography is the best test butit is limited by the time it may require in such emergencies.It can differentiate between occlusive versus nonocclusivedisease. Sometimes the patient is not stable to undergo theprocedure. Immediate laparotomy and surgical revascular-ization is the best approach in such cases.

Chronic intestinal ischemia is rare and almost alwayscaused by AS.134 Buerger’s disease, FMD, and aortic dis-section are very rare causes.



364 • CHAPTER 20

1

2

• FIGURE 20-36. Angiogram in a lateral projection

showing critical stenosis of (1) celiac trunk and (2) 100%

occlusion of SMA in a patient with severe mesenteric angina.


DC.

Catheter angiography has ACC/AHA Class I indicationin patients with suspected nonocclusive intestinal ischemiawhose condition does not improve rapidly with the treat-ment of the underlying disease, e.g., circulatory shock. Itcan also confirm vasospasm and vasodilator agents can beadministered.135−137

CFA approach is most commonly used. Arm approachcan be used if femoral approach is not feasible. A 4 to 5F pigtail or Omniflush catheter is placed at T12-L1 leveland 30–40 cc of contrast injected via power injector usingDSA at 15 cc/s at 4 to 6 FPS. Lateral view will best visualizethese vessels (Figures 20-37 and 20-38). An AP view shouldalso be done to visualize the mesenteric circulation andthe presence of any collateral vessels. “Arc of Riolan” (anenlarged collateral vessel connecting the left colic branchof the IMA with SMA) is an angiographic sign of proximalmesenteric arterial obstruction that is visible on the APview.

Pelvis and Lower Extremity

Infra renal aorta and ileofemoral vessels are amongst themost commonly involved in atherosclerotic PAD. Ile-ofemoral involvement is more common in patents thathave history of hypertension and smoking while below theknee, disease is commoner in diabetic population. Surgical

• FIGURE 20-37. Selective angiography of celiac trunk

utilizing reverse curve Simmons catheter.

• FIGURE 20-38. Selective angiography of superior

mesenteric artery utilizing reverse curve Simmons catheter.




revascularization in the ileofemoral region has a patencyof >80%138−140 but it is associated with significant mortal-ity and morbidity. Endovascular revascularization is rapidlytaking over as the first line of treatment in these cases.

AA bifurcates into common iliac arteries (CIA) at theL4-L5 level. CIA divides at L5-S1 junction into internal il-iac artery (IIA) and external iliac artery (EIA). IIA coursesposteromedially and EIA anterolaterally and exits the pelvisposterior to the inguinal ligament to become the CFA. TheIMA takes off medially at the junction of EIA and CFA.The deep iliac circumflex artery takes off laterally and su-periorly. CFA originates at the inguinal ligament and bifur-cates at the lower part of the head of the femur into SFAanteromedially and DFA posterolaterally. DFA has two ma-jor branches, lateral and medial circumflex femoral arteries.These arteries along with the first perforating branch con-nect with the IIA via the superior and inferior gluteal andobturator arteries. Distally, its branches provide collateralsto the network around the knee, thus communicating withthe popliteal and tibial vessels. Therefore, in cases of occlu-sion of SFA, the DFA becomes a very important source ofcollateral circulation.

The SFA becomes the popliteal artery (PA) as it ent-ers the adductor canal (Hunters canal). PA runs posteriorto the femur and gives sural and geniculate branches. Belowthe knee, the PA divides into anterior tibial artery (AT) thatruns anterior and lateral to the tibia and continues into thedorsum of the foot as the dorsalis pedis artery (DP). Afterthe takeoff of the AT, the PA continues as the tibiopronealtrunk (TPT) that divides into posterior tibial and peronealarteries. The peroneal artery runs between the AT and PT.It joins the PT above the ankle via its posterior division andthe AT via its anterior division. PT runs behind the medialmalleolus and gives medial and lateral plantar branches. Thelateral plantar and distal DP joins to form the plantar arch.

Angiography

CTA and MRA are very good tools to delineate the anatomy(Figures 20-39 to 20-41). Compared to DSA, the MRA hasshown a sensitivity of 97% and specificity of 99.2%.141 In-terest in this technology is growing as the sole diagnostictool prior to surgical revascularization.142 MRA in fact canbe a better imaging modality than CTA and catheter an-giography for below the knee vasculature (Figure 20-42).CTA is also excellent in the diagnosis but limited by CINand radiation hazard.143

Contrast angiography is considered to be the gold stan-dard (Figures 20-43 to 20-45). It should be reserved for thepatients being considered for revascularization and shouldnot be done for diagnostic purposes only if CTA or MRA fa-cility is available. Initially a nonselective angiogram shouldbe done. CFA, brachial, or radial approaches are used.Sheaths and catheters of 4 to 6 F are used. A PT or OFcatheter is positioned at L4–L5 and 30 mL of contrast at 15mL/s is injected with a power injector. DSA at 4 to 6 FPSshould be utilized. In cases of known iliac artery obstru-ction, the catheter should be placed just below the renal

• FIGURE 20-39. CTA of abdominal aorta and pelvic

arteries showing severe calcification of distal aorta, common

and internal iliac arteries. Celiac trunk, superior mesenteric,

and renal and inferior mesenteric arteries are patent.


• FIGURE 20-40. CTA showing aortobifemoral and left

femoral–distal bypass graft.




366 • CHAPTER 20

A B

• FIGURE 20-41. “Thick maximal intensity projection” CTA of (A and B) left lower

extremity arterial circulation and (C) bilateral ileo femoral arteries.


arteries to look for collaterals from the lumbar branches.Selective iliac angiogram is typically done from the con-tralateral side using 4 to 5 F IMA or JR4 catheter. Othercatheters, e.g., Simmons, Omniflush, or SOS, can be usedas needed. An exchange length of 200 to 360 cm angledglide wire is advanced under flouro into the CFA or moredistally and the catheter exchanged for a straight 4 to 5 F

• FIGURE 20-42. MRA of below the knee arteries showing

100% occlusion of right posterior tibial artery (solid arrow) and

100% occlusion of all three arteries on the left (dashed arrows).


glide or MP catheter. A selective stepwise angiogram of theleg is performed. A 10 to 15 cc contrast is used at eachstep. For optimal below the knee angiogram, the cathetershould be advanced to the distal SFA and vasodilators used.Interactive bolus chase technique as described before canalso be used for nonselective angiography of both the legs.

• FIGURE 20-43. Arteriogram of aorto bifemoral graft with

the sheath inserted into the right limb of the graft (arrow).




1

2

• FIGURE 20-44. (1) Hundred percent occlusion of left

superficial femoral artery. (2) Collateral vessels reconstituting

popliteal artery.

Another technique to engage the common iliac arteryis to advance the angled glide wire in the catheter (usu-ally pig tail) already in the abdominal aorta that was usedfor initial angiogram. The tip of the catheter is faced to-ward the contralateral iliac. The wire is advanced to “openup” the catheter and the catheter gently pulled down to-ward the aortic bifurcation. The glide wire will drop downinto the common iliac artery as the catheter hooks the os-tium of the common iliac. The catheter is then exchangedfor the straight catheter as described above. This techniquesaves an extra step of engaging the contralateral iliac withanother catheter first.

After the angiogram of the contra lateral leg is com-pleted, the catheter is pulled just a few inches proximalto the tip of the insertion sheath in the ipsilateral leg andangiogram completed in a stepwise fashion. This can alsobe done with the sheath alone but a smaller catheter hasless risk of causing dissection during angiography. Powerinjector, hand injection, or an “assist device” can be used.Contralateral angle of 30 to 40 degrees will open up theiliac artery bifurcation and 30 to 40 degrees ipsilateral an-gles will open up the vessels below the EIA. Lesions withgreater the 50% diameter stenosis and translesional systolicgradient greater than 10 mm Hg are considered significant.If femoral approach is not feasible, then a brachial or radialapproach utilizing straight catheters can also be used for se-lective angiography of each leg. Vasodilators, for example,NTG 100 to 300 mg, Papavarin 30 to 60 mg, or Tolazo-line 12.5 to 25 mg can be used to optimize below the kneeimaging and also to augment translesional radiant.144

• FIGURE 20-45. Hundred percent occlusion of right SFA

with extensive collateral vessels from deep femoral artery

connecting with the popliteal artery in the same patient. This

“mirror imaging” of AS frequently seen in the thigh vessels.

High success rate with endovascular treatment has nowencouraged most experienced operators to tackle below theknee PAD that was long thought to be only fit for surgicaltherapy. Patients with CLI who are being subjected to am-putation should be given an option for peripheral vascularintervention even if it helps in the short-term healing oftheir infections and to prevent more proximal amputation.

• VENOUS CIRCULATION

With improvement in technology, enthusiasm is gainingmomentum in the endovascular treatment of venous oc-clusive disease (VOD). The most common causes of VODare coagulopathies, extrinsic compression from tumors, andthrombosis from iatrogenic catheters and wires. Venous en-hanced subtracted peak arterial (VESPA) magnetic reso-nance venography is comparable to conventional venog-raphy in the diagnosis of femoral and iliac deep venousthrombosis.145 CTA and MRA are both useful in the di-agnosis of upper extremity and central VOD, stenoses, ex-trinsic masses, and pulmonary embolism.

Venous system parallels arterial system. The superficialveins in the infrainguinal region drain into the small saphe-nous vein, which drains into the popliteal vein, and intothe greater saphenous vein that drains into the commonfemoral vein (CFV). The deep veins converge on the CFVthat continues as the external iliac vein and combines with



368 • CHAPTER 20

the internal iliac vein to form the common iliac veins whichdrain into the IVC that further drains into the right atriumof the heart.

Superficial upper extremity veins drain into the lateralcephalic and medial basilic veins that run along the arm.Cephalic vein empties into the axillary vein and basilicvein drain into the brachial vein. Deep veins drain into thebrachial vein that continues as the axillary and subclavianveins. Each subclavian vein unites with the internal jugularvein to form the right and left innominate veins. They jointogether on the right side to form the superior vena cava(SVC) that empties into the right atrium.

Venous drainage from the pelvic area flows to internaliliac vein that joins with external iliac vein to form thecommon iliac vein. Venous drainage from abdominal vis-cera goes to IVC. The azygous and hemiazygous system ofveins form an important link between IVC and SVC. Thehemiazygous vein and accessory hemiazygous vein is lo-cated along the left side of thoracic vertebrae and receivesblood from the left chest wall and lung and drain into theazygous vein. In two-thirds of cases, the hemiazygous veincommunicates directly with the left renal vein. Azygousvein is located on the right side of the thoracic vertebraeand drains into the SVC at the level of T4. Distally, it con-nects to the IVC at the level of the renal vein.

Venogram

This is still considered the gold standard for VOD. Smallamount of contrast through peripherally inserted catheterswill provide visualization of the veins. Raising the arm im-proves central filling. For lower extremity angiography, ve-nous access is obtained in the dorsum of the foot. DSA isused. For iliac veins 5 to 6 F sheath is inserted in the CFVand angiogram is obtained by hand injection of the con-trast. For IVC, a pigtail or Omniflush catheter is insertedin CIV and 40 mL of contrast is injected. For pulmonaryangiogram a 6 F angled pigtail or a Grollman catheter isadvanced in the main pulmonary artery through a sheathin the CFV or IJ vein. Contrast at 30 mL at 15 mL/s isinjected, and angiography acquired in AP and lateral viewsfor each lung. If pulmonary artery pressure is high, thenselective right and left pulmonary artery angiogram is ob-tained. Care should be taken in patients with preexistingLBBB because the catheter may cause RBBB, thus, causingcomplete heartblock.

• INTRAVASCULAR IMAGING

There are other intravascular imaging techniques that areless commonly used in routine catheter peripheral angiog-raphy. They can however be very useful in cases of ambigu-ous situations or where a decision to intervene is not clearcut.146

IVUS is the most widely available. IVUS catheter usesreflected sound waves to image vascular walls and struc-tures in a two-dimensional tomographic format. Comparedto cardiac echocardiogram, the catheters used in peripheralimaging have a much higher frequency, 20 to 40 MHz ver-sus 2 to 5 MHz. Most new IVUS catheters are compatiblewith 6 F sheaths and guiding catheters. Over the wire andrapid exchange systems are available. In our center we useBoston Scientific Corp. system (Natwik, MA), unfraction-ated heparin at 70 units/kg is given intravenously duringIVUS procedures. Intracoronary nitroglycerin is given priorto delivering the catheter at the area of interest. Automatedpullback is done at 0.5 to 1 mm/s. Interpretation is basedon recognition of blood–intima and media–adventitia in-terface. Lumina and adventitia are much brighter than themedia creating a bright–dark–bright image. Angioscopy isnot FDA-approved in the United States for clinical use.It is probably the best technique for imaging intravascu-lar thrombus. It provides real-time color images of vascularsurfaces and also gives information about atheroscleroticplaque and dissection flaps. Optical coherence tomography(OCT) generates real-time tomographic images from back-scattered reflection of infrared light. It can be conceptual-ized as an optical analog of IVUS. It has 10 times higher res-olution than conventional ultrasound. Imaging procedureis similar to IVUS; however, saline or contrast media mustdisplace blood. There is only one system that is commer-cially available (Light bulb Imaging Inc., Westford. MA). A0.014-inch imaging wire is inserted in the vessel distal tothe occlusion balloon. The diagnostic accuracy of OCT forplaque characterization is confirmed by an ex vivo study of3007 human AS specimens from aorta, carotid, and coro-nary arteries.147 The complications of this procedure appearto be comparable to IVUS and angioscopy. However, dataare lacking.

• ACKNOWLEDGMENT

We wish to thank and acknowledge all who have allowedus to reproduce their figures and tables.

REFERENCES

1. ACC/AHA Guidelines for the Management of PatientsWith Peripheral Arterial Disease (Lower Extremity, Renal,Mesenteric, and Abdominal Aortic). A Collaborative Reportfrom the American Association for Vascular Surgery/Societyfor Vascular Surgery, Society for Cardiovascular Angiog-raphy and Interventions, Society for Vascular Medicineand Biology, Society of Interventional Radiology, and theACC/AHA Task Force on Practice Guidelines (WritingCommittee to Develop Guidelines for the Management of

Patients With Peripheral Arterial Disease). J Am Coll Car-diol. 2006;47(6):1239–1312.

2. Criqui MH, Denenberg JO, Langer RD, et al. The epidemi-ology of peripheral arterial disease: importance of identifyingthe population at risk. Vasc Med. 1997;2:221–226.

3. Murabito JM, D’Agostino RB, Silbershatz H, et al. Intermit-tent claudication. A risk profile from The Framingham HeartStudy. Circulation. 1997;96:44–49.




4. Isner JM, Rosenfield K. Redefining the treatment of periph-eral artery disease. Role of percutaneous revascularization.Circulation. 1993;88:1534–1537.

5. Criqui MH. Peripheral arterial disease and subsequent car-diovascular mortality: a strong and consistent association.Circulation. 1990;82:2246–2247.

6. Hertzer NR. The natural history of peripheral vascular dis-ease: Implications for its management. Circulation. 1991;83(2 suppl):112–119.

7. Management of peripheral arterial disease (PAD). TASCWorking Group. Trans Atlantic Inter-Society Consensus(TASC). J Vasc Surg. 2000;31:S1–S296.

8. Bellar GA, Bonow RO, Fuster V, et al. ACC Revised Recom-mendations for Training in Adult Cardiovascular MedicineCore Cardiology Training II (COCATS 2) (Revision of the1995 COCATS Training Statement). American College ofCardiology, March 8, 2002.

9. White CJ, Ramee SR, Collins TJ, et al. Initial results ofperipheral vascular angioplasty performed by experiencedinterventional cardiologists. Am J Cardiol. 1992;69:1249–1250.

10. Wexler L, Levin DC, Dorros G, et al. Training standards forphysicians performing angioplasty: New developments. Ra-diology. 1991;178:19–21.

11. Guidelines for percutaneous transluminal angioplasty. Stan-dards of Practice Committee of the Society of Cardiovascularand Interventional Radiology. Radiology. 1990;177:619.

12. Guidelines for performance of peripheral percutaneoustransluminal angioplasty. The Society for Cardiac Angiogra-phy and Interventions Interventional Cardiology CommitteeSubcommittee on Peripheral Interventions. Cathet Cardio-vasc Diag. 1988;21:128–129.

13. Pentecost MJ, Criqui MH, Dorros G, et al. Guidelinesfor peripheral percutaneous transluminal angioplasty of theabdominal aorta and lower extremity vessels. Circulation.1994;84:511–531.

14. Spittell JA Jr, Nanda NC, Creager MA, et al. Recommenda-tions for peripheral transluminal angioplasty: training and fa-cilities. American College of Cardiology Peripheral VascularDisease Committee. J Am Coll Cardiol. 1993;21:546–548.

15. Levin DC, Becker GJ, Dorros G, et al. Training standards forphysicians performing peripheral angioplasty and other per-cutaneous peripheral vascular interventions. J Vasc InterventRadiol. 2003;9(Pt2):S359–S361.

16. Babb JD, Collins TJ, Cowley MJ, et al. Revised guidelines forthe performance of peripheral vascular interventions. CathetCardiovasc Intervent. 1999;46:21–23.

17. ACC/ACP/SCAI/SVMB/SVS Clinical Competence State-ment on Vascular Medicine and Catheter-Based PeripheralVascular Interventions. J Am Coll Cardiol. 2004;44(4):941–957.

18. Rofsky NM, Adelman MA. MR angiography in the evalua-tion of atherosclerotic peripheral vascular disease. Radiology.2000;214:325–338.

19. Carpenter JP, Owen RS, Holland GA, et al. Magnetic res-onance angiography of the aorta, iliac, and femoral arteries.Surgery. 1994;116:17–23.

20. Quinn SF, Sheley RC, Szumowski J, et al. Evaluation ofthe iliac arteries: comparison of two-dimensional time of

flight magnetic resonance angiography with cardiac com-pensated fast gradient recalled echo and contrast-enhancedthree-dimensional time of flight magnetic resonance angiog-raphy. J Magn Reson Imaging. 1997;7:197–203.

21. Ruehm SG, Hany TF, Pfammatter T, et al. Pelvic and lowerextremity arterial imaging: diagnostic performance of three-dimensional contrast-enhanced MR angiography. AJR Am JRoentgenol. 2000;174:1127–1135.

22. Meaney JF, Ridgeway JP, Chakraverty S, et al. Stepping-tablegadolinium-enhanced digital subtraction MR angiography ofthe aorta and lower extremity arteries: preliminary experi-ence. Radiology. 1999;211:59–67.

23. Owen RS, Carpenter JP, Baum RA, et al. Magnetic resonanceimaging of angiographically occult runoff vessels in periph-eral arterial occlusive disease. N Engl J Med. 1992;326:1577–1581.

24. Rofsky NM, Johnson G, Adelman MA, et al. Peripheralvascular disease evaluated with reduced-dose gadolinium-enhanced MR angiography. Radiology. 1997;205:163–169.

25. Nelemans PJ, Leiner T, de Vet HC, et al. Peripheral arterialdisease: meta-analysis of the diagnostic performance of MRangiography. Radiology. 2000;217:105–114.

26. Khilnani NM, Winchester PA, Prince MR, et al. Peripheralvascular disease: combined 3D bolus chase and dynamic 2DMR angiography compared with x-ray angiography for treat-ment planning. Radiology. 2002;224:63–74.

27. Maintz D, Tombach B, Juergens KU, et al. Revealing in-stentstenoses of the iliac arteries: comparison of multidetector CTwith MR angiography and digital radiographic angiographyin a phantom model. AJR Am J Roentgenol. 2002;179:1319–1322.

28. Lee VS, Martin DJ, Krinsky GA, et al. Gadolinium–enhancedMR angiography: artifacts and pitfalls. AJR AM J Roentgenol.2000;175:197–205.

29. Sam AD 2nd, Morasch MD, Collins J, et al. Safety of gadolin-ium contrast angiography in patients with chronic renal in-sufficiency. J Vasc Surg. 2003;38:313–318.

30. Rubin GD, Shiau MC, Leung AN, et al. Aorta and iliac arter-ies: single versus multiple detector-row helical CT angiogra-phy. Radiology. 2000;215:670–676.

31. Martin ML, Tay KH, Flak B, et al. Multidetector CT angiogra-phy of the aortoiliac system and lower extremities: a prospec-tive comparison with digital subtraction angiography. AJRAm J Roentgenol. 2003;180:1085–1091.

32. Willmann JK, Wildermuth S, Pfammatter T, et al. Aortoil-iac and renal arteries: prospective intraindividual comparisonof contrast-enhanced three-dimensional MR angiographyand multi-detector row CT angiography. Radiology. 2003;226:798–811.

33. Willmann JK, Mayer D, Banyai M, et al. Evaluation of pe-ripheral arterial bypass grafts with multi-detector row CTangiography: comparison with duplex US and digital sub-traction angiography. Radiology. 2003;229:465–474.

34. Ofer A, Nitecki SS, Linn S, et al. Multidetector CT angiogra-phy of peripheral vascular disease: a prospective comparisonwith intra-arterial digital subtraction angiography. AJR Am JRoentgenol. 2003;180:719–724.

35. Ota H, Takase K, Igarashi K, et al. MDCT comparedwith digital subtraction angiography for assessment of lower



370 • CHAPTER 20

extremity arterial occlusive disease: importance of reviewingcross-sectional images. AJR Am J Roentgenol. 2004;182:201–209.

36. Ricker O, Duber C, Schmiedt W, et al. Prospective compar-ison of CT angiography of the legs with intra-arterial dig-ital subtraction angiography. AJR Am J Roentgenol. 1996;166:269–276.

37. Napel S, Marks MP, Rubin GD, et al. CT angiography withspiral CT and maximum intensity projection. Radiology.1992;185:607–610.

38. Lookstein RA. Impact of CT angiography on endovasculartherapy. Mt Sinai J Med. 2003;70:367–374

39. Rubin GD, Schmidt AJ, Logan LJ, et al. Multi-detectorrow CT angiography of lower extremity arterial inflowand runoff: initial experience. Radiology. 2001;221:146–158.

40. Catalano C, Fraioli F, Laghi A, et al. Infrarenal aortic andlower extremity arterial disease: diagnostic performance ofmulti-detector row CT angiography. Radiology. 2004;231:555–563.

41. Beregi JP, Djabbari M, Desmoucelle F, et al. Popliteal vascu-lar disease: evaluation with spiral CT angiography. Radiology.1997;203:477–483.

42. Bluemke DA, Chambers TP. Spiral CT angiography: an al-ternative to conventional angiography. Radiology. 1995;195:317–319.

43. Huber PR, Leimbach ME, Lewis WL, et al. CO2 angiogra-phy. Catheter Cardiovasc Interv. 2002;55:398–403.

44. Hawkins IF. Carbon dioxide digital subtraction arteriogra-phy. AJR Am J Roentgenol. 1982;139:19–24.

45. Weaver FA, Pentecost MJ, Yellin AE, Davis S, Finck E, Teitel-baum G. Clinical applications of carbon dioxide/digital sub-traction arteriography. J Vasc Surg. 1991;13:266–272.

46. Kerns SR, Hawkins IF Jr, Sabatelli FW. Current status of car-bon dioxide angiography. Radiol Clin North Am. 1995;33:15–29.

47. Kerns SR, Hawkins IF Jr. Carbon dioxide digital subtrac-tion angiography: expanding applications and technical evo-lution. AJR Am J Roentgenol. 1995;164:735–741.

48. Caridi JG, Hawkins IF Jr. CO2 digital subtraction angiogra-phy: potential complications and their prevention [see com-ment]. J Vasc Intervent Radiol. 1997;8:383–391.

49. Hawkins IF, Caridi JG. Carbon dioxide (CO2) digital sub-traction angiography: 26-year experience at the Universityof Florida. Eur Radiol. 1998;8:391–402.

50. Sullivan KL, Bonn J, Shaprio MJ, Gardiner GA. Venographywith carbon dioxide as a contrast agent. Cardiovasc InterventRadiol. 1995;18:141–145.

51. Forssmann W. Die Sondierung des rechten Herzens. KlinWochenschr. 1929;8:2085.

52. Dos Santos R, Lama AC, Pereira-Caldas J. Arteriorgafa daaorta e dos vasos abdominalis. Med Contempo. 1929;47:93.

53. Bettmann MA, Heeren T, Greenfield A, et al. Adverse eventswith radiographic contrast agents: results of the SCVIR Con-trast Agent Registry. Radiology 1997;203:611–620.

54. Waugh JR, Sacharias N. Arteriographic complications in theDSA era. Radiology 1992;182:243–246.

55. Baim DS. Proper use of cineangiographic equipment andcontrast agents. In: Baim DS, Grossman W, eds. Car-diac Catheterization, Angiography, and Intervention. 6thed. Philadelphia, PA: Lippincott, Williams, and Wilkins;2000:15–34.

56. Balter S, Baim, DS. Cineangiographic imaging, radiationsafety and contrast agents. In: Baim DS, Grossman W, eds.Cardiac Catheterization, Angiography and Intervention. 7thed. Philadelphia: Lippincott, Williams, and Wilkins; 2006:31–33.

57. Sutton AG, Ashton VJ, Campbell PG, et al. A randomizedprospective trial of ioxaglate 320 (Hexabrix) vs. iodixanol320 (Visipaque) in patients undergoing percutaneous coro-nary intervention. Catheter Cardiovasc Interv. 2002;57:346–352.

58. Aspelin P, Aubry P, Fransson SG, et al. Nephrotoxic effectsin high-risk patients undergoing angiography (iodixanol). NEngl J Med. 2003;348:491–499.

59. Schwab SJ, Hlatkey MA, Pieper KS, et al. Contrastnephrotoxicity—a randomized controlled trial of a nonionicand an ionic radiographic contrast agent. N Engl J Med. 1989;320:149.

60. Steinberg EP, Moore RD, Powe NR, et al. Safety and costeffectiveness of high-osmolality as compared with low-osmolality contrast agents in patients undergoing cardiac an-giography. N Engl J Med. 1992;326:425.

61. Bertrand ME, Esplugas E, Piessens J, et al. Influence ofa non-ionic, iso-osmolar contrast medium (iodixanol) ver-sus an ionic, low-osmolar contrast medium (ioxaglate) onmajor adverse cardiac events in patients undergoing per-cutaneous transluminal coronary angioplasty. Circulation.2000;101:131–136.

62. Jaff MR, Macneill BD, Rosenfield K. Angiography of theaorta and peripheral arteries. In: Baim DS, Grossman W, eds.Cardiac Catheterization, Angiography and Intervention. 7thed. Philadelphia: Lippincott, Williams, and Wilkins; 2006:257–258.

63. Millward SF, Burbridge BE, Luna G. Puncturing the pulse-less femoral artery: a simple technique that uses palpationof anatomic landmarks. J Vasc Intervent Radiol. 1993;4:415–417.

64. Khangure MS, Chow KC, Christensen MA. Accurate andsafe puncture of a pulse less femoral artery: an aid in per-forming iliac artery percutaneous transluminal angioplasty.Radiology. 1982;144:927–928.

65. Sacks D, Summers TA. Ante grade selective catheterizationof femoral vessels with a 4- or 5-F catheter and safety wire.J Vasc Intervent Radiol. 1991;2:325–326.

66. Cohen DJ. Outpatient transradial coronary stenting: implica-tions for cost-effectiveness. J Invasive Cardiol. 1996;8(supplD):36D–39D.

67. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effects of transra-dial access on quality of life and cost of cardiac catheteriza-tion: a randomized comparison. Am Heart J. 1999;138:430–436.

68. Mann T, Cowper PA, Peterson ED, et al. Transradial coronarystenting: comparison with femoral access closed with an arte-rial suture device. Catheter Cardiovasc Interv. 2000;49:150–156.




69. Campeau L. Entry sites for coronary angiography and ther-apeutic interventions: from the proximal to the distal radialartery. Can J Cardiol. 2001;17(3):319–325.

70. Campeau L. Percutaneous radial artery approach forcoronary angiography. Cathet Cardiovasc Diagn. 1989;16:39.

71. Hovagim AR, Katz RI, Poppers PJ. Pulse oximetry for eval-uation of radial and ulnar arterial blood flow. J CardiothoracAnesth. 1989;3:27–30.

72. Barry WH, Levin DC, Green LH, et al. Left heart catheter-ization and angiography via the percutaneous femoral ap-proach using an arterial sheath. Cathet Cardiovasc Diagn.1979;5:401.

73. Nath PH, Soto B, Holt JH, Satler LF. Selective coronaryangiography by translumbar aortic puncture. Am J Cardiol.1983;52:425?

74. Hill BB, Zarins CK, Fogarty TJ. Endovascular repair of tho-racic aortic aneurysms. In: White R, Fogarty T, eds. PeripheralEndovascular Interventions. New York, NY: Springer-Verlag;1999:383–389.

75. Arko FR, Lee WA, Hill BB. Aneurysm-related death: primaryendpoint analysis for comparison of open and endovascularrepair. J Vasc Surg. 2002;36:297–304.

76. Crawford ES, Hess KR, Sati HJ. Ruptured aneurysm of thedescending thoracic and thoracoabdominal aorta. Ann ofSurg. 1991;213:417–426.

77. Ehrlich M, Grabenwoeger M, Cartes-Zumelzu F. Endovas-cular stent graft repair for aneurysms on the descending tho-racic aorta. Ann Thorac Surg. 1998;66:19–24.

78. Endarterectomy for Asymptomatic Carotid Artery Stenosis-Executive Committee for the Asymptomatic Carotid ArteryStenosis Study. JAMA. 1995;273:1421–1428.

79. Carotid and Cerebral Angiography Performed by Cardiol-ogists. Cerebrovascular Complications. CCI. 2002;55:277–280.

80. Beneficial effect of carotid endarterectomy in symptomaticpatients with high-grade carotid stenosis. North AmericanSymptomatic Carotid Endarterectomy Trial Collaborators.N Engl J Med. 1991;325:445–453.

81. MRC European Carotid Surgery Trial: interim results forsymptomatic patients with severe (70%-99%) or withmild (0%-29%) carotid stenosis. European Carotid SurgeryTrialists’ Collaborative Group. Lancet. 1991;337:1235–1243.

82. Casserly IP, Yadav JS. Carotid intervention. In: Yadav JS,Casserly Ip, Sachar R, eds. Manual of Peripheral Vascu-lar Interventions. Philadelphia, PA: Lippincott Williams, &Wilkins; 2005:84–86.

83. Mukherjee D, Rosenfield K. Vertebral artery disease. In:Yadav JS, Casserly Ip, Sachar R, eds. Manual of PeripheralVascular Interventions. Philadelphia, PA: Lippincott Williams& Wilkins; 2005:110–111.

84. Phatouros CC, Higashida RT, Malek AM, et al. Endovasculartreatment of noncarotid extra cranial cerebrovascular disease.Neurosurg Clin N Am. 2000;11(2):331–350.

85. Gabella G. Cardiovascular System. In: Williams PL, Bannis-ter LH, Berry MM, eds. Gray’s Anatomy. New York, NY:Churchill Livingstone; 1995:1505–1546.

86. Horejs D, Gilbert PM, Burstein S, Vogelzang RI. Nor-mal aortoiliac diameters by CT. J Comput Assist Tomogr.1988;12:602–603.

87. Ebaugh JL, Garcia ND, Matsumura JS. Screening and surveil-lance for abdominal aortic aneurysms: who needs it andwhen. Semin Vasc Surg. 2001;14:193–199.

88. Alcorn HG, Wolfson SK Jr, Sutton-Tyrrell K, et al. Risk fac-tors for abdominal aortic aneurysms in older adults enrolledin The Cardiovascular Health Study. Arterioscler Thromb VascBiol. 1996;16:963–970.

89. Pedersen OM, Aslaksen A, Vik-Mo H. Ultrasound measure-ment of the luminal diameter of the abdominal aorta andiliac arteries in patients without vascular disease. J Vasc Surg.1993;17:596–601.

90. Lanne T, Sandgren T, Sonesson B. A dynamic view on the di-ameter of abdominal aortic aneurysms. Eur J Vasc EndovascSurg. 1998;15:308–312.

91. Johnston KW, Rutherford RB, Tilson MD, et al. Suggestedstandards for reporting on arterial aneurysms. Subcommit-tee on Reporting Standards for Arterial Aneurysms, Ad HocCommittee on Reporting Standards, Society for VascularSurgery and North American Chapter, International Soci-ety for Cardiovascular Surgery. J Vasc Surg. 1991;13:452–458.

92. Krupski WC, Selzman CH, Floridia R, et al. Contempo-rary management of isolated iliac aneurysms. J Vasc Surg.1998;28:1–11; discussion 11–13.

93. Kasirajan V, Hertzer NR, Beven EG, et al. Management ofisolated common iliac artery aneurysms. Cardiovasc Surg.1998:6:171–177.

94. Rubin GD, Armerding MD, Dake MD, et al. Cost identifi-cation of abdominal aortic aneurysm imaging by using timeand motion analysis. Radiology. 2000;215:63–70.

95. Turnipseed WD, Archer CW, Detmer DE, et al. Digital sub-traction angiography and B-mode ultrasonography for ab-dominal and peripheral aneurysms. Surgery. 1982;92:619–626.

96. Bandyk DF. Preoperative imaging of aortic aneurysms: con-ventional and digital subtraction angiography, computed to-mography scanning, and magnetic resonance imaging. SurgClin North Am. 1989;69:721–735.

97. Galt SW, Pearce WH. Preoperative assessment of abdominalaortic aneurysms: noninvasive imaging versus routine arteri-ography. Semin Vasc Surg. 1995;8:103–107

98. Hallett JW Jr. Splenic artery aneurysms. Semin Vasc Surg.1995;8:321–326.

99. Kasirajan K, Greenberg RK, Clair D, et al. Endovascularmanagement of visceral artery aneurysm. J Endovasc Ther.2001;8:150–155.

100. Angelakis EJ, Bair WE, Barone JE, et al. Splenic arteryaneurysm ruptured during pregnancy. Obstet Gynecol Surv.1993;48:145–148.

101. Holley KE, Hunt JC, Brown AL Jr, et al. Renal artery stenosis:a clinical–pathologic study in normotensive and hypertensivepatients. Lancet. 1964;37:14–22.

102. Dustan HP, Humphries AW, Dewolfe VG, et al. Normal ar-terial pressure in patients with renal arterial stenosis. JAMA.1964;187:1028–1029.



372 • CHAPTER 20

103. Scoble JE. The epidemiology and clinical manifestationsof atherosclerotic renal disease. In: Novick AC, Scoble JE,Hamilton G, eds. Renal Vascular Disease. London, UK: WBSaunders; 1996:303–314.

104. Hansen KJ, Edwards MS, Craven TE, et al. Prevalence ofrenovascular disease in the elderly: a population based study.J Vasc Surg. 2002;36:443–451.

105. Olin JW, Melia M, Young JR, Graor RA, Risius B. Preva-lence of atherosclerotic renal artery stenosis in patients withatherosclerosis elsewhere. Am J Med. 1990;88:46–51.

106. Harding MB, Smith LR, Himmelstein SI, et al. Renal arterystenosis: prevalence and associated risk factors in patients un-dergoing routine cardiac catheterization. J Am Soc Nephrol.1992;2:1608–1616.

107. Weber-Mzell D, Kotanko P, Schumacher M, et al. Coronaryanatomy predicts presence or absence of renal artery stenosis:a prospective study in patients undergoing cardiac catheter-ization for suspected coronary artery disease. Eur Heart J.2002;23:1684–1691.

108. Jean WJ, al-Bitar I, Zwicke DL, et al. High incidence of re-nal artery stenosis in patients with coronary artery disease.Cathet Cardiovasc Diag. 1994;32:8–10.

109. Scoble JE, Maher ER, Hamilton G, Dick R, Sweny P, Moor-head JF. Atherosclerotic renovascular disease causing re-nal impairment—a case for treatment. Clin Nephrol. 1989;31:119–122.

110. Zierler RE, Bergelin RO, Isaacson JA, Strandness DE.Natural history of atherosclerotic renal artery stenosis: Aprospective study with duplex ultrasonography. J Vasc Surg.1994;19:250–258.

111. Wright JR, Shurrab AE, Cheung C, et al. A prospective studyof the determinants of renal functional outcome and mortal-ity in atherosclerotic renovascular disease. Am J Kidney Dis.2002;39(6):1153–1161.

112. Suresh M, Laboi P, Mamtora H, et al. Relationship ofrenal dysfunction to proximal arterial disease severity inatherosclerotic renovascular disease. Nephrol Dial Trans-plant. 2000;15(5):631–636.

113. Rimmer JM, Gennari FJ. Atherosclerotic renovascular dis-ease and progressive renal failure. Ann Intern Med. 1993;118:712–719.

114. Mailloux LU, Napolitano B, Bellucci AG, et al. Renal vascu-lar disease causing end-stage renal disease, incidence, clinicalcorrelates, and outcomes: a 20-year clinical experience. AmJ Kidney Dis. 1994;24:622–629.

115. Guzman RP, Zierler RE, Isaacson JA, et al. Renal atrophyand arterial stenosis. A prospective study with duplex ultra-sound. Hypertension. 1994;23:346–350.

116. Caps MT, Zierler RE, Polissar NL, et al. Risk of atrophy inkidneys with atherosclerotic renal artery stenosis. Kidney Int.1998;53:735–742.

117. Mitsuzaki K, Yamashita Y, Sakaguchi T, et al. Ab-domen, pelvis, and extremities: diagnostic accuracy of dy-namic contrast-enhanced turbo MR angiography comparedwith conventional angiography-initial experience. Radiology.2000;216:909–915.

118. Beregi JP, Elkohen M, Deklunder G, et al. Helical CT angiog-raphy compared with arteriography in the detection of renalartery stenosis. AJR Am J Roenrtgenol. 1996;167:495–501.

119. Halperin EJ, Rutter CM, Gardiner GA Jr, et al. Comparisonof Doppler US and CT angiography for evaluation of renalartery stenosis. Acad Radiol. 1998;5:524–532.

120. Johnson PT, Halpern EJ, Kuszyk BS, et al. Renal arterystenosis: Ct angiography—comparison of real-time volume-rendering and maximum intensity projection algorithms. Ra-diology. 1999;211:337–343.

121. Kim TS, Chung JW, Park JH, et al. Renal artery evaluation:comparison of spiral CT angiography to intra-arterial DSA.J Vasc Interv Radiol. 1998;9:553–559.

122. Rubin GD, Duke MD, Napel S, et al. Spiral CT of renalartery stenosis: comparison of three-dimensional renderingtechniques. Radiology. 1994;190:181–189.

123. Kawashima A, Sandler CM, Ernst Rd, et al. CT evaluationof renovascular disease. Radiographics. 2000;20:1321–1340.

124. Lufft V, Hoogestraat-Lufft L, Fels LM, et al. Contrastmedia nephropathy: intravenous CT angiography versusintra-arterial digital subtraction angiography in renal arterystenosis: a prospective randomized trial. Am J Kidney Dis.2002;40:236–242.

125. Rihal CS, Textor SC, Grill DE, et al. Incidence and prog-nostic importance of acute renal failure after percuta-neous coronary intervention. Circulation. 2002;105:2259–2264.

126. Parfrey PS, Griffiths SM, Barrett BJ, et al. Contrast material-induced renal failure in patients with diabetes mellitus, renalinsufficiency or both. A prospective controlled study. N EnglJ Med. 1989;320:143–149.

127. Aspelin P, Aubry P, Fransson SG, et al. Nephrotoxic effectsin high-risk patients undergoing angiography. N Engl J Med.2003;348:491–499.

128. Kay J, Chow WH, Chan TM, et al. Acetylcysteine for pre-vention of acute deterioration of renal function followingelective coronary angiography and intervention: a random-ized controlled trial. JAMA. 2003;289:553–558.

129. Ottinger LW, Austin WG. A study of 136 patients withmesenteric infarction. Surg Gynecol Obstet. 1967;124:251–261.

130. Hertzer NR, Beven EG, Humphries AW. Acute intestinalischemia. Ann Surg. 1978;44:744–749.

131. Bergan JJ. Recognition and treatment of intestinal ischemia.Surg Clin North Am. 1967;47:109–126.

132. Mikkelsen WP. Intestinal angina: its surgical significance. SurgGynecol Obstet. 1957;94:262–267; discussion, 267–269.

133. Buchardt Hansen HJ. Abdominal angina: results of arterialreconstruction in 12 patients. Acta Chir Scand. 1976;142:319–325.

134. Fisher DF Jr, Fry WJ. Collateral mesenteric circulation. SurgGynecol Obstet. 1987;164:487–492.

135. Kawauchi M, Tada Y, Asano K, et al. Angiographic demon-stration of mesenteric arterial changes in postcoarctectomysyndrome. Surgery. 1985;98:602–604.

136. Siegelman SS, Sprayregen S, Boley SI. Angiographic di-agnosis of mesenteric arterial vasoconstriction. Radiology1974;112:533–542.

137. Nalbandian H, Sheth N, Dietrich R, et al. Intestinal ischemiacaused by cocaine ingestion: report of two cases. Surgery.1985;97:374–376.




138. Vitale GF, Inahara T. Extra peritoneal endarterectomy for il-iofemoral occlusive disease. J Vasc Surg. 1990;12:409–413;discussion 414–415.

139. van den Dungen JJ, Boontje AH, Kropveld A. Unilateral il-iofemoral occlusive disease: long-term results of the semi-closed endarterectomy with the ring-stripper. J Vasc Surg.1991;14:673–677.

140. de Vries SO, Hunink MG. Results of aortic bifurcation graftsfor aortoiliac occlusive disease: a meta-analysis. J Vasc Surg.1997;26:558–569.

141. Cambria RP, Yucel EK, Brewster DC, et al. The potential forlower extremity revascularization without contrast arteriog-raphy: experience with magnetic resonance angiography. JVasc Surg. 1993;17:1050–1056.

142. Sueyoshi E, Sakamoto I, Matsuoka Y, et al. Aortoiliac andlower extremity arteries: comparison of three-dimensionaldynamic contrast-enhanced subtraction MR angiographyand conventional angiography. Radiology. 1999;210:683–688.

143. Poletti PA, Rosset A, Didier D. Subtraction CT angiog-raphy of the lower limbs: a new technique for the eval-uation of acute arterial occlusion. AJR Am J Roentgenol.2004;183:1445–1448.

144. Legemate DA, Teeuwen C, Hoeneveld H, Eikelboom BC.Value of duplex scanning compared with angiography andpressure measurement in the assessment of aortoiliac arte-rial lesions. Br J Surg. 1991;78:1003–1008.

145. Fraser DG, Moody AR, Davidson IR, et al. Deep venousthrombosis: Diagnosis by using venous enhanced subtractedpeak arterial MR venography versus conventional venogra-phy. Radiology. 2003;226(3):812–820.

146. Honda Y, Fitzgerald PJ, Yock PG. Intravascular Imaging tech-niques. In: Baim DS, Grossman W, eds. Cardiac Catheteriza-tion, Angiography and Intervention. 7th edition; Philadelphia,PA: Lippincott Williams & Wilkins; 2006:371–391.

147. Yabushita H, et al. Characterization of human atherosclero-sis by optical coherence tomography. Circulation. 2002;106:1640–1645.



374

Peripheral Angiography - Semantic Scholar€¦ · peripheral vascular procedures.9−16 Specialties...

Documents

Transcript of Peripheral Angiography - Semantic Scholar€¦ · peripheral vascular procedures.9−16 Specialties...